Uterine atony remains the leading cause of postpartum hemorrhage, accounting for 70% to 80% of cases.[1] A systematic approach to the evaluation of postpartum hemorrhage aids in a timely and accurate diagnosis. Treatment should begin with less-invasive options, moving to more aggressive treatments as necessary.[2] In rare cases, uterine artery embolization or definitive therapy in the form of hysterectomy may be necessary. While a step-wise algorithm is important, the optimal approach depends on many factors such as route of delivery, severity of bleeding, patient’s desire to preserve fertility, and available resources. OB/GYN hospitalists should be aware and capable of performing procedures to treat atony and should champion system-wide efforts to reduce maternal morbidity and mortality from postpartum hemorrhage.

Knowledge

OB/GYN hospitalists should be able to:

• Identify risk factors associated with uterine atony.
• Describe an algorithm for managing uterine atony.
• Discuss the dosing, mechanism of action, contraindications, and adverse effects of uterotonic medications and antifibrinolytic agents.
• Describe methods for uterine tamponade.
• Explain the techniques for uterine compression sutures.
• Describe the technique for uterine curettage.
• Describe the technique for vascular ligation of uterine arteries.
• Discuss the use of uterine artery embolization for management of hemorrhage due to uterine atony.
• Describe the technique for performing peripartum hysterectomy.
• Identify signs and symptoms of disseminated intravascular coagulation and hemorrhagic shock.

Skills

OB/GYN hospitalists should be able to:

• Quantify blood loss.
• Recognize abnormal postpartum bleeding, perform an examination to diagnose uterine atony, and develop a systematic treatment approach.
• Perform uterine massage and administer uterotonic agents and antifibrinolytic agents appropriately.
• Communicate effectively with patients and families, counsel patients on the risks and benefits of procedures used to treat postpartum atony, and obtain informed consent.
• Perform uterine tamponade techniques.
• Place uterine compression sutures.
• Ligate the uterine arteries.
• Perform postpartum curettage.
• Complete or coordinate an emergent hysterectomy.
• Order and interpret laboratory tests as needed.
• Counsel patients on the risks and benefits of blood transfusion.
• Select appropriate blood components for resuscitation.
• Initiate the emergency response team and massive transfusion protocols when necessary.
• Engage consultants and coordinate a multidisciplinary approach, including the patient, those who support the patient, nursing staff, anesthesiologists, critical care specialists, operating room personnel, maternal-fetal medicine specialists, and primary OB/GYN provider, when indicated.
• In the medical record, document informed consent, the risks and benefits of procedures used to treat postpartum atony, and the procedural steps.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Collaborate and communicate effectively within a multidisciplinary team including the patient, those who support the patient, nursing staff, anesthesiologists, critical care specialists, operating room personnel, maternal-fetal medicine specialists, and primary OB/GYN provider, to ensure a patient-centered, comprehensive response to postpartum hemorrhage due to uterine atony.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead, coordinate, and/or participate in the development and use of evidence-based protocols for the management of uterine atony and postpartum hemorrhage.
• Lead, coordinate, and/or participate in implementing strategies such as unit-based simulation drills and other tools to help OB/GYN providers maintain competency in uterine atony procedures.
• Lead, coordinate, and/or participate in multidisciplinary simulations (including anesthesiologists, laboratory and blood bank staff, nursing staff, and OB/GYN providers), implement before and after knowledge testing, and track team performance.

References