Managing Complications in Pregnancy and Childbirth: - IAWG

Vaginal bleeding after childbirthS-33Note: Avoid forceful cord traction and fundal pressure as they maycause uterine inversion.• If controlled cord traction is unsuccessful, attempt manual removalof placenta (page P-77).Note: Very adherent tissue may be placenta accreta. Efforts toextract a placenta that does not separate easily may result in heavybleeding or uterine perforation which usually requireshysterectomy.• If bleeding continues, assess clotting status using a bedsideclotting test (page S-2). Failure of a clot to form after 7 minutes or asoft clot that breaks down easily suggests coagulopathy (page S-19).• If there are signs of infection (fever, foul-smelling vaginaldischarge), give antibiotics as for metritis (page S-110).RETAINED PLACENTAL FRAGMENTSThere may be no bleeding with retained placental fragments.When a portion of the placenta—one or more lobes—is retained, itprevents the uterus from contracting effectively.• Feel inside the uterus for placental fragments. Manual explorationof the uterus is similar to the technique described for removal ofthe retained placenta (page P-77).• Remove placental fragments by hand, ovum forceps or largecurette.Note: Very adherent tissue may be placenta accreta. Efforts toextract fragments that do not separate easily may result in heavybleeding or uterine perforation which usually requireshysterectomy.• If bleeding continues, assess clotting status using a bedsideclotting test (page S-2). Failure of a clot to form after 7 minutes or asoft clot that breaks down easily suggests coagulopathy (page S-19).