The seventeen-year old lady, Adriana, in this photo presents to the maternity ward at the Lubango Evangelical Medical Center in Angola, southern Africa. Her last menstrual period is unknown, but her uterus is full-term in size. She is in labor and shortly delivers a healthy infant, followed by delivery of her intact placenta.
One hour later you receive a call from the maternity nurse urging you to come quickly. On arrival, Adriana is conscious but her systolic blood pressure is 80, and her pulse is 140 and weak. Clots of blood are flowing from her birth canal.
Your initial differential diagnosis for the cause of this postpartum hemorrhage includes all of the following EXCEPT which ONE?
A Inadequate contraction of the uterus (atony)
B Laceration of the vagina
C Retained placenta in the uterus
D Inadequate blood clotting
E Laceration of the cervix
Explanation: The correct answer is B. Postpartum hemorrhage (bleeding after childbirth) continues to result in one-quarter of all maternal deaths worldwide. Some 98 percent of these deaths occur in low-income nations. Atonic uterus (failure of the uterus to contract) is the most common cause of postpartum hemorrhage and is the single leading cause of maternal death. Laceration of the vagina, which is not highly vascular, rarely causes life-threatening hemorrhage.
You realize that basically trained personnel can manage most delivery complications, so you immediately instruct the maternity nurse and her team to palpate Adriana’s uterus, which is soft and pliable. You rapidly guide them through a vaginal exam that does not identify a cervical laceration. You would like to explore the uterine cavity for retained placenta parts, but do not have the proper instruments. Next you ask the team the following question.
All of the following should be done to manage inadequate contraction of the uterus EXCEPT which ONE?
A Administration of isotonic intravenous fluids
B Message of the uterus
C Administration of cephalexin
D Administration of oxytocin
E Administration of misoprostol
Explanation: The correct answer is C. Immediately initiate multiple modes of therapy. Oxytocin, misoprostol, and uterine message lead to uterine contraction and control of hemorrhage. Intravenous fluid replacement controls cardiovascular shock and ideally carried out via two large bore catheters. Though uterine manipulation is accompanied by a theoretical increased risk of endometritis, broad-spectrum antibiotic administration is not routine recommended nor does it control hemorrhage.
Reference: WHO Recommendations for the Prevention of Postpartum Haemorrhage, World Health Organization. 2012 , accessed 2015-05-13
Adriana’s hemorrhage rapidly resolves. You sense a deep satisfaction over not only preserving her life, but realizing that next time the maternity personnel will be better capable of handling this crisis without outside assist.
We must move beyond simply providing care, onward to equipping others to care for their own. INMED is devoted to protecting mothers and newborns through multiplying skilled individuals. Join the ranks of those assisting local people to protect women like Adriana!