Clinical Assessment

• Uterus is soft (not contracted) — classic sign of uterine atony
• Fundus is above the umbilicus — consistent with atony/uterine distension
• Episiotomy already sutured — excludes perineal laceration as source
• Oxytocin started 30 mins ago — first-line already commenced, but not yet effective enough

Immediate Management (Stepwise)

Step 1 — Resuscitation (simultaneous)

• Call for help — activate PPH team/protocol
• Establish 2 large-bore IV lines
• Fluid resuscitation with crystalloid; initiate massive transfusion protocol if ongoing haemorrhage
• Send urgent bloods: FBC, coagulation screen (PT, APTT, fibrinogen), cross-match, renal/liver function
• Continuous monitoring: BP, pulse, urine output (insert Foley catheter)

Step 2 — Optimise Uterotonic Therapy

• Oxytocin 20–40 units in 1L crystalloid infused at 200–500 mL/hr — titrate to sustain uterine contractions
• Do not administer as IV bolus — causes severe hypotension
• — Roberts & Hedges' Clinical Procedures in Emergency Medicine, p. 1367

Step 3 — Uterine Massage

• Bimanual uterine compression/massage: one hand compresses the anterior uterine wall via the vagina (fist), other hand massages the posterior uterus through the abdominal wall
• Avoid vigorous downward massage — risk of uterine inversion or broad ligament vessel injury
• — Roberts & Hedges', p. 1367

Step 4 — Second-Line Uterotonics (if bleeding persists despite oxytocin)

Step 5 — Intrauterine Tamponade

• Bakri balloon or intrauterine balloon tamponade (reported success rates up to 91%)
• Alternatively, sterile gauze packing while awaiting surgical/radiological intervention
• — Management of PPH, Textbook of Interventional Radiology, p. 2067

Step 6 — Surgical / Radiological Intervention

• Uterine compression sutures (B-Lynch suture) — if abdomen is open
• Uterine artery embolisation — should not be first-line but also not a last resort; aim to preserve uterus
• Peripartum hysterectomy — definitive, life-saving if all else fails

Do Not Miss — Exclude Other Causes

• Retained placental fragments — check placenta is complete; may need manual exploration
• Cervical/vaginal lacerations — inspect carefully even with sutured episiotomy
• Coagulopathy — check DIC screen, especially with ongoing haemorrhage
• Uterine inversion — suspected if fundus is not palpable abdominally and there is haemodynamic collapse (not the case here, fundus is palpable above umbilicus)

Summary Priority Order

1. Resuscitate + activate PPH protocol
2. Optimise oxytocin (confirm correct concentration and rate)
3. Bimanual uterine massage
4. Add second-line uterotonic (carboprost or misoprostol preferred here given low BP)
5. Intrauterine balloon tamponade if above fails
6. Surgical/radiological intervention as last resort

Episiotomy Haematoma — Management

Background

Clinical Features

• Acute onset of severe perineal pain disproportionate to the clinical picture
• Tense, tender, bluish swelling at or near the episiotomy site
• Increasing perineal pressure
• Haemodynamic compromise if haematoma is large (tachycardia, hypotension)
• Fever if infected (septic haematoma)

Management Pattern

1. Initial Assessment

• Examine the perineum carefully — compare size with serial measurements or marking
• Assess haemodynamic status (pulse, BP)
• Evaluate size: small (<3–4 cm) vs large (expanding or >4 cm)

2. Small, Stable, Non-Expanding Haematoma

• Ice packs to the perineum (20 min on/off) to reduce swelling and provide analgesia
• Analgesia — NSAIDs and/or opioids as needed
• Pressure dressing to the perineum
• Close observation — re-examine every 15–30 minutes to ensure it is not expanding
• Most small haematomas will resorb spontaneously over days to weeks

3. Large, Expanding, or Symptomatic Haematoma

1. Anaesthesia — adequate analgesia/regional or general anaesthesia (often required due to severe pain)
2. Open the haematoma — incise directly over the haematoma (through the episiotomy incision if possible, or at the point of maximal fluctuance)
3. Evacuate the clot — manually remove all clotted blood
4. Identify and ligate bleeding vessels — ligate with absorbable suture; often no single vessel is found
5. Obliterate dead space — close the cavity with interrupted absorbable sutures to prevent re-accumulation; do NOT leave dead space
6. Drain if needed — a small closed suction drain or Penrose drain may be left if haemostasis is uncertain
7. Re-close the wound — repair the episiotomy in layers as for primary closure (vaginal mucosa → perineal muscle → skin), using 2-0 or 3-0 absorbable suture

