he fundus is always palpated following placental delivery to conirm that the uterus is well contracted. If it is not irm, hemorrhage from atony (Hofmeyr, 2013). Simultaneously, 20 units of oxytocin in 1000 mL of crystalloid solution will of 200 m U / min. Higher concentrations are minimally more efective (Tita, 2012). Oxytocin is never given as an undiluted bolus dose because serious hypotension or cardiac arrhythmias can develop.
In many women with known risks, uterine atony can at least be anticipated well in advance of delivery. In one study, however, up to half of women with atony after cesarean deliveY had no risk factors (Rouse, 2006). The magnitude of risk for atony imposed by each of the factors shown in Table 41-2 varies considerably between reports. Primiparity and high parity are risk factors (Driessen, 2011). In one study, the incidence of postpartum hemorrhage rose from 0.3 percent in women of low parity to 1.9 percent with parity of four or greater. It was 2.7 percent with parity of seven or greater (Babinszki, 1999). The overdistended uterus is prone to hypotonia after delivery, and thus women with a large fetus, multiple fetuses, or hydramnios are at greater risk. Labor abnormalities predispose to atony and include hyper-or hypotonic labor. Similarly, labor induction or augmentation with either prostaglandins or oxytocin is more likely to be followed by atony (Driessen, 2011). he frequency of hemorrhage increases with prolongation of the third stage (Frolova, 2016). Finally, the woman who has had aprior postpartum hemorrhage is at risk for recurrence.
With immediate postpartum hemorrhage, careful inspection is done to exclude birth canal laceration. Because bleeding can be caused by retained placental fragments, inspection of the placenta after delivery should be routine. If a defect is seen, the uterus should be manually explored and the fragment removed. Occasionally, retention of a succenturiate lobe may cause postpartum hemorrhage (Chap. 6, p. 112). During examination for lacerations and causes of atony, the uterus is massaged and uterotonic agents are administered.
Several compounds can prompt the postpartum uterus to contract (Chap. 27, p. 527). One of these is routinely selected and given to prevent postpartum bleeding by ensuring uterine contractions. Nfost of these same agents are also used to treat uterine atony with bleeding. Moreover, because many trials combine results from atony prophylaxis and treatment, their evaluation is problematic. For example, oxytocin has been used for more than 70 years, and in most cases, it is infused intravenously or given intramuscularly after placental delivery. Neither route has been shown to be superior (Dagdeviren, 2016). his or other utero tonics given prophylactically will prevent most cases of uterine atony.