Extraplacental causes of postpartum hemorrhage

The surgical causes of primary postpartum hemorrhage include 'obstetric' lacerations of the cervix, vagina, paravaginal spaces, and perineum, and episiotomy. As a group these comprise about 20 per cent of all primary postpartum hemorrhage. Bleeding from uterine rupture may be revealed vaginally, but may be entirely concealed within the abdomen; this is a rare but extremely treacherous cause of postpartum hemorrhage and should be considered where shock is out of proportion to vaginal blood loss, particularly with vaginal delivery following a previous Cesarean section. Persistent bright red vaginal bleeding associated with a firm well-contracted uterus suggests one of these causes.

Laceration of blood vessels underneath the vaginal or vulval epithelium results in hematoma formation. In these circumstances the bleeding is concealed and may be particularly dangerous since, in inexperienced hands, it may go unrecognized for several hours until the patient becomes shocked. In the case of episiotomy and perineal tears, postpartum hemorrhage may result if the cut involves arteries or large varicosities, if it is extended and difficult to repair, if there is a delay between episiotomy and delivery, or if there is a delay between delivery and repair of the episiotomy.

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