- Administer oxytocin if not administered in previous step
- Perform fundal massage if not performed in previous step
- If no response to oxytocin, consider administration of a second-line agent:
- Consider administration of TXA
- If no response to medication, consider intrauterine balloon placement (eg, Bakri balloon)
Uterine atony is the cause of 75% to 80% of cases of postpartum hemorrhage. Risk factors for uterine atony include prolonged labor, induction of labor, prolonged use of oxytocin, chorioamnionitis, multiple gestations, polyhydramnios, and uterine leiomyomas; however, uterine atony may occur in the absence of risk factors. Clinically, uterine atony presents as a soft, poorly contracted, or boggy uterus.
Initial treatment for uterine atony consists of emptying the bladder by placing a Foley catheter, providing vigorous uterine massage while evacuating any intrauterine clots, and administering oxytocin. In patients with uterine atony, an additional agent (eg, methylergonovine, carboprost, or misoprostol) can be utilized if there is no response to the oxytocin. If bleeding is not controlled with these agents, tranexamic acid may be considered. Table 3 provides medical therapy dosing options.
If there is persistent uterine bleeding, an intrauterine tamponade device (eg, a Bakri balloon) or a compression suture can be considered. If a Bakri balloon is used, the device should be inserted under ultrasound guidance, inflated with 300 to 500 mL of sterile water or saline, and secured to the patient’s leg for traction. If an intrauterine balloon device is not available, an alternative approach using a condom over a Foley catheter has been shown to be efficacious.
Continued severe blood loss requires consultation with obstetrics for surgical intervention. If medical management and conservative therapies fail, emergent hysterectomy is the definitive treatment for postpartum hemorrhage.
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