A 32-year-old woman is brought into the delivery suite by ambulance 6 days following a vaginal delivery at 39 weeks’ gestation. The pregnancy and labour had been unremarkable and the placenta was delivered by controlled cord traction. Following delivery the woman had been discharged home after 6 h. She reported that the lochia had been heavy for the first 2 days but that it had then settled to less than a period. However today she had suddenly felt crampy abdominal pain and felt a gush of fluid, followed by very heavy bleeding. The blood has soaked through clothes and she had passed large clots, which she describes as the size of her fist. She feels dizzy when she stands up and is nauseated.
Examination
She is pale with cool and clammy extremities. She is also drowsy. Her blood pressure is 105/50 mmHg and heart rate is 112/min. On abdominal palpation there is minimal tenderness but the uterus is palpable approximately 6 cm above the symphysis pubis. Speculum examination reveals large clots of blood in the vagina. When these are removed, the cervix is seen to be open.
Questions
• What is the diagnosis?
• What is your immediate and subsequent management?
• Should an ultrasound scan be requested?
Secondary PPH
Cause- Retained Bits of Placenta/ Atonic Uterus
Manual exploration of uterus under GA.