This patient's clinical presentation is consistent with postpartum hemorrhage, which is caused by uterine atony in 90% of cases. The first-line treatment for this condition is bimanual uterine massage.
Postpartum hemorrhage is defined by blood loss totaling >500 cc in the first 24 hours after a vaginal birth, or >1000 cc with a Caesarian section. The vast majority of postpartum hemorrhage is caused by uterine atony, which is characterized by a boggy uterus that is not able to effectively compress the spiral arteries. Risk factors for uterine atony include a history of fibroids, multiparity, and multiple gestations. Bimanual uterine massage, along with administration of oxytocin and prostaglandins, can be used to stimulate uterine contraction, and surgical treatment can be used if medical management fails.
Anderson and Etches discuss management of postpartum hemorrhage. They note that bimanual uterine massage should be performed by placing one hand (or fist) in the vagina and pushing against the uterus, while the other hand presses on the abdomen over the uterine fundus. Uterine massage should be attempted as a first-line treatment, followed by medication treatment, and only then by surgical treatment.
Collins et al. performed a prospective cohort study to evaluate the use of two fibrinogen function assays for prediction of outcomes in postpartum hemorrhage. FIbrinogen function was assayed in 356 women with 1000-1500 cc of blood loss postpartum. Increased need for transfusion correlated with decreased fibrinogen quantity and function.
Illustration A shows the protocol for bimanual uterine massage.
Answer 1: Surgical ligation of the uterine artery should be considered if uterine massage and medical management fails. This procedure is preferable over hysterectomy in patients who may want to become pregnant in the future.
Answer 2: Genital tract lacerations are the second most common cause of postpartum hemorrhage, but account for less than 10% of cases.
Answer 3: Inspection of the placenta for missing cotyledons should be performed if retained placental tissue is suspected.
Answer 4: Hysterectomy should be considered if uterine massage and medical management fails in patients who do not wish to have children in the future. In patients who wish to have children, this procedure should be considered a last resort.
Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007 Mar 15;75(6):875-82.
PMID:17390600 (Link to Abstract)
Collins PW, Lilley G, Bruynseels D, Burkett-St Laurent D, Cannings-John R, Precious E, Hamlyn V, Sanders J, Alikhan R, Rayment R, Rees A, Kaye A, Hall JE, Paranjothy S, Weeks A, Collis RE. Fibrin-based clot formation an early and rapidly available biomarker for progression of postpartum hemorrhage: a prospective cohort study. Blood. 2014 Jul 14. pii: blood-2014-04-567891.
PMID:25024304 (Link to Abstract)