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for marking Posted by narmin B.
A 30-year-old multiparous woman is bleeding heavily following your management.
spontaneous vaginal delivery of a twin pregnancy. There are no genital tract lacerations and the placentas are complete. Justify

This is a case of atonic uterus and quick and effective approach is necessary. Resuscitation is the first step. Patient should be placed in a trendlenburg position in order to facilitate venous return. Two large bore canullaes should be inserted and infusion of intravenous fluids should be started. Hartmann and normal saline are the first choices as they expand blood volume and prevent severe hypotension and renal failure. Blood should be taken for group and cross match of 4 units of blood. Consultant obstetrician, anaesthetist and haematologist and blood bank and senior midwife and porters should be informed. Bladder should be catheterised as full bladder can prevent uterine contraction and also urinary output should be documented. Uterotonic agents such as syntocinone and ergometrine and syntocinon infusion and rectal misoprostol should be given for uterine contraction. Rubbing up of the uterus helps the uterus to contract firmly. If these measures were unsuccessful, patient should be transferred to the theatre and bimanual massage should be performed. Intra uterine balloon can be inserted for compression on the uterine sinuses and if bleeding continues, uterine artery embolisation should be considered if practical. It blocks uterine arteries and is less invasive than hysterectomy. Laparotomy and bilateral hypogastric ligation or B-Lynch brace suture can be considered if bleeding continues. Hysterectomy with conservation of ovaries is another option in massive bleeding. Blood transfusion should be started as soon as possible in case of heavy bleeding to replace blood loss and prevent complications of hypovolemia. Disseminated intravascular coagulation can happen in massive bleeding and fresh frozen plasma and platelet transfusion should be considered if necessary. All procedures should be documented and patient should be seen and all the events should be explained in an appropriate