Postpartum Hemorrhage et causa Atonia Uteri and Ruptured Portion with Complications of Shock Hemorrhagic and Anemia: A Case Report from Southwest Sumba, East Nusa Tenggara

Postpartum hemorrhage is one of the most common obstetric emergencies, and it is the most significant contributor to maternal mortality in the world. The most common cause is uterine atony, followed by laceration in the perineum or portion. P4A0 spontaneous postpartum at the primary health care facility (Puskesmas), a baby boy with a birth weight of 3000 grams cries spontaneously. After delivering the baby, the placenta was born 15 minutes later, with active bleeding afterwards of more than 1500 cc without uterine contractions. The patient was then diagnosed with spontaneous postpartum P4A0 with uterine atony, and the management of uterine atony was performed by massaging the fundus with external and internal bimanual compression, accompanied by fluid resuscitation by inserting a 2-line IV line. She was then given vaginal misoprostol, but contractions were still absent. She was then given a uterotonic drip of oxytocin (30 iu/30 dpm), and the contractions are getting better and stronger. Bleeding was evaluated, but still active then exploratorium on the birth canal and the source of the bleeding was found to be a portion of the tear from front to back, towards 5 o'clock. Then stitching was performed on the portion, and 1 hour after suturing, the bleeding was no longer active. The patient was treated at Puskesmas, with a final HB of 7.5 g/dL.


I. INTRODUCTION
Postpartum hemorrhage is a type of emergency in obstetrics which is the largest contributor to maternal mortality in the world, which is as much as 25% [1], [2].Uterine atony is the most common cause of postpartum hemorrhage, as much as 82.4% is caused by uterine atony [1].The next most common cause of post partum bleeding is caused by a tear (perineum, cervix, or portion) [3], [4].
In the case of an obstetric emergency, postpartum hemorrhage if not treated quickly and appropriately can cause complications that will endanger the mother, for example, such as anemia, myocardial ischemia, anterior pituitary ischemia (Seehan's syndrome), hemorrhagic shock and can result in death.Around 29.3% of maternal deaths in the world and 26.7% of severe complications for mothers after giving birth are caused by heavy bleeding [5], [1].This case requires special attention as well as speed in establishing a diagnosis and prompt and appropriate treatment so that it can reduce the maternal mortality rate after childbirth, even though in Indonesia itself the maternal mortality rate after childbirth is decreasing year after year.This case report is useful for increasing awareness, vigilance, accuracy of diagnosis and speed in handling emergency obstetric cases [5], [6].
II. CASE PRESENTATION G4P3A0 came to Puskesmas opening 6, after 1 hour of evaluation of complete opening and 10 minutes after the patient gave birth.P4A0 spontaneous postpartum at the health center, with a baby born weighing 3000 grams, a baby boy crying spontaneously.After delivery of the baby, the placenta was born 15 minutes later accompanied by active bleeding thereafter more than 1500 cc without any uterine contractions.The patient was then diagnosed with spontaneous postpartum P4A0 with uterine atony, then the uterine atony was treated by massage, external and internal bimanual compression, accompanied by fluid resuscitation by installing a 2-way IV line, then given vaginal misoprostol, but there were still no contractions, until the latter was given a uterotonic drip, namely oxytocin 30 iu 30 dpm, the contractions then improved.Evaluation of the bleeding was carried out, the bleeding was still very active, then reexplored the birth canal and looked for the source of the bleeding, found that there was a portion tear from the front to the back at 5 o'clock.Next, the portion was sutured, evaluated 1 hour after the bleeding suture was no longer active.The patient was treated at the Puskesmas, with a final HB of 7.5 g/dL.

III. DISCUSSION
Uterine atony is a state of inadequate contraction of the uterine corpus myometrium in response to endogenous oxytocin released during labor.[6] The first management of cases of uterine atony is fluid resuscitation, oxygenation, catheter placement, and administration of uterotonics, and at the same time if it does not improve, bimanual compression, both external and internal, and inserting a condom catheter.If the bleeding is still active and does not stop, then the next action that must be taken immediately is conservative surgery with the B-Lynch suture technique and if this technique has not succeeded in treating the bleeding, the action that must be taken immediately is to perform a hysterectomy [1], [5], [6].Fig. 1.Algorithm for treatment of post partum bleeding (atonia uteri) [5].
Tear of the birth canal is a tear or injury that occurs along the birth canal which is usually caused by trauma, a large baby, or fast parturition [3], [4].The tear can start from the upper uterine segment to the lower uterine segment or portio and perineum [4].The management in this case is to explore and evacuate the bleeding and perform suturing to stop the bleeding and repair the tear [3], [4].

IV. CONCLUSION
Postpartum hemorrhage, or bleeding after giving birth, is one of the emergency cases in obstetrics that contributes to the highest maternal mortality rate in the world, with uterine atony as the cause and followed by cases of tears in the birth canal.The main treatment in this case is fluid resuscitation.In addition, determining the cause of postpartum hemorrhage with the 4 T principles (tonus, tissue, trauma, and thrombin) is very important for planning therapy and further action so as not to result in further complications, which can then harm the mother.Speed in handling will provide a good prognosis for the mother and reduce cases of maternal mortality after childbirth.