Managing Complications in Pregnancy and Childbirth: - IAWG

S-34 Vaginal bleeding after childbirthINVERTED UTERUSThe uterus is said to be inverted if it turns inside-out during delivery ofthe placenta. Repositioning the uterus should be performed immediately(page P-91). With the passage of time the constricting ring around theinverted uterus becomes more rigid and the uterus more engorged withblood.• If the woman is in severe pain, give pethidine 1 mg/kg body weight(but not more than 100 mg) IM or IV slowly or give morphine 0.1mg/kg body weight IM.Note: Do not give oxytocic drugs until the inversion is corrected.• 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).• Give a single dose of prophylactic antibiotics after correcting theinverted uterus (page C-35):- ampicillin 2 g IV PLUS metronidazole 500 mg IV;- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.• If there are signs of infection (fever, foul-smelling vaginaldischarge), give antibiotics as for metritis (page S-110).• If necrosis is suspected, perform vaginal hysterectomy. This mayrequire referral to a tertiary care centre.DELAYED (“SECONDARY”) POSTPARTUM HAEMORRHAGE• If anaemia is severe (haemoglobin less than 7 g/dL or haematocritless than 20%), arrange for a transfusion (page C-23) and provideoral iron and folic acid (page S-26).• If there are signs of infection (fever, foul-smelling vaginaldischarge), give antibiotics as for metritis (page S-110).Prolonged or delayed PPH may be a sign of metritis.• Give oxytocic drugs (Table S-8, page S-28).