Post-partum Hemorrhage

[RESQDOC]

OK, Post-partum bleeding, or bleeding after delivery. Great question Tangent!!!!!

First of all, what is it? The textbook definition is more than 500cc blood loss, although it has been shown that the average blood loss after an uncomplicated vaginal delivery is often in the 500-600cc range. Also note that vaginal blood loss is consistently UNDERestimated by 50-100% so that if you think you lost 500cc, it’s probably more! Blood loss after delivery is normal in this amount, and assuming that mom was healthy and not severely anemic before delivery is not a problem. Also it is normal for bleeding to continue in small amounts after the delivery, and bloody mucus (lochia) can continue for some time. But continued bright red bleeding, like a heavy period or greater, increasing size of the uterus (womb), etc. is not normal. Post partum hemorrhage accounts for 5% of maternal deaths.

What causes this? Failure of the uterine muscles to contract and close off the connection site of the placenta, lacerations of the cervix (especially anterior lip)-vagina-vulva, retained fragments/pieces of placenta, abnormal location of the placenta during the pregnancy (like all the way into the uterine muscle), rupture of the uterus, inversion/prolapse of the uterus, bleeding disorders & coagulopathies either as a result on inheritance or pre-eclampsia/eclampsia, ruptured fibroids or tumors, or implanted alien space parasites (joke).

The most common is failure of the uterine muscles to clamp down (atony), lacerations especially the cervix, and retained placental fragments.

What can you do? First of all, treat for shock just as you would any hemorrhagic condition. Lay flat, keep warm, IV fluids if available, monitor vitals, etc. MAST units can be considered and have been effective in controlling uterine hemorrhage.

Brief history: Full or pre term, how long was labor, single baby/twins/etc., prior deliveries (vaginal and c-section) and prior bleeding/tears/episiotomies?

This labor: Difficult, shoulder dystocia, hand presentation, nuchal cord, placenta slow or difficult to remove, lots of traction on cord? Pre-eclampsia or signs of abruption?

Mom: palpate fundus, is uterus firm and small, soft and small, or soft and big getting bigger? Use gloves and examine outer vulva & rectum for tears, examine inside vagina for same, examine anterior cervical lip. Bleeding will either be coming from a visible source or out of the cervix & therefor intrauterine. Funniest cause of “post partum hemorrhage” I ever saw – undiagnosed twin still on board!

Placenta: intact, all lobes present and not ripped off as with a retained fragment?

Actions to take: Most important – breastfeed or brisk nipple stimulation!!!! This stimulates the natural production of mom’s own oxytocin – very, very helpful in speeding up the normal process and limiting bleeding.

1. If it is an obvious external or vaginal laceration manage appropriately i.e. repair.
2. If intrauterine start vigorous massage of the uterus after the placenta has delivered. Two handed external massage to start, occasionally a gloved hand inside the vagina is used.
3. Have mom empty bladder as this can interfere with uterine recovery.
4. A Foley catheter can be placed in the lower uterine segment if you think that is the bleeding source, and balloon inflated.
5. Explore inside uterus with gloved hand for retained placenta, inversion, or uterine tear – very painful for mom if no anesthesia & infection risk.
6. Ice water lavage may help slow bleeding – do just like enema.
7. Uterine packing with sterile material, controversial some feel this actually prevents muscles from clamping down but I would do if no other option. Technique dependant. Do NOT leave in place more than 6-12 hours as toxic shock risk develops.
8. Medications – oxytocin, methergine, carboprost produce vasoconstriction.
9. Dilatation & Curettage or frank surgical exploration and possible ligation of arteries or hysterectomy.
10. Pray. This can be scary at times.

Anything other than a simple repair job should be covered with antibiotics due to high infection risk. Remember that maternal deaths after delivery went down 90-95 % after we started washing our hands before delivering a baby!

Two herb/plant sources are know to be used by those familiar with them: Ergot (Claviceps Purpurea) and Broom (Cytisus Scoparius). I have NO experience using these and cannot discuss them intelligently or recommend them, but have been told about them. Anyone with practical experience, please share.

