Emergency Peripartum Hysterectomy

Abstract

Uterine atony is a major cause of postpartum hemorrhage (PPH), an emergency event that remains one of the leading causes of maternal morbidity and mortality worldwide. This study reviews a case of severe atonic PPH after a primary cesarean, which resulted in an emergency peripartum hysterectomy. In the United States, prevalence studies have revealed a peripartum hysterectomy rate of almost 1 per 1,000 births. Multidisciplinary collaboration using effective communication is needed when responding to the severity of Stage 3 PPH. A 28-year-old woman, gravida 3 para 0, at 40.0-weeks gestation arrived at the labor and delivery unit in active labor. During labor, she received oxytocin augmentation and an epidural. Cervical dilation progressed slowly, with the patient remaining at 9.5 cm for 5 hr. On complete dilation, the patient pushed for 1.5 hr before the decision was made to proceed with a cesarean due to failure of the fetus to descend and maternal exhaustion. After the successful birth of a 4,042-g newborn by cesarean, persistent uterine atony developed. Interventions were then enacted, guided by the California Maternal Quality Care Collaborative Obstetric Emergency Management Plan. Additional staff arrived in operating room to provide support. Multidisciplinary teamwork was achieved through use of effective communication techniques, including situation–background–assessment–recommendation and closed-loop communication. Pharmacologic interventions included the use of oxytocin, misoprostol, methylergometrine maleate (×2), and carboprost tromethamine (×2). Procedural interventions by the physician included bimanual uterine massage, uterine packing, B-Lynch suture, and intrauterine balloon tamponade. Maternal hypotension and tachycardia developed, leading to the initiation of the massive transfusion guidelines. Despite interventions, severe uterine atony and brisk vaginal bleeding continued, resulting in a total quantitative blood loss of 4 L. The decision was made to proceed with an emergency peripartum hysterectomy. Postpartum emotional support was provided by a multidisciplinary team that included nursing, physician, chaplain, and social services. The mother and her newborn were discharged home on Postoperative Day 4. This case study demonstrates the success of quickly initiated PPH protocol interventions that are necessary to prevent maternal mortality and knowing the current literature on risk identification, management, and treatment of severe PPH.