If bleeding is mild, observation may be all the patient needs. If she continues to bleed, or has signs of infection, treat with chloramphenicol and metronidazole.
If bleeding is severe, she will need antibiotics, resuscitation, and exploration of her uterus for retained pieces of placenta. Be sure she is well resuscitated before you start exploring her!
EXPLORING AND EVACUATING A SEPTIC UTERUS is difficult. Sterilize 2 ring forceps (or swab holders), a Sims’ speculum, and a big, blunt curette. Add them to the vaginal examination tray.
Use septic precautions. Use ergometrine 0.5 mg, pethidine 50 mg, and diazepam 10 mg IV. Or use general anaesthetic.
Clean her vulva with an antiseptic solution. Put the Sims’ speculum into her vagina. Ask a helper to hold it, so that you can see her cervix. Hold the front of her cervix with one ring forceps. Put the other ring forceps into her uterus. Push it in very gently, until it is at her fundus. Feel the size of her uterine cavity. Open the handles, turn the forceps and close them again. Pull out any placenta you have grasped. Do this several times in different parts of her uterus, until nothing more comes out.
Curette her uterus. Scrape it down the anterior wall, then the two side walls, and then the posterior wall. Lastly, scrape it across the fundus. Don’t scrape too hard, or you may harm its lining. It will still feel irregular when you have finished scraping.
CAUTION! Emptying a uterus in the puerperium is difficult, and can be dangerous. Its wall is soft, and you can easily perforate it. Never use a small curette, or any small instrument, because they will make a hole very easily. Work gently and carefully, and don’t use a sound.
If her uterus is empty and she is still bleeding severely, pack it and her vagina (23.11).
If packing her uterus fails to control bleeding, proceed to laparotomy, and tie her uterine or internal iliac arteries. If this also fails (rare) do a hysterectomy (20.12).
