1

2.4 UTERINE ATONY

Uterine atony is the most frequent cause of postpartum hemorrhage. It is caused by
failure of the uterus to contract sufficiently after delivery and stop the bleeding from
vessels at the placental implantation site.1

Figure X Uterine atony (Source : medicalexhibits.com)

The fundus should always be palpated following placental delivery to confirm that
the uterus is well contracted. The uterus should be massaged if it is not contracted firmly.
If bleeding continues, then manual removal of the placenta may be necessary.1
2.4.1 Risk Factors
Risk factor for incidences of uterine atony are :
Table 1 Risk factors for uterine atony2,3
Factors associated with uterine over distension
Multiple pregnancy
Polyhydramnios
Fetal macrosomia
Labour related factors
Induction of labour
Prolonged labour
Precipitate labour
Oxytocin augmentation
Manual removal of placenta
Use of uterine relaxants
Deep anaesthesia
Magnesium sulphate
Intrinsic factors
Previous postpartum haemorrhage
Antepartum haemorrhage

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Pre-eclampsia
Anemia
Obesity
Age > 35 years

It is recommended that the active management of the third stage of labour to be

used to all women during childbirth, whenever a skilled provider is assisting the
delivery.
Multiple pregnancies, polyhydramnios and fetal macrosomia (big baby >4 kg)
cause uterine to be over-distension, because of the imperfect retraction and a large
placental site are responsible for excessive bleeding. The odds ratio to develop PPH
from fetal macrosomia and multiple pregnancies are 1.8 and 2 respective, but some of
the studies suggest that they did not find any relationship between multiple
pregnancies with the occurrence of uterine atony. Studies had reported an association
of polyhydramnios with uterine atony requiring blood transfusion in the odds ratio of
1.9. Multipara could induce inadequate retraction and frequent adherent placenta
contribute to it. Although the general appearance of the mother may also probably
play a role such as anemia, malnutrition and etc. Even the slightest amount of blood
loss may develop clinical manifestations of postpartum hemorrhage. 2
Intrapartum factors such as induction of labour, prolonged labour, oxytocin
exposure and abnormal third stage are also recognised to associate with uterine atony.
Induction of labour had an odds ratio of 1.5 and was the cause of 17% of uterine atony
requiring blood transfusion. Prolonged usage of oxytocin in labour contributes to
uterine atony. Studies has demonstrated that massive PPH secondary to uterine atony
was significantly higher in women who were exposed to oxytocin. The authors
proposed that persistent oxytocin administration causes desensitisation of oxytocin
receptors which further contributed into uterine atony. 2
Antepartum hemorrhage such as placenta previa or abruption cause excessive
bleeding could cause the manifestations to grow. Even prolonged labor (>12 hours)
could cause poor retractions, infection (chorioamnionitis) and dehydration. These are
some important maternal factor that contribute to the tone. 2
Use of the anesthetic agents (such as esther or halothane) or depth of the
anesthesia could also relax the uterus and may cause atonicity. The use of tocolytics
agents (such as ritodrine) or magnesium sulphate, even nifedipine could cause atonic

hemorrhage in some literature. 2 The presence of uterine fibroids or connective tissue

disorders may decrease the myometrium contractility then this leads to uterine atony.
However, the existing data are conflicting with regards to relationship between uterine
fibroids and uterine. So the mechanism of this is not well known, but it is caused by
imperfect retraction mechanically. Patients with connective tissue disorders are at a
higher risk of PPH as compared to the general population.2
2.4.2 Evaluation and Management
Evaluate the patient to exclude birth canal laceration and retaind of placental
fragments after delivery should be routine. If the placenta defect, the uterus should be
manually explored and the fragments removed. During examination for lacerations
and causes of atony, the uterus is massaged and uterotonic agents are administered. 1
The diagnosis is usually made by the observation that the uterus is soft and boggy,
contracts following massage, and relaxes again resulting in more bleeding. 4 The
management of uterine atony include non-pharmacological, pharmacological and
surgical interventions.
2.4.2.1

Non-pharmacological treatment

2.4.2.1.1 Uterine massage

Uterine massage is performed by rubbing or stimulating the fundus of the
uterus. It is hypothesized that massage releases local prostaglandins that
promote uterine contractility hence reduces bleeding. Systematic review has
shown that uterine massage is effective in preventing PPH. Uterine massage
should be started once PPH has been diagnosed. The low cost and safety of
uterine massage were taken into account in making this recommendation
strong.
2.4.2.1.2 Aortic compression
Aortic compression can assist in controlling the amount of blood loss by
decreasing the blood flow at the distal end including uterine artery. Aortic
compression is achieved via applying pressure with the flat surface of the
knuckles above the contracted uterus and slightly to the left (Figure 1).
Absence of femoral pulse indicates correct and complete occlusion of the
aorta. It is crucial to release and re-apply the pressure every 30 minutes to
allow intermittent blood flow to the lower limbs. Aortic compression is a
simple intervention that can be used while preparing for a definitive

