Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?

Manual exploration of the uterus

Thirty minutes after vaginal delivery of a 2780-g (6-lb 2-oz) newborn at term, a 25-year-old woman, gravida 1, para 1, has heavy vaginal bleeding. Her pregnancy was complicated by pre-eclampsia. Her pulse is 111/min and blood pressure is 95/65 mm Hg. Physical examination shows a fundal height 2 inches below the xiphoid process of the sternum. A drug with which of the following mechanisms of action is most appropriate for this patient?

Depolarization of the motor end plate

Increased synthesis of cyclic AMP

Inhibition of norepinephrine reuptake

Binding to prostaglandin I2 receptors

29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?

Intravenous clindamycin and gentamicin treatment

Prophylactic intravenous cefazolin treatment

Intramuscular cefotetan treatment

Uterine atony management — USMLE Lesson

Initial Management - The First Response

Call for Help: Activate emergency response. Notify anesthesia, OR staff, and blood bank.
Bimanual Uterine Massage: The cornerstone of initial management. One hand on the abdomen massages the fundus, while the other internally supports the uterus.
Secure IV Access: Establish two large-bore IVs (≥18 gauge).
- Draw blood for CBC, type & crossmatch, and coagulation panel.
Pharmacotherapy (Uterotonics):
- Oxytocin (Pitocin): First-line agent. Administer 20-40 units in 1L of crystalloid, run at a rate to control bleeding.
Bladder Decompression: Insert a Foley catheter to empty the bladder, preventing interference with uterine contraction.

Bimanual Uterine Compression for Uterine Atony

⭐ Tranexamic Acid (TXA): If initial measures are insufficient, administer 1g of TXA IV over 10 minutes. Must be given within 3 hours of delivery to be effective.

Uterotonic Agents - The Contraction Crew

First-line therapy to ↑ uterine tone. Administer sequentially; assess response before adding next agent.

Uterotonic Agents: Myometrial Contraction Mechanism

Agent	Dose & Route	Contraindications (C/I)	Key Side Effects (S/E)
Oxytocin (Pitocin)	10-40 units in 1L IV	None for PPH	Water intoxication, hypotension
Methylergonovine (Methergine)	0.2 mg IM	Hypertension, preeclampsia, Raynaud's	↑↑ BP (stroke risk)
Carboprost Tromethamine (Hemabate)	250 mcg IM or intramyometrial	⚠️ Asthma	Bronchospasm, N/V/D, fever
Misoprostol (Cytotec)	800-1000 mcg rectally	None for PPH	Shivering, pyrexia, diarrhea

⭐ Exam Favorite: Carboprost (a prostaglandin F2α analog) is a potent uterotonic but is absolutely contraindicated in patients with asthma due to its significant risk of inducing bronchospasm.

Refractory Hemorrhage - Escalation Steps

When initial uterotonic therapy fails to control bleeding, escalate management immediately. The goal is to achieve hemostasis while preserving fertility if possible.

Intrauterine Balloon Tamponade:
- A Bakri balloon is inserted into the uterus and inflated with ~500 mL of saline.
- Provides an internal stent, applying direct pressure to stop bleeding from the placental site.
Surgical Intervention (Laparotomy):
- Uterine Compression Sutures: The B-Lynch suture is a common, effective technique.
- Vascular Ligation (Stepwise):
  - Uterine artery ligation (O'Leary stitch).
  - Internal iliac (hypogastric) artery ligation; reduces pulse pressure by ~85%.
Hysterectomy: The definitive and final treatment when all other measures fail.

Bakri balloon for uterine tamponade: placement and inflation

⭐ High-Yield: Internal iliac artery ligation is highly effective but carries a risk of ureteral injury due to anatomical proximity. It preserves uterine function.

High-Yield Points - ⚡ Biggest Takeaways

Uterine atony is the most common cause of postpartum hemorrhage (PPH).

First-line management is always bimanual uterine massage and a high-dose oxytocin infusion.

If bleeding persists, administer second-line uterotonics like methylergonovine, carboprost, or misoprostol.

Be aware of contraindications: avoid methylergonovine in hypertensive disorders and carboprost in asthma.

Refractory cases may require intrauterine balloon tamponade, compression sutures (e.g., B-Lynch), or hysterectomy.

Always ensure the bladder is empty to facilitate uterine contraction.

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