# Beyond Standard Algorithms: Diagnostic, Procedural, and Analgesic Challenges in Refractory Postpartum Hemorrhage

## TL;DR

This case study discusses a challenging postpartum hemorrhage case and highlights the importance of proper diagnosis, analgesia, and timely interventions to manage severe bleeding.

## Contribution

The paper emphasizes the under-recognized issue of localized uterine atony and analgesia challenges in managing refractory postpartum hemorrhage.

## Key findings

- Persistent bleeding occurred despite a firm uterine fundus and standard uterotonic therapy.
- Procedural pain delayed hemorrhage control and worsened hemodynamic compromise.
- Neuraxial anesthesia is critical for timely intrauterine interventions in acute obstetric hemorrhage.

## Abstract

Postpartum hemorrhage (PPH) remains a leading cause of preventable maternal morbidity and mortality, with management often complicated by overlapping etiologies, delayed manifestations of hypovolemia, and procedural challenges related to analgesia availability. We report a case of recurrent PPH in a 24-year-old gravida 2, para 2 woman following spontaneous vaginal delivery without neuraxial anesthesia, in whom persistent bleeding refractory to uterotonic therapy was associated with discordant findings of a firm uterine fundus and a boggy lower uterine segment. Hemorrhage control was delayed by significant procedural pain during placement of an intrauterine vacuum-induced hemorrhage-control device, leading to continued bleeding and hemodynamic compromise with an estimated blood loss of 1,400-1,500 mL and activation of a massive transfusion protocol. Hemostasis was achieved with repeat device placement and blood product transfusion, followed by clinical stabilization. This case highlights the importance of recognizing localized uterine atony, the limitations of visual blood loss assessment, and the critical role of neuraxial anesthesia and analgesia planning in facilitating timely intrauterine interventions during acute obstetric hemorrhage.