Uterine atony causes about 70 percent of PPHs. This condition is usually very responsive to non-pharmacologic measures, and these may be tried first. I generally start with fundal massage and nipple stimulation, uterine re-positioning, then abdominal aortic compression, and finally bimanual compression. I consider whether the woman has emptied her bladder recently and is otherwise comfortable. If the uterus remains soft but bleeding is being controlled, herbal therapies like blue cohosh or motherwort may be considered, reserving oxytocic drugs for circumstances where a more definitive, heavy-handed approach is indicated. (Of course situations vary, requiring an individualized, dynamic response. For example, torrential hemorrhages I have managed responded well to immediate aortic compression followed by other interventions, which did not usually include pharmaceuticals.) Administration of oxygen at 4-5 liters/min. should begin with any signs of shock and/or blood pressure at or below 70/50. Emergency response measures should be initiated; steps taken to assure fluid resuscitation; and core-perfusion maintained via lower extremity elevation, and in some cases, anti-shock compression pants or wrap.
Should pharmaceutical oxytocics be indicated, the American Academy of Family Physicians recommends the following protocol: up to 40 units of oxytocin (Pitocin) in a liter of normal saline, administered at a rate of 250/mlhour, or 10-20 units IM. Oxytocin acts to rhythmically contract the upper uterine segment. (Direct, undiluted IV injection of oxytocin is to be avoided, as it increases hypotension, exacerbating perfusion problems associated with hemorrhage.) If the response to oxytocin is inadequate after several minutes and the woman is not hypertensive or toxemic, give ergonovine (Methergine) 0.2 mg IM. This agent acts on both upper and lower uterine segments, causing tetanic contraction and vasoconstriction. Note that ergot administration commonly causes transient hypertension, nausea or vomiting, dizziness, headache, palpitations, chest pain, or shortness of breath. Since many of these side effects are synonymous with symptoms of shock, special care should be taken to determine if adequate treatment response is occurring. Onset of action is two to five minutes.
Some practices have access to Prostaglandin F2 15-methyl (Hemabate), which may be administered IM or intramyometrially (injected directly into the uterus through the abdominal wall). Dosage is 0.25 to 1.0 mg, repeated up to a total of 2 mg. Onset of action is five minutes.
All the while the practitioner should be actively assessing the root cause of the bleeding, whether the treatments are working, and planning for the next step.
-Judy Edmunds, CPM, in Midwifery Today Issue 48
Reprinted from Midwifery Today E-News (Vol 1 Issue 35, Aug 27, 1999)
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