Peripartum hysterectomy is a major surgical endeavor often performed in the setting of life-threatening hemorrhage. It involves removal of the uterus following either vaginal delivery or cesarean delivery when conservative management of postpartum hemorrhage has failed or is contraindicated. The incidence of emergent peripartum hysterectomy ranges from 0.24 to 8.7 per 1000 deliveries.[1] Abnormal placentation is the most common indication for peripartum emergent hysterectomy, accounting for 45% to 73% of cases, followed by uterine atony and uterine rupture.[1] OB/GYN hospitalists possessing knowledge and skills pertaining to peripartum hemorrhage can be a life-saving resource for labor and delivery units.

Knowledge

OB/GYN hospitalists should be able to:

• Define postpartum hemorrhage.
• List causes of postpartum hemorrhage and their risk factors.
• Describe the pathophysiology of uterine atony, abnormal placentation, disseminated intravascular coagulation, and hemorrhagic shock.
• Discuss the evaluation of postpartum hemorrhage and management plans for each possible etiology.
• List the most common indications for peripartum hysterectomy.
• List relative contraindications to peripartum hysterectomy.
• Describe the specific types of hysterectomies and the rationale for performing one over another.
• List blood products that should be readily available when performing a peripartum hysterectomy.
• Discuss the use of uterotonics and antifibrinolytics in peripartum hemorrhage.
• Explain the pertinent preoperative preparation for patients at risk for hysterectomy, for those undergoing planned postpartum hysterectomy, and in the setting of emergent hysterectomy.
• Discuss the most common intraoperative and postoperative complications of peripartum hysterectomy and their management.
• Explain the postoperative care after a hysterectomy.

Skills

OB/GYN hospitalists should be able to:

• Identify patients at risk for peripartum hysterectomy and develop a delivery plan.
• Quantify blood loss.
• Diagnose peripartum hemorrhage, identify the etiology, and apply a stepwise, evidence-based approach to management.
• Activate massive transfusion protocols and identify transfusion risks.
• Determine when emergent hysterectomy is indicated and promptly mobilize resources to minimize morbidity.
• Obtain informed consent for peripartum hysterectomy and blood transfusion.
• Stabilize patients with intravenous fluids, blood products, and tamponade while preparing for hysterectomy.
• Perform and assist in peripartum hysterectomy.
• Diagnose and manage intraoperative complications such as bowel injury, cystotomy, and ureteral injury and engage consultants as appropriate.
• Manage the postoperative course in conjunction with critical care and/or internal medicine as needed.
• Diagnose and manage postoperative complications such as ileus, fever, sepsis, and wound infection and engage consultants as appropriate.
• Arrange appropriate and timely follow-up for the patient and ensure accessible outpatient postoperative evaluation.
• Explain the value of avoiding a primary cesarean delivery to decrease the risk of abnormal placentation and consequent peripartum hysterectomy.
• In the medical record, document informed consent, the indications for peripartum hysterectomy, and the procedural steps.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Follow evidence-based recommendations when assessing candidates for hysterectomy.
• Collaborate and communicate effectively within a multidisciplinary team, including the patient, nursing staff, operating room personnel, anesthesiologists, gynecologic oncology specialists, urologists, radiologists, blood bank staff, critical care specialists, and primary OB/GYN provider, to ensure a patient-centered and comprehensive response to peripartum hemorrhage and hysterectomy.
• Demonstrate awareness of and ability to address the emotional needs of a patient requiring hysterectomy.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Coordinate efforts to reduce primary cesarean delivery rates.
• Lead, coordinate, and/or participate in the development and use of a comprehensive peripartum hemorrhage management plan inclusive of patients who refuse blood products.
• Lead, coordinate, and/or participate in the development and use of massive transfusion protocols.
• Lead, coordinate, and/or participate in unit-based stimulation drills for postpartum hemorrhage, implement before and after knowledge testing, and track team performance.
• Implement strategies to improve team awareness and education in quantifying blood loss.
• Lead, coordinate, and/or participate in formulating a plan for managing patients with morbidly adherent placentas and other patients at risk for hysterectomy, including establishing relationships with facilities with a higher level of care and developing guidelines and processes for transferring to these facilities when appropriate.
• Implement strategies to maintain surgical skills needed to perform peripartum hysterectomy.
• Implement methods for tracking quality of care related to postpartum hemorrhage to improve outcomes, such as reduction in use of blood products, hysterectomy rate, intensive care unit admission, and length of stay.

References