Snapshot A 17 year-old woman, gravida 1, now para 1, just underwent a spontaneous delivery of a 4200 g (9 lb 4 oz) male with Apgar scores of 8 and 9 at 1 and 5 minutes. Onset of regular contractions were at noon. The delivery took place 8 hours later. She received IV oxytocin for the last 5 hours of delivery. After the placenta was delivered, she experienced postpartum hemorrhage estimated at 1200 ml of blood. Introduction Defined as the loss of > 500mL of blood within the first 24 hours after delivery 1000ml with cesarean Usually occurs immediately after the delivery of the placenta Five most common causes are uterine atony (most common) genital track trauma (lacerations) retained placental tissue uterine inversion coagulation disorder Uterine Atony Normally uterus contacts and compresses down on spiral arteries Uterine atony defined as a boggy and enlarged uterus Causes 90% of postpartum hemorrhages Risk factors include multiple gestations hydraminos multiparity macrosomia previous h/o postpartum hemorrhage fibroids magnesium sulfate general anaesthesia prolonged labor amnionitis Diagnosis by palpation of a soft, flaccid, boggy uterus without a firm fundus Treatment includes first give bimanual uterine massage to stimulate contractions resuscitate with IV fluids and transfusions Medical treatment oxytocin infusion IM methergine prostaglandins if patient is not hypertensive or asthmatic If refractory surgical ligation of uterine artery arterial embolization hysterectomy Genital Track Trauma Risk factors include precipitous labor operative vaginal delivery (forceps, vacuum extraction) Laceration greater than 2 cm are repaired surgically Retained Placental Tissue Occurs when separation of placenta from uterine wall or expulsion of placenta is incomplete Risk factors include placenta accreta, increta, percreta preterm delivery placenta previa previous cesarean prior uterine curettage uterine leiomyomas Diagnose with careful inspection of the placenta for missing cotyledons Ultrasound may also be helpful Treat with manual removal of the retained placental fragments curretage with suctioning with special care not to perforate the uterine fundus In cases of placenta accreta, increta, percreta, where the placenta villi has invaded into the uterine tissue, hysterectomy is often required as a life saving procedure Coagulation Disorders DIC associated with severe preeclampsia amniotic fluid embolism placental abruption