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Postpartum hemorrhage: Management approaches requiring laparotomy

Michael A Belfort, MBBCH, MD, PhD, FRCSC, FRCOG
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


Postpartum hemorrhage (PPH) is an obstetric emergency with many potentially effective interventions for management (table 1). In patients with PPH who have had a vaginal birth or whose cesarean delivery has been completed, medical and minimally invasive approaches are the preferred treatment approaches; laparotomy is generally a last resort that is performed when less invasive interventions have failed. During cesarean delivery, uterotonic drugs and manual uterine massage and compression are still the initial treatments for bleeding due to atony, but uterine compression sutures and other operative interventions for control of hemorrhage are performed sooner since the abdomen is already open.

This topic will discuss treatment approaches to PPH that require laparotomy. Medical and minimally invasive management of patients with PPH is reviewed separately (see "Postpartum hemorrhage: Medical and minimally invasive management"). An overview of issues related to PPH: incidence, pathogenesis, risk factors, clinical presentation and diagnosis, general principles of planning and management, morbidity and mortality, and recurrence, is also available separately. (See "Overview of postpartum hemorrhage".)


Laparotomy to assess and treat suspected pelvic bleeding is, in the author's opinion, best performed through a vertical midline incision to provide exposure of both the pelvis and abdomen. In patients at or post cesarean delivery, the existing incision is used, and extended if needed to provide adequate exposure.

A self-retaining retractor, such as a Balfour or Bookwalter, provides adequate lateral exposure. A posterior rupture is not readily visualized upon entering the abdomen so the entire uterus needs to be inspected carefully.

At laparotomy, the abdominal cavity is irrigated to remove blood and clots and inspected for the source of bleeding. The source of bleeding is usually readily apparent if pelvic, but may not be immediately recognized when it is retroperitoneal (including vaginal and vulvar hematomas), confined to the uterine cavity after vaginal delivery or after closure of the uterine incision at cesarean, or under surgical drapes. These sites should be actively evaluated in patients with compensated shock (normal blood pressure with increasing heart rate).


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Literature review current through: Jun 2017. | This topic last updated: Jun 30, 2017.
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