4. Resuscitation (for large haematomas)

• Establish IV access — large-bore cannula
• IV fluids — crystalloid resuscitation
• Blood transfusion if haemoglobin drops significantly or haemodynamic instability
• Send FBC, coagulation screen, cross-match

5. Antibiotics

• Give broad-spectrum antibiotics (e.g. co-amoxiclav or cephalosporin + metronidazole) whenever the haematoma is opened surgically, or if there are signs of infection
• Septic haematoma — a life-threatening complication; urgent surgical drainage + IV antibiotics mandatory
• Note: Range of infection can extend to necrotizing fasciitis — maternal fever + unusual pain/swelling must always be thoroughly evaluated to exclude this. — Pfenninger & Fowler's, p. 1162

6. Post-Operative Care

• Sitz baths — warm soaks 2–3x daily to promote healing and hygiene
• Stool softeners — to prevent straining and disruption of the repair
• Continue analgesia as needed
• Wound inspection at 24–48 hours for signs of re-accumulation or infection
• Follow-up at 1–2 weeks

Summary Decision Tree

Episiotomy Haematoma
        |
   ─────────────────
   |               |
Small (<3–4 cm)  Large / Expanding / Septic
Stable             |
   |          Surgical Evacuation:
Conservative    - Anaesthesia
 - Ice            - Open & drain
 - Analgesia      - Ligate vessels
 - Pressure       - Obliterate dead space
 - Observe        - Re-close in layers
                  - Antibiotics
                  - Drain if uncertain
                        |
                  Resuscitate if
                  haemodynamically
                  compromised

Key Points

• Most episiotomy haematomas present within hours of delivery
• Never ignore worsening perineal pain after delivery — it is the cardinal symptom
• The most dangerous error is delayed recognition of an expanding paravaginal or ischiorectal haematoma, which can accumulate over 1 L of blood before it becomes clinically obvious
• Septic haematoma and necrotizing fasciitis are rare but life-threatening — have a low threshold to open and drain with fever + perineal signs

Stepwise Escalation of PPH Management

PPH = blood loss ≥500 mL after vaginal delivery or ≥1000 mL after caesarean, with signs of haemodynamic compromise within 24 hours.

STEP 0 — Simultaneous Resuscitation (All Steps)

• Call for help — activate multidisciplinary team (obstetrician, anaesthesiologist, midwife, haematologist)
• 2 large-bore IV cannulae
• Oxygen by face mask; monitoring — BP, pulse, SpO₂, urine output (Foley catheter)
• IV crystalloid resuscitation; initiate massive transfusion protocol (MTP) if ongoing loss
• Blood products — packed red cells : FFP : platelets in 1:1:1 ratio (MTP); early FFP shown to improve outcomes
• Fibrinogen — low fibrinogen predicts severe haemorrhage and developing DIC; replace with cryoprecipitate/fibrinogen concentrate
• Bloods — FBC, coagulation screen (PT, APTT, fibrinogen), cross-match, U&E, TEG/ROTEM if available
• Tranexamic acid (TXA) 1g IV — give as early as possible once PPH diagnosed; repeat 1g if bleeding continues after 30 min or restarts within 24h (WOMAN trial — reduces death from bleeding, most effective within 3 hours)

STEP 1 — First-Line Uterotonics + Uterine Massage

• 20–50 units in 1L crystalloid IV infusion — titrate to maintain contractions
• Do NOT give as IV bolus — causes severe hypotension and vasodilation
• If no IV access: 10 units IM

• One hand compresses anterior uterine wall via the vagina (fist)
• Other hand massages posterior uterus through the abdominal wall
• Sustained firm pressure — do not massage vigorously downward (risk of uterine inversion)

STEP 2 — Second-Line Uterotonics

STEP 3 — Intrauterine Tamponade

• Bakri balloon (or BT-Cath, Sengstaken-Blakemore) — inflate with 300–500 mL saline
• Uterine gauze packing — sterile gauze tightly packed into uterine cavity
• Success rates reported up to 91% for balloon tamponade
• Allows time for resuscitation, transfer to theatre, or interventional radiology
• Can be used as a "test of tamponade" — if bleeding stops, surgical intervention may be avoided