Most bleeding will be controlled with patience, avoiding panic, repair as indicated, ensuring no retained placenta fragments, thorough uterine massage, and breastfeeding.

“A Book for Midwives” by Susan Kline, Hesperian Foundation 1995 is the best single source of info on delivery, problems, newborn care. Don’t be fertile without it!

Later,

Keith

[tangent]

Fantastic reply! - thank you.

Deffinantly have some questions, will get back w/ you.

thanks!

[tangent]

OK, sorry to take so long on a reply to this.

there were a couple of rather surprising facts in there - that blood loss is under-estimated (usually it's over-estimated) and that only 5% of maternal deaths were caused by it. I was under the impression that the % was considerably higher. So what's the causes and breakdowns (%) of the other 95% of maternal deaths? (eclampsia, I thought was very rare and the only other cause of maternal death I can think of, well, untreated infection, again rare now a days.). OH WAIT! - I'd totally forgotten about implanted alien space parasites, that's a *BIG* problem out in the mid-west, isn't it? ;-)

As to causes, most of that was new to me. I've seen diagrams of normal placental attachment and separation, but nothing as to it's abnormal location of placenta, inversion/prolapsed of uterus, etc. And why lacerations only on the anterior lip of the cervix? - do kids like to bite on their way out? :smile: Anyway, if you could flesh out what's normal and abnormal and why in an A&P type discussion, that should help. One paragraph was a little concise. (but VERY interesting!).

brief Hx and this labor: and the answers to each of those questions has what diagnostic significance?

on palpating the fundus(3 to 4 finger widths distal to the sternum?): I think small and firm is good - the uterine muscles are contracting and placenta has separated correctly. Soft and small - maybe you still have some attached placenta and/or minor bleeding and the uterine muscles aren't contracting? Soft and large: No contraction and massive internal hemorrhage (OR) you haven't delivered the placenta yet? - I don't know, just guessing there - what's correct? They never trained us in that and even Carolines paramedic txt seems to skip it.

How do you tell if the placenta is intact and all lobes are present? I'm guessing it's going to look torn vs smooth if they aren't, but how many lobes are there supposed to be and do individual lobes separate cleanly, giving an intact, untorn appearance?

Very interesting about brisk nipple stimulation (though I imagine that it could get you arrested in some townships ;-) It's been some years since I read it, but Ima Gaskins book, Spiritual Midwifery talks getting the husband/mate/SO to sensually stimulate the mom in order to get her to relax and make birth easier, but this is pre, as opposed to post birth. The effects of flooding the system w/ oxytocin earlier as a side effect might be worth looking into. Might be worth contacting the farm and asking if they have kept any records of post-partum bleeding or blood loss during delivery when this has been done. Even a senior midwives impressions would be interesting.

on Tx options:
2) this does what? encourages muscles to contract or breaks free any pieces of placenta still attached?
on 4-7) how do you get inside the uterus? - I've always thought of it as a very sensitive one way valve. Definitely not designed to be entered.
4) I'm guessing a 30cc balloon,
5) hard to imagine how you could tell the difference if you felt something. and what would you do about it if you found it? anesthesia - what kind?
6) in uterus or vagina? Isn't cooling the core of the body going to produce a shock reaction, constricting vessels in limbs and increasing the heart rate in an attempt to warm the core and hence increasing the pressure at the site of blood loss?
7) technique dependent?
:cool: could we get a short lecture on different types of vasoconstrictors? is methergine the same as methyrgometrine? there is also ergometrine. Have never heard of carboprost but the former all have serious stability issues, esp at elevated temperatures.
9) can you define "frank", I've seen it in reference to bleeding - bright red oxegenated blood, but never seen an explanation of "frank surgical exploration", though I have seen the phrase used a few times.
10) I agree! - very scary!

one you didn't address, was how you repair anterior cervical lip damage. actually several - prolapsed uterus, not clear which Tx would be for retained pieces of fetus in the uterus - guessing massage, D&C, and exploration.

overall, very interesting! - way beyond what they taught us. thanks!

[tunneldiver]

I don't have medical knowledge to add, but do have personal experience that might help. One week after having c-section, I started bleeding heavily (enough to soak one pad every half hour or so) Pregnancy had been complicated by preeclampsia (gaining approx 20 pounds in two weeks prior to delivery).

