How is postpartum hemorrhage (PPH) diagnosed?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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Answer

PPH usually manifests with such rapidity that diagnostic procedures are almost entirely limited to a physical examination of the involved structures.

  • Assessment of uterine tone and size is accomplished using a hand resting on the fundus and palpating the anterior wall of the uterus. The presence of a boggy uterus with either heavy vaginal bleeding or increasing uterine size establishes the diagnosis of uterine atony. The presence of uterine atony and resulting hemorrhage usually prevents the diagnosis of PPH from other causes because of an inability to visualize other sites. For this reason, and because of the rapidity of blood loss secondary to atony, management and control of atony is paramount.

  • If the placenta has been delivered, inspection findings suggest whether portions of it have been retained. If it is undelivered or if retained clots or placental fragments are distending the uterus and bleeding is persisting despite appropriate ongoing treatment, manual exploration and removal should be undertaken. This is simultaneously therapeutic by emptying the uterus and permitting contraction while also aiding in the diagnosis of placenta accreta and uterine rupture. Cervical and vaginal lacerations may also be palpated at this time.

  • If uterine atony has been controlled and bleeding from the uterus is minimal, careful inspection of the lower genital tract reveals bleeding sites in this area. Palpation and inspection may also reveal hematomas that require treatment. The cervix and vagina should be completely visualized following all operative vaginal deliveries.


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