Predisposed risk for retained uterine products includes history of previous curettage, cesarean section, multiple births or endometrial infection or

injury [15]. If the placenta has not been delivered within 15-30 minutes of childbirth or in cases suspicious for retained placental fragments, the placenta must be retrieved [7]. Golan and colleagues, 1983 [15], showed success of medical management by injecting 10 IU of oxytocin directly into the umbilical vein. Providing bleeding cessation in 10 of 10 patients treated for PPH due to delayed (>30 min) expulsion of placenta. If this umbilical vein injection is bypassed, or not successful, adequate regional anesthesia or general anesthesia should be ensured; current hemostatic parameters should be reassessed with cross-matched blood available, broad spectrum antibiotics administered and an oxytocin drip (40 IU oxytocin in 500 mL of 0.9% saline, at 125 Cyclosporin A nmr mL/hr) should be started before attempting to remove retained uterine products. The best way to remove retained products is to approach transvaginally, finding the plane between the placenta and uterine wall then gently separate the placental parts from the uterus sweeping the surgeon’s AZD1480 datasheet fingers in a side-to-side motion. After this has been completed, the uterine cavity should again be checked to ensure it is empty [11].

Injuries to the genital tract may produce severe bleeding, a quantity that may be unexpected to the inexperienced. Optimal repair includes correct positioning of the patient to allow for adequate vision and access of surgical instruments. In order to gain effective control of the bleeding, the injured area should be sutured, starting at the apex of the tear. If the apex cannot be reached, the suture should be started as close to the apex as possible, then, once the remainder of the tear has been approximated, place traction Resveratrol to reach the previously hidden apex. If there is extensive trauma to the vaginal wall, with multiple lacerations, Compound C price bruising and oozing repairs, vaginal packing to provide hemostasis should be placed and maintained for 12-24 hours [11]. Vaginal

packing consists of gauze tape, roller gauze or gauze 4 × 4′s that are tied end to end, placed loosely at first, then more tightly in subsequent layers using a ring or dressing forceps to create a mass the size of a softball. It is important to ensure foley catheter has been placed to allow an outlet for urination in addition to monitoring of urine output [16]. Failure of Hemorrhage Control If postpartum hemorrhage has not been controlled at this point the patient should be emergently moved to the labor and delivery OR suite, notifying the anesthesia provider, the blood bank (of the possibility for massive transfusion protocol) and the following staff, if available: Staff General/Trauma surgeon, senior general surgery residents, the patient’s nurse and any available nurse’s assistants.