I contacted LaLeche buddy who suggested continuous Breastfeeding, after an hour or two of continual bleeding I called and was advised to go to ER. I was having painful contractions amplified of course by fear. I was prepped for a transfusion (which did not become necessary) given morphine for pain, and had very vigorous massage. I sat on commode while nurse rubbed her fist into my uterus until I passed an orange/grapefruit size mass. I was weak, but felt instant "relief".

I am sorry to not have a more detailed medical account, I do recall the MD, on initial exam, asking if I had douched recently. I had not, but I was expelling a lot of fluid. In the month around the birth, my weight changed 60 pounds, I gained 20# two weeks prior, and lost 40# two weeks after birth. Major swelling!!

I am not sure what the medical reason for this happening, since I had the c-section, I feel confidant that the placenta was removed intact. Perhaps the uterus was so distended by fluid it was unable to contract correctly. During my second labor, my uterus began to tear and another section was needed.

I thought that maybe my account would help testify to the massage component of treatment. I do not believe that I was given any "contraction stimulating drugs", since I was contracting very well on my own. I was still pretty aware of the treatment approach, and other than the morphine, do not think that I was given any meds.

[RESQDOC]

EXCELLENT f/u questions. Yes, much brevity in the 1st post, due to both time constraints and need to get a structure in place to work off of. I'll reply as time allows, on call today, so check back as I will paste into this answer.

Several studies and practical experience have shown that the amount of blood lost during delivery is frequently underestimated, ref. On-Call OB/GYN, a couple of texts I don't have in front of me at the moment, and several joural articles over the years. We always play "guess the blood in the bag" with our students and nurses to see how much blood we have recovered in our drip catcher. It takes a lot of experience to come close, about a 50% undershoot is very typical. And of course this doesn't recover blood in 4x4's, pads, etc. We, as in the profession, have pretty much quit offering specific estimates of blood loss at a delivery 'cause it's so subjective and just estimate "less than 500cc" or "more than 500cc" blood loss, which is much more functional in terms of how moms do post partum. Mom's blood volume increases 30-40% during pregnancy as protection against delivery blood loss.

Maternal deaths vary by setting. In the US PP hemorrhage accounts for perhaps 5%. In underdeveloped settings perhaps 15-18%. Actual numbers really are meaningless as every study comes up with different ones. In the US maternal deaths result from amniotic fluid embolism, cardiac failure, reespiratory failure, hypertension/ eclampsia, anesthesia, and of course hemorrhage. Cardiac, respiratory, and eclampsia accounts for the majority. In developing countries obstructed labor (failure to progress, dystocia, etc.) with uterine rupture, hemorrhage, eclampsia, and infection are the big killers. See:

Maternal mortality in developing countries. An ongoing but neglected 'epidemic'.
Rosenfield A - JAMA - 21-Jul-1989; 262(3): 376-9

for a pretty good article, there are others. Note that many of the deaths from above in these underdeveloped countries are a result of do it your self village abortions. The article uses the term "illegal" but in my experience overseas the patients poverty and availability of health care resources has a lot more to do with it than local laws, FYI. I have no interest in a discussion of abortion here, so nobody start one, I mean it.

I think that in a low tech routine delivery setting with limited resources available i.e. no surgical capability that my greatest fears are undeliverable postions/dystocias, hemorrhage, and infection. Solutions? Training, knowledge, practice, experience, prayer, luck. More later.

