Thread by @imacuriosguy

My experience with Atonic PPH:
Can write this with a bit of conviction and confidence after spending years tending to postpartum uteri.
The traditional teaching is empty uterus ceases to bleed. Meaning we have been taught to clear out everything from it......

Placental fragments, membranes, and clots. Fine. But when faced with Atonic PPH, I changed my tactic which is counter intuitive. After a vaginal delivery, if the PPH is present, I institute all the usual measures like uterotonics- methergin, syntocinon, PG's.....

Once in control and if I don't see alarming flow with fairly contracted uterus, I simply let go. Do not keep on digging out/expel the clots from uterus. Clots are our friend. Nature is trying to help us. Once we dislodge them, fresh bleeding will ensue, continuing the cycle...

Continue close monitoring with NIBP, urine output with S/R catheter and vaginal blood loss. Keep patient on the bed for atleast 12-18 hours. I call the patient next day in my office for ultrasound. I know the uterus was full of clots....

Most of the times the clots resolve the next day when I put the probe on the uterus. So this natural packing offered for free by nature aided by tranexaminc acid injection should be fully utilized.
My adage is don't touch the reasonably contracted uterus full of blood clots..

I am talking only of blood clots. Ofcourse you have to evacuate the plac fragments/membranes.
Trust me I have never have to comeback again for second bout of bleeding pv after this regime.
In C-section, if I detect atony, I simply do not allow blood loss...

Simply compress the uterus anteropost and ask assistant to massage while instituting uterotonics and tranexamic acid. I give TA preop in all pts. If within 10-15 minutes the uterus refuses to cooperate, I just put 2 modified B lynch sutures with 3inch straight needle. That's it..

Luckily only once I had to ligate the uterines. Never had to do a hysterectomy.
I have a non pneumatic antishock garment(NASG) for PPH. It gives you time for resuscitation and is a life saver for the patient. Always overestimate the bloodloss despite the natural tendency not to..

Start fluids aggressively at the first sign of PPH. Most of the young patients will tolerate slight overload very well. Call and shout for HELP.
Make a protocol and SOP in your labor room.
Conduct regular drills with NASG.
and lastly CONSIDER BLOOD CLOTS IN UTERUS your ally..

This thread may seem absurd. But it has withstood the test of time and experience. So in next atonic pph, keep your mind at zen level and institute this.
Never panic during PPH.
Thank you for patient reading. Questions are welcome.
P.S : never needed balloon catheter for packing

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