management or during the transfer of patient from a district hospital to another

tertiary hospital.
External aortic compression devices have been shown to be effective in
reducing the resuscitation time and also the amount of blood being transfused
with minimal side-effects reported. Successful aortic compression, as
documented by absent femoral pulse unrecordable blood pressure in a lower
limb, was achieved in 11 of 20 subjects. The authors concluded that the
procedure is safe in healthy subjects and may be of benefit as a temporizing
measure in treatment of PPH until appropriate care is available
2.4.2.1.3 Bimanual uterine compression
There are occasions when uterine atony does not respond to the administration
of uterotonic agents. If bleeding persists after initial measures for atony have
been implemented, then move on to next management, immediately and
simultaneously. Firstly, bimanual uterine compression, the posterior uterine
wall is massaged by one hand on the abdomen, while the other hand is made
into a fist and placed into the vagina. The fist squeeze the anterior uterine wall
through the anterior vaginal wall. 1

Figure X Bimanual compression for uterine atony1

2.4.2.1.4. Uterine Packing or Balloon Tamponade
Uterine packing using the tip of a 24F Foley catheter with a 30-mL balloon is
guided into the uterine cavity and filled with 60-80 mL of saline. The open tip
permits continuous drainage of blood from the uterus. If bleeding subsides, the
catheter is typically removed after 12 to 24 hours. Another devices that have
been used for tamponade include Segstaken-Blakemore and Rusch balloons
and condom catheters. Alternatively, the uterus or pelvis may be packed
directly with gauze1 or in situations where none of this is possible to use a

condom with the open end closely tied around a size 16 rubber catheter that
will be used to inflate the condom with water.4
There is another new devices that is specially constructed intrauterine
balloons to treat hemorrhage from uterine atony and other causes. A Bakri
Postpartum Balloon or BT-Cath may be inserted and inflated to tamponade the
endometrial cavity and stop bleeding.1
The Sengstaken-Blakemore balloon was designed to control bleeding from
esophageal varices. It consists of two balloons: one smaller and spherical in
shape, the second being larger, elongated, tubular in shape. Ideally the
spherical balloon should be removed and the tubular balloon used for uterine
tamponade. However, removal of the spherical balloon sometimes causes
leakage of the tubular balloon and the expensive device cannot be used. The
recently available SOS Bakri tamponade balloon is a tubular balloon designed
specifically for this obstetrical emergency, which can tolerate up to 500 ml of
fluid.4
2.4.2.2 Pharmacological : Uterotonic Agents
Uterotonic agents used in management of the third stage routinely selected and
given to prevent postpartum bleeding. Most of these same agents are also used to
treat uterine atony with bleeding. 1
2.4.2.2.1 Oxytocin
Oxytocin can be given by infused intravenously or intramuscularly after placental
delivery. Neither route has been shown to be superior and can be given
prophylactically to prevent most cases of uterine atony.

Studies have

demonstrated that the use of 4050 units of oxytocin in 1 L of LR or saline is an

effective measure to prevent postpartum bleeding following cesarean section
(Munn et al., 2001).4 Guideline from American Academy of Family Physician
recommended 10 IU should be injected IM , or 20 IU in 1 L of saline infused at a
rate of 250 mL per hour.5
2.4.2.2.2 Ergot derivatives
When atony persists despite preventive measures, ergot derivatives have been used
for second-line treatment. These include methylergonovine (Methergine) and
ergonovine, rapidly stimulate tetanic uterine contractions with dose 0.2 mg IM act
for approximately 45 minutes. Methylergonovine may be repeated as required at
intervals of two to four hours.