*****
OK, more on causes. First, birth trauma lacerations. The anterior lip of the cervix is generally that last part of the cervix to stretch out, and in some cases has not completed dilating when the baby is delivered past it, resulting in tears. This can happen anywhere on the cervix but 90%+ are anterior lip. They bleed like stink. They need careful evaluation & need to be sutured, the tissue is too wet to glue. Often we will place a long suture into the
cervix and use that for traction to pull it forward for ease of repair. It is best sutured from the base of the lac out to the edge of the lip. Anesthesia is needed, either local or cervical block. Ditto other lacerations. Perineal/epis lacerations can be rather complicated, rectal sphincter & rectal Even more so. Lacerations are graded as 1st, 2nd, 3rd, 4th. 1st are “skid marks” shallow little tears that almost never need repaired, or can be glued with great success. They heal fast, usually only sting a bit the first day or so. 2nd degree tears
are into the body of the muscles and through the exterior skin. Some women opt not to
have these repaired, I am not in favor of this as they heal slowly, are more prone to
infection, and if the wrong muscles are involved can lead to inadequate function, difficulty with bowel movements, etc. later. Very small shallow 2nds could be glued or skin could be glued after all deeper muscles are stitched to obliterate dead space & reapproximate appropriately. 3rd degree lacerations involve the rectal sphincter muscles, either a partial or full tear. This is serious, as inadequate repair may lead to incontinence. Special suturing techniques are used, then the associated 2nd is repaired in standard fashion. 4th degree
tears are through the rectal sphincter all the way in to the rectal vault. These are quite serious, with a high potential for infection and occasional development of fistulas (unclosed tracts that reflect abnormal healing process and can be very difficult to get healed) between the rectum and vagina. Special repair techniques for these also, along with significant post-partum limitations for weeks to allow healing. One could argue for a 5th degree category as well, involving the rectal mucosa on the opposite side of the
rectum, very bad. Lacerations can also involve the urethra, healing can be a problem and careful repair around a catheter is needed. Repair skills are needed if planning on “doing” OB, I teach it in my OB classes. The Midwife book already cited is the place to start. Surgical Obstertrics by Plauche and Atlas of Obstetric Technique by Wilson (?out of print? excellent illustrations) are good, as is Obstetrics by Gabbe (best general purpose medical level text).
More later.

*****
OK, next is uterine inversion/prolapse. Inversion means that the fundus, the upper portion of the uterus, has been pulled down into the body of the uterus, like it’s turning inside out, although it doesn’t make it all the way. If it makes it out the cervix, it’s a prolapse, partial or complete. Management by placing your gloved hand inside the vagina and pushing back
through the cervix back into normal position, then packing, in combination with uterine muscle relaxants such as terbutaline, and avoiding use of oxytocin, etc., until back in place. Goes pretty easy unless you wait too long and let the cervix and lower uterine segment muscles contract, then you’ve got a problem. The cervix and lower segment stay soft & floppy for minutes to hours after delivery, so getting your entire hand into the uterus is not a problem. Otherwise, surgery.

Placenta can have three contributions to post-partum hemorrhage, retained fragments,
abnormal position inside the uterus, abnormal attachment to the uterus. Retained
fragments or sections of the placenta are more likely in those who have had several prior deliveries, surgery of the uterus (especially D&C), over term, smokers. The placenta is made up of many small segments, which sometimes do not separate from the uterine wall and stay attached when the rest of the placenta comes off. The circulation through this segment continues to bleed, often heavily. It can also serve as a source of infection later. Management starts with examining the placenta to see if any segments seem to be missing. The baby side of a placenta is smooth, the uterine side is rough, looks like meatloaf only firmer, no set number of segments or lobes, but a missing piece is usually obvious unless
quite small. Once you’ve seen one, you’ll know. If a piece seems to be missing, or if
bleeding with no other source, manual examination of the uterus will be required. With sterile gloved hand reach all the way up into the uterus, other hand outside on anterior abdominal wall, feel entire inside surface of uterus for retained fragments, tears, etc. If you find a retained fragment it can usually be peeled off with fingers. Sometimes a sterile gauze pad wrapped around the fingers helps get traction on the very slick surface. As above, there is no problem getting your entire hand into the uterus if you don’t wait too long after delivery. If no success then D&C, then surgery.

Regarding abnormal position of the placenta inside the uterus, low implantation of the
placenta on the lower uterine segment or across the cervical opening can of course
produce severe bleeding during pregnancy, a true emergency. During delivery it can
contribute to intrauterine tears. Also placental fragments or portions of membrane can stick here. Management by examination & repair.

Abnormal attachment. Placenta accreta means stuck to the inside of the uterus lining,
placenta increta results from the placenta actually growing into the uterine muscle,
placenta percreta means through the muscle to the outside of the uterus. Management by D&C or surgery.

