What is included in the physical exam to evaluate postpartum hemorrhage (PPH)?

Updated: Jan 02, 2018
  • Author: Maame Yaa A B Yiadom, MD, MPH; Chief Editor: Bruce M Lo, MD, MBA, CPE, RDMS, FACEP, FAAEM, FACHE  more...
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Answer

As mentioned earlier, patients with postpartum hemorrhage (PPH) should be managed like all emergency department resuscitation situations, with the history and physical examination occurring simultaneously while following acute life support algorithms.

The physical examination should focus on determining the cause of the bleeding. The patient may not have the typical hemodynamic changes of shock early in the course of the hemorrhage due to physiologic maternal hypervolemia.

Important organ systems to assess include the pulmonary system (evidence of pulmonary edema), the cardiovascular (heart murmur, tachycardia, strength of peripheral pulses), and neurological systems (mental status changes from hypovolemia).The skin should also be checked for petechiae or oozing from skin puncture sites, which could indicate a coagulopathy, or a mottled appearance, which can be indicative of severe hypovolemia.

Looking for occult postpartum hemorrhage—in the form of a pelvic, vaginal, uterine, or abdominal wall hematoma, or intra-abdominal or perihepatic bleeding—is always an important consideration when unstable hemodynamic findings are present without evidence of excessive vaginal blood loss.

Having a gynecologic examination bed is helpful but not necessary. The patient's pelvis can always be elevated on an inverted bedpan (thick-side toward the patient's feet) cushioned with towels and a sheet for comfort.


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