Examination under anesthesia the first operative procedure

The potential exists for mismanagement if the pathophysiology is not appreciated. If the initial management is incorrect, a cascade of problems may ensue. Most obstetric textbooks highlight the importance of ensuring initial intravenous access, the use of uterotonic drugs, and bimanual compression of the uterus. While these are reasonable 'first-aid' measures, this approach fails to address causes other than atonic postpartum hemorrhage.

The most crucial decision in the management of a case of postpartum hemorrhage is whether the bleeding is atonic (placental bed) or traumatic (extraplacental causes). While the former merely requires the use of uterotonic drugs, bimanual compression, and/or uterine packing, patients in the latter category will continue to deteriorate until dealt with surgically. The erroneous 'default' assumption of atony wastes both time and precious circulating blood volume—sadly until hypovolemic shock ensues, thereby precipitating a general anesthetic under the worst circumstances. Secondary DIC and systemic hypotension are the pathway towards maternal mortality, a postoperative situation that need not arise if prompt initial surgical action is taken.

A clinician faced with a woman with postpartum hemorrhage has to assume temporarily that the cause is uterine atony, provided that the uterus is soft and enlarged, becoming smaller and firm with the expulsion of clots and administration of a uterotonic agent (Syntometrine and/or an oxytocin infusion). Therefore this is a diagnostic/clinical test pending cross-matching of blood. Other uterotonic options include oral or rectal administration of inexpensive prostaglandins such as misoprostol. If the patient continues to bleed despite the use of these medications, the clinician needs to exclude genital tract trauma or retained placental tissue reliably by performing an adequate examination under anesthesia, bearing in mind that any final diagnosis of atonic uterus is by careful exclusion of surgical causes. It is worth noting that blood accumulating in the vaginal vault (from a surgical cause) can elevate the well-contracted uterus into the abdomen, giving the impression that the uterine cavity is full of blood.

Rather than simply examining the patient in the lithotomy position in the delivery room, it is better to examine the patient in the operating room under general anesthesia to ensure that an accurate diagnosis is made. This should be performed or attended by the most experienced clinician available. With the patient in the lithotomy position, under good light, and with at least one assistant, the entire genital tract should be examined. During the procedure it is likely that previous stitches used to repair an episiotomy or tear will be disrupted. This should not be of concern, since good access is needed to inspect the fornices fully. The uterus should be examined digitally to exclude uterine rupture or retained placental tissue. Having ensured that the uterus is intact, the obstetrician should then examine the cervix and vagina and repair any tears. Perineal repair sutures should be undone to ensure a complete examination. If no obvious cause is found, a diagnosis of intractable atonic postpartum hemorrhage can be made with certainty.

If vaginal bleeding continues following exclusion of trauma within the lower genital tract, it must be ensured that the uterus is firmly contracted. A second-line uterotonic agent (intramyometrial carboprost or rectal misoprostol) should be given if there is any doubt. If these measures fail to control the bleeding, the lower uterine segment should be rechecked using bimanual examination to confirm that it is intact. In instances where the bleeding is persistent, but not heavy, packing the uterus can be considered. This procedure is controversial since it may distract the obstetrician from hysterectomy. Some believe that packing will interfere with uterine contractility and that this procedure will only conceal further bleeding. We believe that it has a place as a temporary measure provided that it is done properly. It is most important to pack the fundus of the uterus thoroughly; a common mistake is to introduce a 'half-hearted' pack into the lower part of the uterus only, leaving a large cavity within which blood will accumulate. If inserted for too long, such a pack can interrupt the blood supply to the pelvic organs, in particular the base of the bladder, leading to fistula formation. The pack is also a focus for infection, and for this reason some obstetricians soak the pack in Betadine. It should be removed within 24 h as an operative procedure; significant postpartum hemorrhage can occur at this point and one should be in a position to proceed rapidly to hysterectomy to secure hemostasis.

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