Lets see, history, especially prior OB history. You always want to know everything you can about prior deliveries ‘cause problems tend to repeat themselves, and injuries, repairs, etc. can fail during the delivery process. Thus prior lacerations very good to know about as is prior retained placenta, D&C, etc. Twins or several prior deliveries make the uterus more likely to have problems with atony (muscles won’t firm up), etc. Full term, pre-term, problems during pregnancies, etc. general background info.

History of this pregnancy also very important. Problems, bleeding, illness, drugs. How long & difficult was labor (uterine atony or rupture), any malposition/ dystocia of infant (tears, etc.), how long and how easily did placenta deliver (retained, accreta, etc.), how much traction on cord (inversion/prolapse), etc.

More later.
_________________
Do No Harm. Do Know Harm.

[RESQDOC]

TD,

Your failure of the uterus to clampdown 100% (sub-involution) was due to a large clot (or retained placenta segment) sitting in the fundus, thus continued bleeding. Pre-eclampsia also not only causes fluid retention but also abnormalities in clotting i.e. too thin and poor clotting, so that didn't help either. Sometimes that clot will act as "ball valve" and block the bleeding until there is too much & it starts leaking past. Sub-involution is the #1 cause of late, several day later, bleeding. Glad you came out OK.

[tangent]

Keith,

hope you are going to finish this... very interesting!

[RESQDOC]

(Best cheesy 60's Star Trek computer voice)

WORKING

maybe nextweekend, have not forgotten, promise. :smile:

[RESQDOC]

OK, made it through another call cycle and have a few days breathing room, so back to work. It's been very busy here.

Picking up where we left off on Tangent’s excellent questions, palpating the uterus. Initially you do not want to do much massage/palpation, until the placenta is delivered. Aggressive massage may hinder separation. After the placenta is out, aggressive massage of the uterus through the abdominal wall will help the uterus firm up and stop bleeding. The uterus shrinks up pretty fast, maybe 50% within minutes and most of the rest of the way back to “normal” in a few hours. So yes, small and firm is good. Big and firm is ok, it should get small soon unless there is a hidden hemorrhage in the muscle tissue, i.e. not bleeding out into the vagina but between layers of the vaginal side-wall or similar – this is accompanied by pain and swelling. Off to surgery. Big and soft may indicate uterine atony, where the muscles just won’t tighten up. The normal post delivery uterus will be a finger width or two below the belly button in a few hours.

Placenta. The baby side is smooth and shiny, the mom side where it was attached to the uterine wall is irregular, rough, divided into “lobes” a few cm wide, also irregular. If one is missing, i.e. retained, there is a bare spot on the placenta. Once you’ve seen one, you’ll know what I mean. I always bring a preserved placenta & cord to my OB classes. No set number/shape/size to lobes or placenta.

Nipple stimulation after delivery does help contract the uterus, yet another reason for the infant to go to mom and breast-feed promptly after delivery.

More on hemorrhage. I commented that intrauterine massage was occasionally needed. One hand on outside abdomen. One hand inside vagina in a fist, rub uterus between your hands. This stimulates the uterine muscle to contract. If you suspect a retained fragment inside the uterus, a gloved hand needs to go all the way into the uterus to explore the inner lining for the missing bits. Sometimes wrapping a gauze pad around your hand helps by increasing friction, making it easier to sweep off the fragments. The cervix remains dilated after delivery for a variable amount of time, and quite soft for hours, so it is usually possible to get your entire hand right into the uterus with absolutely no problem. If you wait too long the cervix will return to normal dimensions, and you will only be able to pass a type of curette, or scraping device, through the cervix in order to clean off the interior wall and lining. Thus be vigilant for missing placenta bits and post partum bleeding! No problem passing catheters, etc. Yes a 30 cc Foley or so would be the size, although smaller might work.

Regarding the ice water lavage, that is intrauterine. You are not going to transmit enough cold to cause a significant hypothermia, and certainly not produce shock. Patient will feel a bit cold. You are not going to increase blood pressure to any significant degree.