2.4.2.2.3 Prostaglandins
In more recent years, second-line agents for atony have included the E- and Fseries prostaglandins. Carboprost tromethamine (Hemabate) is the 15-methyl
derivative of prostaglandin F2 with dose of 250 mcg given intramuscularly, can be
repeated if necessary at 15- to 90-minute intervals with maximum of 8 doses.
Carboprost causes side effects such as diarrhea, hypertension, vomiting, fever,
flushing, and tachycardia. Another pharmacological effect is pulmonary airway and
vascular constriction. So, it is contraindicated in patients with asthma, suspected
amnionic-fluid embolism and pre-eclampsia.1
Prostaglandin E2 (Dinoprostone) is given 20-mg suppository per rectum or per
vaginam every 2 hours. Sulprostone also prostaglandin E2, used intravenously.
Misoprostol (Cytotec) is a synthetic prostaglandin E1 analogue that has also been
evaluated for both prevention and treatment of atony and postpartum hemorrhage.
Studies evaluating misoprostol and its effect on hemorrhage still conflicting. Some
said, misoprostol was not more effective than intravenous oxytocin in preventing
postpartum hemorrhage. And one study found that the drug decreased hemorrhage
incidence from 12 to 6 % and that of severe hemorrhage from 1.2 to 0.2 %.1 WHO
recommended misoprostol given 800 mcg sublingual for treatment of postpartum
haemorrhage if oxytocin is unavailable or the bleeding doesnt respond. 6 However
FIGO recommended 1 mg (1000 mcg) misoprostol administered rectally. Higher
peak levels and larger doses are associated with more side effects, including
shivering, pyrexia, and diarrhea.5
2.4.2.3 Surgical Procedures
Several invasive procedures can be used to control hemorrhage from atony such
as uterine compression sutures, internal iliac artery ligation, angiographic
embolization, and hysterectomy. 1
Compression sutures are the best surgical approach for the treatment of uterine
atony. They preserve the anatomical integrity of the uterus, attack the root of the
problem by keeping the uterus contracted, easy to perform, and have minimal
morbidity. The best known procedure is the B-Lynch stitch. It is performed using
a long absorbable suture which is placed in the anterior aspect of the lower
uterine segment, through fundus of the uterus, anchored in the posterior aspect of
the lower uterine segment, going back anteriorly passing over the fundus of the
uterus, anchored near the entrance point on the anterior aspect of the lower

segment, and then tied while the uterus is massaged and manually compressed to
reduce its size to a minimum.4

Figure X Uterine compression suture (B-Lynch suture technique)

In addition to the longitudinal B-Lynch stitch, one or more circumferential sutures

are placed, encircling the uterus in the transverse plane. The transverse sutures are
anchored anteriorly and posteriorly and they are passed through the broad
ligament, being sure that the round ligament and the Fallopian tube are not
included in the suture. It is also important to avoid the vessels running on the left
and right sides of the uterus. This method achieves a degree of uterine
compression much better than the B-Lynch stitch alone. Uterine compression
sutures have almost completely replaced uterine artery ligation, hypogastric artery
ligation, and postpartum hysterectomy for the surgical treatment of uterine atony.4
Internal Iliac Artery Ligation It is not particularly helpful to reduce hemorrhage in
uterine atony. Non absorbable suture is passed under the artery with a clamp, and
the vessel is then securely ligated.1

Figure X Internal Iliac Artery Ligation

Angiographic embolization performed by an interventional radiologist who

catheterizes the hypogastric artery, identifies the source of the bleeding, and
embolizes the bleeding vessels with small particles of gelfoam. This procedure is
extremely effective in providing bleeding control. In the absence of an
interventional radiologist and in the face of continuous bleeding, it is necessary to
proceed to surgical intervention consisting in compression sutures to keep the
uterus contracted.4
2.5 UTERINE INVERSION
2.5.1 Risk Factors
Risk factors for uterine inversion are fundal implantation of placental, uterine
atony, cord traction applied before placental separation, and abnormally adhered
placentation such as with the placenta accreta. 1 Another risk factors that could lead to
uterine inversion are fetal macrosomia,excessive fundal pressure , short umbilical
cord, ligaments laxity, and congenital abnormalities of the uterus.7
2.5.2 Recognition and Management
Active management of the third stage of labor may reduce the incidence of
uterine inversion. Fundal implantation of the placenta may lead to inversion; the roles
of fundal pressure and undue cord traction are uncertain. The inverted uterus usually
appears as a bluish-gray mass protruding from the vagina and there are cupping or
dimpling of the fundal surface.8 Vasovagal effects producing vital sign changes
disproportionate to the amount of bleeding may be an additional clue. 5 Many
inexperienced attendants may have a delayed recognition for diagnosing an uterine
inversion especially if only partial and thus not protruding through the introitus. Even
so, the partially inverted uterus can be mistaken for a uterine myoma, and this can be
resolved by sonography.1

Figure X Progressive degrees of uterine inversion1

Management of uterine inversion must be implemented urgently and

simultaneously, such as preparing for blood, whole blood or PRCs and administering
infusion of crystalloid rapidly.
2.5.2.1 Non-pharmacological treatment
1. The Johnson method
If the inverted uterus has not contracted and retracted completely and if the
placenta has already separated, then the uterus may often be replaced simply by
pushing up on the inverted fundus with the palm of the hand and fingers in the
direction of the long axis of the vagina. Some use two fingers rigidly extended to
push the center of the fundus upward (The Johnson method). 1

