In the face of intractable hemorrhage in an undelivered patient or totally obstructed labor, emergency cesarean section will probably be life-saving. For those abdominal surgeons with lesser amounts of training in cesarean section, a midline lower abdominal incision and midline uterine incision are the wisest.
Continue in a midline fashion through the wall of the uterus until the uterine cavity is entered. You may extend the uterine midline incision as high as necessary to gain the needed exposure for delivery of the infant and the placenta. Avoid going too low and risking entering the bladder. Close the uterus in two or three layers.
Manual Removal of the Placenta
After delivery of the infant, the placenta normally separates within a few minutes. At this time, if hemorrhage occurs, you may need to manually remove the placenta. Insert your hand through the vagina into the uterus and grasp the placenta. Gently remove it.
Immediate Post Partum Hemorrhage
This is generally caused by the uterus failing to contract. After manually exploring the uterus to make sure no placenta was left inside, manually massage the uterus to encourage it to contract. Give Oxytocin (10-20 units in 1 L crystalloid) or ergotamine 0.2 mg IM.
Post Partum Hysterectomy
This is performed for uncontrollable hemorrhage. Typically, this is a supracervical hysterectomy. By staying well away from the bladder, these hysterectomies usually go quite well.
Unruptured Ectopic Pregnancy
A woman with an unruptured ectopic pregnancy may have the typical unilateral pain, vaginal bleeding, and adnexal mass described in textbooks. Alternatively, she may have minimal symptoms. The pregnancy test is positive. For all practical purposes, a negative sensitive pregnancy test rules out ectopic pregnancy.
Patients with a positive pregnancy test and unilateral pelvic pain or tenderness may have an unruptured ectopic pregnancy and should have an ultrasound scan to confirm the placement of the pregnancy.
Alternative diagnoses which can cause similar symptoms include a corpus luteum ovarian cyst commonly seen in early pregnancy, or occasionally appendicitis. PID is characterized by bilateral rather than unilateral pain. With a threatened abortion, the pain is central or suprapubic and the uterus itself may be tender.
While awaiting OB/GYN, the following are wise precautions:
- Keep the patient on strict bedrest. The patient is less likely to rupture while lying still.
- Keep a large-bore IV in place. If the patient should suddenly rupture and go into shock, you can respond more quickly.
- Know the patients blood type and have a plan for possible transfusion.
The jostling over rough roads in an ambulance or other transport may provoke the actual rupture. Try to minimize this risk and be prepared with IV fluids, oxygen, etc.
If the patient develops peritoneal symptoms, the rupture may have started and you should react appropriately.
Ruptured Ectopic Pregnancy
Women with a ruptured ectopic pregnancy will nearly always have pain, sometimes unilateral and sometimes diffuse. Right shoulder pain suggests substantial blood loss. Within a few hours (usually), the abdomen becomes rigid, and the patient goes into shock. Serum pregnancy tests are positive.
Treatment is immediate surgery to stop the bleeding. If surgery is not an available option, stabilization and medical transport should be promptly arranged. While awaiting medical transport:
- Give oxygen, IV fluids and blood according to ATLS guidelines.
- Keep the patient at absolute rest.
- Monitor urine output hourly with a Foley catheter and take frequent vital signs to detect shock.
If abdominal surgery is not an available option, the outlook for a patient with a ruptured ectopic pregnancy is not totally bleak. Aggressive fluid and blood replacement, oxygen and complete bedrest will result in about a 50/50 chance of survival. If this approach is necessary:
Maintain the urine output between 30 and 60 ml/hour.
If the pulse is >100 or urine output <30, more fluids.
If the patient becomes short of breath and the lung sounds become “crackly,” slow down the fluids as the patient probably is becoming fluid overloaded.
If there is shortness of breath and the lungs sound dry, increase the fluids and give blood as the patient is probably anemic and in need of more oxygen carrying capacity.
As the blood into abdomen increases, the patient will become distended. If the patient becomes so distended she can’t breath, put a chest tube into the abdomen through a small, midline incision just below the umbilicus to drain off fluid or blood so she can breathe.
The patient may require as many as 15 or 20 units of blood.
Back to Obstetrics and Gynecology
See also Emergency Hysterectomy