Uterine packing is technique dependent. That means if you do a crappy job, it doesn’t work. The packing has to be layered in TIGHT, all voids filled, you are after pressure on the muscle wall. We used to practice by cutting the edge off a cantaloupe or melon to make a few cm hole, clean guts out, and pack the cavity (cleaned guts out with curette to practice that).

Frank. You know, Frank Pus and his sister, Lotta? Sorry, medicalese slipped in. Just means “major” as in major surgery.

Repairing anterior cervical lip – just sew it up. Easiest to start at the apex of the tear, and work out. No need for fancy multi-layer closure, but do remember to use absorbable suture or be prepared for one unhappy mother when you take then out 10 days later. To visualize, think of a tongue split half way up. The cervix is just a bit smaller and thinner.

Lets see, what else. Prolapsed uterus – push it back in, literally, it turns “right side in” & goes back into place pretty easy if you get it done before the cervix clamps down. Keeping it in can be a problem. Look up “pessary”.

Retained fetal fragments, i.e. an incomplete miscarriage, yes, D&C.

Vasoconstrictors, for obstetric hemorrhage, also known as uterotonics, include:
- carboprost (Hemabate) (methyl-prostaglandin)
- methylergonovine (Methergine)
- and of course oxytocin (Pitocin)
All carry risk of a variety of adverse reactions including blood pressure changes, bronchospasm, anaphylaxis, blood clots etc., to one degree or another. None store well. We need a herbal alternative, or freeze dried formula, or something. All to be used with caution and consideration of risk/benefit equation.

Hope this helps,

Keith

[tangent]

thank you for getting back to this!

on re-reading the entire thread, I have additional questions - some I will be able to answer myself, once I can access my medical dictionary (there are many words in medicalese that are not defined), others are conditions that are not elaborated on. In some cases, they are things like "how big should the uterus be at this point - baseball?, grapefruit?, cantalope?", another is that you have brought up doing D&C's in the post-delivery and miscarage state where there is additional fetal material a couple of times, but not elaborated on what needs to be done in these cases. I had a MD as an instructor for an A&P class, many years ago (I was in Jr High School) that described the procedure for the "normal" reason that this is done, but I imagine that it would be slightly different in these circumstances and that there might be subtleties to safely and effectivly doing this in any circumstances that may not have survived the passage of years in my memory or just never been taught in the first place. What I remember is that the opening of the cervix is "tickled" with a rounded object (something having NO sharp edges, to avoid dire concequences!) a "bullet" probe seeming ideal, and that such object should be sterile. That was about it. Manipulating such a thing past several inches of vagina was not discussed (though I understand that 2 teaspoons rubber banded together, face to face, make a fine improvised speculum) also, the treatment, in this case of working on an inflamed and recently exhausted cervical opening might warrent a slightly differnet technique.

anatomical possitioning, size, and vigor of massage or other on the uterous, fundus, etc was also somewhat lacking. I know the fundus is toward the top of the uterous and is where the placenta attaches, the uterous is where the baby grows and the cervical opening is where it enters the vagina - many readers don't. after that my anatomy goes weak fast - the fundus is maybe the top 1/4 of the uterous and you imply has muscles that fold onto themseves. is somehow attached in a way that can become unatached and prolapsed. that bleeding can occure from the lower part of the uterous (30cc cath inflated in lower part of...) yet, blood vessle attachment is in the upper part... hmmm... no mention of using the cath farther upward, but implied that it shouldn't be. (off topic, but wow! foley caths are great things! - can be used for airway management, as chest tubes, as tournaquetes(sp?), for rectal fluid administration, and just read today about cutting one off and using it to extract an insect from someones ear! (via suction), I'm sure I'm forgetting some uses...)

on packing the uterous(sp?) PLEASE GET A SPELL CHECKER ON THIS BOARD! how - and how do you get it tight? ditto on using a currette to "clean out" the uterous? Interesting about using a cantalope.

you've mentioned OB classes several times - when do you teach classes and and what classes do you offer? some of these things would really bennefit from personal interaction and having someone looking over your sholder, telling you what you're doing wrong.

[RESQDOC]

ALL of this topic would really benefit from personal interaction and hands on teaching, as learning this sort of material is much harder than some things in medicine.

