Management of postpartum hemorrhage

A. Following delivery of the placenta, the uterus should be palpated to determine whether atony is present. If atony is present, vigorous fundal massage should be administered. If bleeding continues despite uterine massage, it can often be controlled with bimanual uterine compression.

B. Genital tract lacerations should be suspected in patients who have a firm uterus, but who continue to bleed. The cervix and vagina should be inspected to rule out lacerations. If no laceration is found but bleeding is still profuse, the uterus should be manual^ examined to exclude rupture.

C. The placenta and uterus should be examined for retained placental fragments. Placenta accreta is usually manifest by failure of spontaneous placental separation.

D. Bleeding from non-genital areas (venous puncture sites) suggests coagulopathy. Laboratory tests that confirm coagulopathy include INR, partial thromboplastin time, platelet count, fibrinogen, fibrin split products, and a clot retraction test.

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