Postpartum Hemorrhage (Operative Management)
Patient phenotype
Active hemorrhage post-delivery — atony (#1 cause), retained products, lacerations, placenta accreta spectrum, coagulopathy. Often previously stable patient now exsanguinating. Sometimes already with neuraxial in place from labor/cesarean.
Procedure
Variable: D&C for retained products, B-Lynch suture, uterine artery ligation, hysterectomy. Increasingly: IR with uterine artery embolization. Time = blood. MTP early.
Anesthetic plan
Depends on stability + existing anesthesia. Awake/topical for D&C if stable. GA for unstable, OR conversion. Existing neuraxial may be used if not in shock. Massive transfusion with 1:1:1 ratio. Treat coagulopathy.
Setup
- ·MTP activation early (don't wait for crash)
- ·2× 16-gauge PIVs minimum
- ·A-line if shock or expected ongoing bleeding
- ·Rapid infuser (Belmont/Level 1)
- ·Cell saver for cesarean hysterectomy
- ·TEG/ROTEM if available
- ·Calcium, fibrinogen concentrate, PCC, TXA available
- ·Forced air warmer + fluid warmer
Biggest concerns by phase
Recognize PPH early — quantitative blood loss
EBL frequently underestimated visually. Use weight-based calibrated drapes + suction canisters. PPH = > 1000 mL or signs of hypovolemia. Stage 1: 500-1000, stage 2: 1000-1500, stage 3: > 1500. Escalate at each stage.
Uterotonic ladder
Oxytocin 10-40 U IV (first-line), methylergonovine 0.2 mg IM (avoid if HTN/preeclampsia), carboprost 0.25 mg IM (avoid if asthma), misoprostol 800-1000 mcg PR/SL. TXA 1g IV early (within 3h, repeat at 30 min if continued).
Hypovolemic induction
Reduced doses (etomidate 0.1 mg/kg, ketamine 0.5 mg/kg, sux 1.5 mg/kg). Expect significant BP drop. Pressors at hand. RSI standard (full stomach in pregnancy).
Massive transfusion + coagulopathy
1:1:1 PRBC:FFP:platelets. Fibrinogen drops fast in OB hemorrhage — replace if < 200 (cryo or fibrinogen concentrate 4 g). TEG-guided ideal. Calcium replacement (citrate). Avoid LR (citrate-Ca chelation).
Hypothermia + acidosis = lethal triad
Maintain temp ≥ 36 °C. Avoid acidosis (worsens coagulopathy). Bicarbonate for severe acidosis. Warm everything.
DIC + amniotic fluid embolism differential
Refractory bleeding + coagulopathy → consider AFE (sudden hypoxia + cardiovascular collapse + DIC during/after delivery). Treatment supportive: ECMO consideration, factor support, A-OK protocol.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
G3P3 just delivered vaginally, now 30 min postpartum with continuing bleeding, EBL 1500, BP 90/50, HR 130, uterus boggy. Walk me through.
What an examiner probes for
- ▹Activates MTP
- ▹Uterotonic ladder applied + escalates
- ▹Establishes wide-bore access + A-line
- ▹Plans for OR — likely D&C/exam ± hysterectomy
- ▹TXA + fibrinogen/cryo + calcium
- ▹Anticipates AFE if cardiovascular collapse
Sources
- Chestnut's OB Anesthesia 6e
- WOMAN trial (TXA)
- ACOG Practice Bulletin 183
Anatomy reference
Sourced reference images. 4 matches for "uterus pelvic obstetric".
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