ROBERT L. BARBIERI, MD (EDITORIAL, JULY 2012)
In his July editorial, Dr. Robert L. Barbieri observed that postpartum hemorrhage is a common—and sometimes deadly—obstetric complication and advocated routine use of a uterotonic to reduce this risk. He also invited pearls from readers—and you happily provided them, thank you! Here, we present a collection of your suggestions and the rationales behind them. As Dr. Barbieri notes in response to these letters, the readers of OBG Management have once again demonstrated broad and deep knowledge of an important clinical issue.
Be vigilant for retained placental products
Thank you for the very comprehensive article concerning postpartum hemorrhage. I have worked in many parts of the world and have found it to be a universal problem, especially in places where nonhospital birthing practices are common.
One thing that I have found to be very practical and productive, when I am faced with postpartum hemorrhage, is to promptly evaluate and inspect the uterine cavity for any retained products of conception using a large placental curette. I place one hand on the uterine fundus and gently pass the curette into the cavity. In a matter of 30 to 60 seconds, in a systematic fashion, I evaluate and curette the cavity in a clockwise (or counterclockwise) manner. I then withdraw the curette and begin vigorous uterine massage.
We have all encountered retained products of conception and are acutely aware of how their presence and persistence can alter the success of treatment protocols for postpartum hemorrhage.
Jim Alonzo, MD
New Plymouth, New Zealand
Timing of oxytocin administration is important
Proper use of a uterotonic such as oxytocin can reduce the risk of postpartum hemorrhage and diminish the impact of one of the major causes of maternal mortality, as Dr. Barbieri pointed out. About 40 years ago, I was taught how to use oxytocin properly: Upon delivery of the anterior shoulder, stop the delivery, preventing further exit of the baby. During this interval, suction the baby and administer a prompt bolus of intravenous (IV) oxytocin. Then allow the delivery to proceed slowly, so that the uterus shrinks in volume and permits shearing and separation of the placenta. This approach has served me well as it helps avert a trapped placenta and uterine atony.
I never pull out a placenta that is resistant, unless it is just sitting in the vagina. If the delivery has been managed properly and the placenta does not follow, there is probably a reason, such as placenta accreta.
When placenta accreta does occur, my aim is not to disturb the placenta, which would cause further bleeding. Instead, I pack the uterus and administer methotrexate and an antibiotic to prevent hemorrhage and infection and to preserve the uterus for future pregnancy.
Stefan Semchyshyn, MD
Jonesborough, Tennessee
Give oxytocin upon delivery of the anterior shoulder
I have given 10 U of oxytocin, when possible, upon delivery of the anterior shoulder ever since my training in 1968. I teach the same approach to all students and residents. It helps when I explain the rationale behind the intervention—physicians are more likely to comply. I have found that nurse midwives use oxytocin regularly, with great success, but not all doctors do.
Gabriel F. Nassar, MD
East Point, Georgia
Turn on the lights!
I appreciate Dr. Barbieri’s editorship of such a consistently high-quality publication over the years!
My clinical pearl for postpartum hemorrhage: First, turn on the lights!
I have had the experience of being called to see a patient because of concerns about vital signs—usually unexplained tachycardia—only to find the room lights lowered for “bonding” and a large amount of blood on the bed, visible only with adequate lighting. So, “turn on the lights” is my first order.
Maurice Druzin, MD
Stanford, California
Oxytocin may help in some cases, but routine use isn’t warranted
Although I appreciated many aspects of Dr. Barbieri’s editorial, I am opposed to the “routine” use of anything in medicine. For postpartum hemorrhage, it pays to be aware of the variables that can cause it, to be prepared, and to manage the patient accordingly. I massage the uterine fundus well immediately after placental delivery.
Alfred L. Franger, MD
Brookfield, Wisconsin