The discussion and information here is for general reference and understanding - background info if you like - only. For that reason I do not care to go into detail on things like performing a D&C, which is completely technique dependant and fraught with disaster if done improperly. But fairly easily taught and practiced.

Anyone who is seriously considering providing medical care, and who does not have a medical dictionary, is not seriously considering providing medical care. Get one now. It is not possible to carry on an informal discussion of these medical topics without using medical and anatomical terms, as in many cases there are no plain English equivalents, at least not without deviating into vocabulary lessons (idea – vocabulary forum with medical vocab lessons?). I like Dorland’s medical dictionary, either pocket or full size if finances will allow, an investment you will NOT regret. There are many other excellent dictionaries out there, even the $5.95 Bantam paperback at Wally World is OK.

Ditto an anatomy text. Just about every topic on this forum is going to require one. It would be possible, server space allowing, to upload a lot of visual material in forum discussions, but just not practical. So everybody get an anatomy book. Again, many fine ones, a used anatomy & physiology text from the nearest school would be very valuable. For a dedicated text, I would recommend the softcover Netter’s as the best to study from. Spendy, but the best.

And everyone with an interest in this topic get the Handbook for Midwives discussed elsewhere in this forum and read it! The Q & A here will make a lot more sense if you have some OB background. Great book!

Now, on with some more answers. As noted above, this is an informal discussion, not a dedicated textbook by correspondence. Thus some of the answers lack every detail. Everyone please do chime in if you don’t understand something.

How big is a uterus? How long is a string? This, and many other things in medicine do not have a cookbook, er… textbook, answer. Or rather, the answer is our favorite “It depends.” The non-pregnant uterus is about the size of a pear, sitting just above the pubic bone. The twenty-week pregnant uterus sits at about the level of the belly button, the full term uterus sits a variable distance below the bottom of the breastbone. After delivery the uterus rapidly gets smaller, but with no particular standard change. As a general rule of thumb, the first day after delivery should have the top of the uterus at or a little below the belly button, gradually getting smaller thereafter. Most of the time it is back to pear size in a week or two, sometimes a bit longer, and after multiple pregnancies perhaps more mango sized.

More on bleeding, etc. How hard to massage the uterus, lets see, about like gently kneading bread dough. Does that help? The tactile feedback you receive when doing it is your guide, along with common sense. There is a separate blood supply into the lower segment and cervical area of the uterus, and this is where the Foley balloon pressure is intended to work, not up in the fundus. It's just one more possible tool to help, not the Holy Grail by any means. How tight do you pack the uterus, why tight enough to stop the bleeding of course! I don't think that a pounds per square inch pressure load has ever been quantified. “As tight as you can” is of course the answer.

Regarding prolapse, the uterus is suspended by ligaments that stretch and soften to accommodate the growing size and shape of the pregnant uterus. Sometimes these are not tight enough to prevent the uterus from partially or completely sliding forward and involuting. There is a contribution from the pelvic floor muscles also, but it is difficult to explain without pictures, and not really necessary. On the rare chance that you ever see one, you will recognize it you recall that it exists.

Regarding classes, I have taught private classes extensively over the years on a variety of topics, including OB & delivery, as well as wound repair, orthopedics, and many other things. I am considering offering to do so here, but just considering at the moment, as I have my own set of concerns about doing so. I have discussed this in some detail with RR. We’ll see.

I do apologize that it took me a couple of weeks to get back to this, but I have responsibility for numerous things, and our work schedule is such that I have two or three busy weeks and one a little slower, which is when I have time to spend on things like this. So don’t think that I have blown things off, I may just not get to it for a bit.

On the other hand, if you all want to chip in and pay my salary for six months, I would love to devote myself fulltime to writing a text book on remote medical care…:D

Later,
Keith


_________________
Do No Harm. Do Know Harm.

[tangent]

thanks for clearing those things up! Great Reply!

if the dictionary comment was directed to me, I own one, but am on vaccation at the moment.

[RESQDOC]

Nothing is directed at anyone, rather above is directed to us all - none of us can consider medical training without a dictionary and anatomy book.