Management of immediate and delayed postpartum hemorrhage with cesarean delivery

The management of immediate and delayed postpartum hemorrhage with cesarean delivery presents specific challenges in diagnosis and treatment. Real-time monitoring and quantitation of intraoperative and postoperative blood loss facilitate rapid recognition of immediate or delayed abnormal bleeding, enabling timely intervention. Effective response to ongoing postpartum hemorrhage depends on clear communication and collaboration among the nursing, obstetric, and anesthesiology teams. Medical management involves multiple courses of uterotonics and associated resuscitative measures, which should be applied concurrently with surgical interventions if needed (targeted sutures, vessel ligation, uterine compression sutures, and, in the most severe cases, peripartum hysterectomy). Surgical injuries, such as unintended extension of the hysterotomy leading to uterine vascular pedicle injury, are among the most frequent causes of postpartum hemorrhage during or after cesarean delivery. In these cases, bleeding may occur in the intra-abdominal or retroperitoneal spaces and may not present as vaginal bleeding or be detectable with bedside ultrasound. Therefore, delayed postpartum hemorrhage should be considered a likely cause of any alteration in maternal clinical condition in the hours after cesarean delivery, even without vaginal bleeding or intra-abdominal fluid on ultrasonography. Relaparotomy remains the gold standard for diagnosing and treating suspected intra-abdominal or retroperitoneal bleeding and should be performed without unnecessary delays. Intrauterine devices, such as tamponade balloons or vacuum-induced control systems, have not been sufficiently evaluated during cesarean delivery, and uterine-sparing surgical procedures should be considered for managing refractory postpartum hemorrhage after cesarean. However, these devices may be useful to temporize bleeding until surgical control of bleeding is attained. Similarly, arterial embolization requires time and is feasible only for hemodynamically stable patients with slow persistent bleeding. We propose management algorithms for 2 types of postpartum hemorrhage associated with cesarean delivery: perioperative immediate hemorrhage and postoperative delayed hemorrhage.