STEP 4 — Surgical Intervention

• B-Lynch suture — brace suture compresses the uterus longitudinally; highly effective for atony
• Hayman suture, Cho suture — alternatives
• Applied when abdomen is already open (caesarean) or at laparotomy

1. Uterine artery ligation bilaterally (O'Leary sutures) — reduces uterine blood flow by ~90%
2. Utero-ovarian ligament ligation
3. Internal iliac (hypogastric) artery ligation — technically demanding; reduces pulse pressure to pelvis

• Not first-line, but not a last resort — should be used before hysterectomy if available and patient is haemodynamically stable enough for transfer
• Bilateral uterine artery embolisation using Gelfoam via femoral artery approach
• Preserves uterus and fertility
• Recurrent bleeding can be treated with repeat embolisation

• Balloon catheter inserted via femoral artery into the aorta
• Acts as internal aortic occlusion to control haemorrhage while definitive treatment is arranged
• Useful in haemodynamically unstable patients with massive haemorrhage (e.g. abnormal placentation)

STEP 5 — Peripartum Hysterectomy (Definitive)

• Indicated when all conservative and surgical measures have failed
• Total or subtotal (supracervical) hysterectomy — subtotal is faster and preferred in unstable patients
• Mandatory for placenta accreta/percreta that cannot be managed conservatively
• Associated with significant morbidity but is life-saving
• Audit of peripartum hysterectomy rate is used to measure PPH protocol effectiveness

STEP 6 — Concurrent Management of Coagulopathy

Summary Ladder

STEP 0 ── Resuscitate + TXA 1g IV (ALWAYS CONCURRENT)
   │
STEP 1 ── Oxytocin IV infusion + Bimanual uterine massage
   │  ↓ fails
STEP 2 ── Add Ergometrine / Carboprost / Misoprostol
   │  ↓ fails
STEP 3 ── Intrauterine balloon tamponade (Bakri)
   │  ↓ fails
STEP 4 ── Surgery:
          └─ 4a: Compression sutures (B-Lynch)
          └─ 4b: Uterine / internal iliac artery ligation
          └─ 4c: UAE (interventional radiology)
          └─ 4d: REBOA (haemodynamic instability)
   │  ↓ fails
STEP 5 ── Peripartum hysterectomy (definitive)

• Steps 0–1 are simultaneous and immediate — never delayed
• Steps may be skipped or combined depending on clinical severity and resources
• Uterine-preserving options should always be attempted before hysterectomy in women who desire future fertility
• Multidisciplinary coordination is mandatory from STEP 0 onwards

Ulcer Description — Surgical Semeiology

How to Describe an Ulcer on Examination

1. SITE

• Anatomical location (e.g. medial malleolus, heel, shin, dorsum of foot, leg)
• Which limb, which surface
• Relationship to bony landmarks

2. SIZE

• Measure length × width × depth in centimetres
• Note if multiple ulcers are present

3. SHAPE

• Round, oval, irregular, serpiginous, stellate

4. EDGE (Most diagnostically important)

5. FLOOR (what you see at the base of the ulcer)

6. BASE (what lies beneath the floor — felt on palpation)

7. DEPTH

• Superficial (epidermis/dermis only)
• Deep (into subcutaneous fat, fascia, muscle, bone)

8. DISCHARGE / SECRETIONS

9. SURROUNDING SKIN

• Lipodermatosclerosis, brown pigmentation (haemosiderin) → venous
• Pallor / hair loss / shiny atrophic skin → arterial
• Callous ring → neuropathic / diabetic
• Cellulitis / erythema → infected
• Satellite ulcers → malignant or tuberculous

10. LYMPH NODES

• Regional lymph nodes — enlarged, tender (infective), hard and non-tender (malignant)

Comparison of Common Ulcer Types

Mnemonic for Ulcer Description

Key Diagnostic Clue — The Edge

• Sloping → healing/venous
• Punched-out → arterial/syphilitic
• Undermined → TB
• Everted → carcinoma (SCC)
• Raised/pearly/rolled → BCC