Figure X Reposition of uterine inversion5

While doing this manuever must be careful not to apply so much pressure as
to perforate the uterus with the fingertips. But if the placenta still attached,
placenta isnt removed until infusion systems are operational and a uterine
relaxant drug administered.1
2.5.2.2 Pharmacological treatment
If these fail to provide sufficient relaxation, then a rapidly acting halogenated
inhalational agent is administered by anaesthesist. 1 Alternatively, AAFP
recommended if initial attempts to replace the uterus fail or a cervical
contraction ring develops, administration of MgSO4, terbutaline (Brethine),
nitroglycerin may allow sufficient uterine relaxation for manipulation. 5 After the
placenta removed, give a steady pressure with the fist, palm, or fingers to the
inverted fundus in an attempt to push it up. Once the uterus is restored to its
normal configuration, tocolysis is stopped and oxytocin is administered.
Meanwhile, the operator maintains the fundus in its normal anatomical position

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while applying bimanual compression to control further hemorrhage until the

uterus is well contracted.1
2.5.2.3 Surgical Intervention
If the manual management fails, laparotomy is imperative. With tocolytic agents
given, a combined effort is made to reposition the uterus by simultaneously
pushing upward from below and pulling upward from above. Application of
atraumatic clamps to each round ligament and upward traction may be helpful
the Huntington procedure. In some cases, placing a deep traction suture in the
inverted fundus or grasping it with tissue forceps may be of aid. If the
constriction ring still prohibits repositioning, a longitudinal surgical cut
Haultain incisionis made posteriorly through the ring to expose the fundus
and permit reinversion. After uterine replacement, tocolytics are stopped,
oxytocin and other uterotonics are given, and the uterine incision is repaired.1

x.x Prevention of Postpartum Haemorrhage

Prevention of postpartum haemorrhage can be done since ante natal care (ANC).
This prevention including improving the health status of the woman and keep the
hemoglobin > 10 g/dL so that the patient can withstand some amount of the blood loss,
high risk patients who are likely to develop postpartum hemorrhage should be screened
and delivered in a well equipped hospital. Another prevention such as blood preparation
so that no time is wasted during emergency, placental localization in all women with
previous cesarean delivery by USG or MRI to detect if any abnormalities of placenta
implantation (accreta or percreta). The best preventive strategy is active management of
the third stage of labor.8
All women giving birth should be offered uterotonics during the third stage of
labour for the prevention of PPH. Oxytocin 10 IU IM/IV is recommended as the
uterotonic drug of choice. Other injectable uterotonics (ergometrine/methylergometrine
or the fixed drug combination of oxytocin and ergometrine) and misoprostol (600 mcg
per oral) are recommended as alternatives.6
Controlled cord traction (CCT) now regarded as optional in settings where skilled
birth attendants are available, and is contraindicated in settings where skilled attendants
do not assist with births.6

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Figure X Brandt-Andrews maneuver for cord traction

Early cord clamping (< 1 minutes baby born) is generally contraindicated, unless
the neonate is asphyxiated and needs to be moved immediately for resuscitation. Late
cord clamping (performed after 1 to 3 minutes after birth) is recommended for all births
while initiating simultaneous essential newborn care. Delaying cord clamping for about
60 seconds has the benefit of increasing iron stores and decreasing anemia, which is
especially important in preterm infants and in low-resource settings 6
Continuous uterine massage is not recommended as an intervention to prevent PPH
in women who have received prophylactic oxytocin. However, surveillance of uterine
tonus through abdominal palpation is recommended in all women for early identification
of postpartum uterine atony. 6
Oxytocin is the recommended uterotonic drug for the prevention of PPH in
caesarean sections. If an IV bolus injection is used, a slow injection rate is preferred.
Cord traction is recommended in preference to manual removal when assisting placental
delivery in caesarean sections. 6

DAFTAR PUSTAKA
1. Williams Obstetrics. 24th edition. 2014 : McGrawHill.
2. Lim PS, Sulaiman AS, Lee CY, Shafiee MN, Omar MH, Yassin MAJM, et al. Uterine
Atony: Management Strategies [Internet]. INTECH Open Access Publisher; 2012
[cited 2016 Jul 26]. Available from: http://cdn.intechopen.com/pdfs-wm/32726.pdf
3. Risk Factors for Uterine Atony/Postpartum Hemorrhage Requiring Treatment after
Vaginal Delivery
4. Arias, Daftary, and Bhide . Practical Guide to High-Risk Pregnancy and Delivery: A
South Asian Perspective. 3rd edition. 2008 : Elsevier. Delhi

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5. Anderson, Janice M. Etches, Duncan. Prevention and Management of Postpartum

Hemorrhage. 2007 : American Academy of Family Physicians
6. WHO recommendations for the prevention and treatment of postpartum haemorrhage.
2012
7. Rui Filipe Monteiro Leal, Rita Mano Luz. Total and acute uterine inversion after
delivery: a case report. 2014
8. DC DUTTAs TEXTBOOK OF OBSTETRICS Including Perinatology and
Contraception 7th edition. 2013 : Jaypee Brothers Medical Publishers (P) Ltd
9.