Obgyn · Year 3 · from Obgyn
Case 1: Postpartum Hemorrhage from Uterine Atony
Patient Demographics
- Age: 29 years
- Sex: Female
- Occupation: Graphic designer
Chief Complaint
"The patient is bleeding heavily after delivery."
History of Present Illness
The patient is a G3P3 who just delivered a 4,200-gram infant vaginally after a prolonged second stage of labor (3 hours of pushing with epidural). Oxytocin was running during labor for augmentation. Within 10 minutes of placental delivery, the nurse notes heavy vaginal bleeding with clots. The uterus is palpated above the umbilicus and feels soft and "boggy."
Risk Factors Present
- Prolonged labor with oxytocin augmentation
- Macrosomic infant (uterine overdistension)
- Multiparity (G3P3)
- Prolonged second stage
Vital Signs (At Time of Recognition)
- BP: 100/60 mmHg (baseline was 118/72)
- HR: 110 bpm (baseline was 78)
- RR: 20 breaths/min
- SpO2: 98% on room air
Initial Assessment
Quantified Blood Loss:
- Estimated blood loss at recognition: 800 mL (by calibrated collection drape and weighed pads)
- Ongoing heavy flow
Four T's Assessment:
- Tone: Uterus boggy, fundus above umbilicus - PRIMARY CAUSE
- Trauma: Cervix and vagina examined - no lacerations identified
- Tissue: Placenta appeared complete on inspection
- Thrombin: No history of coagulopathy, recent labs normal
Diagnosis
Primary Postpartum Hemorrhage from Uterine Atony
- Blood loss exceeding 1,000 mL (cumulative)
- Maternal tachycardia indicating early hypovolemic response
Immediate Management
Step 1: Call for Help
- Activated hemorrhage response team
- Called for additional nurses, obstetrician, anesthesiologist
Step 2: Establish Access and Labs
- Second large-bore IV placed (18-gauge)
- Blood sent for type and crossmatch, CBC, coagulation studies
Step 3: Uterine Massage
- Bimanual uterine compression initiated
- Vigorous fundal massage performed
Step 4: Uterotonic Agents
- Oxytocin: 40 units in 1L lactated Ringer's, infusing rapidly
- Methylergonovine: 0.2 mg IM (no hypertension)
- Carboprost (Hemabate): 0.25 mg IM (no asthma)
- Misoprostol: 800 mcg rectally
Step 5: Tranexamic Acid
- 1 gram IV given within 3 hours of delivery
Step 6: Continued Monitoring
- Cumulative blood loss tracked
- Vital signs every 5 minutes
Response to Treatment
After 15 minutes:
- Uterus becoming firmer with massage and uterotonics
- Bleeding slowing
- Cumulative blood loss: 1,400 mL
Laboratory Results:
- Hemoglobin: 9.2 g/dL (admission was 11.8)
- Platelets: 165,000
- Fibrinogen: 280 mg/dL (normal)
- PT/INR: Normal
Decision:
- Blood transfusion initiated (2 units packed red blood cells)
- Conservative management successful - no need for Bakri balloon or surgery
Final Outcome
- Total estimated blood loss: 1,500 mL
- Received 2 units PRBCs
- Hemoglobin post-transfusion: 9.8 g/dL
- Uterus firm, bleeding controlled
- Stable for transfer to postpartum unit
Postpartum Management
- Continued oxytocin infusion for 4 hours
- Serial hemoglobin checks
- Iron supplementation
- Early ambulation with assistance (DVT prophylaxis)
- Counseling regarding increased PPH risk in future pregnancies
Clinical Image
Image Description: Algorithm diagram showing the stepwise management of postpartum hemorrhage, including uterine massage technique, uterotonic medications with doses and contraindications, and escalation to procedural interventions.
Attribution: Educational illustration adapted from ACOG hemorrhage bundle. Used for educational purposes.