Management of Postpartum Bleeding after Cesarean Section

Initial Assessment and Diagnosis

The American College of Radiology suggests that fever or foul-smelling discharge may indicate endometritis, which is more common after cesarean section than vaginal delivery 3
Severe pain may indicate retained products of conception (RPOC) or cesarean scar complications, according to the American College of Radiology 2
The American College of Radiology recommends transvaginal ultrasound as the primary diagnostic tool for RPOC, looking for vascular echogenic mass or endometrial thickness >8-13 mm 3, 2
Color Doppler helps identify vascular RPOC requiring additional intervention, as suggested by the American College of Radiology 2

The American College of Radiology states that postpartum endometritis is more common after cesarean section than vaginal delivery, and clinical diagnosis is made by fever, uterine tenderness, and foul-smelling discharge 3
Cesarean scar defects occur in 24-88% of women and may cause abnormal bleeding patterns, according to the American College of Radiology 1
Uterine scar dehiscence is difficult to distinguish from normal cesarean scar appearance on ultrasound, as noted by the American College of Radiology 3
Vascular complications, such as pseudoaneurysms, appear as hypoechoic masses with turbulent flow on Doppler, according to the American College of Radiology 3

If hemodynamically stable with light spotting, obtain focused history, perform pelvic examination, and order transvaginal ultrasound if bleeding persists or is associated with significant pain or fever, as recommended by the American College of Radiology 1, 2, 3
If concerning features are present, obtain baseline labs, perform immediate transvaginal ultrasound, and consider ultrasound-guided gentle suction curettage for RPOC, according to the American College of Radiology 2, 3
If hemodynamically unstable, initiate resuscitation, obtain stat labs, and activate massive transfusion protocol if indicated, as suggested by the American College of Radiology 2

Never assume absence of menstruation guarantees lack of fertility after 6 weeks postpartum, according to the American College of Radiology 1
Do not perform blind digital examination before excluding low-lying placenta or vascular abnormalities, as noted by the American College of Radiology 2
Avoid aggressive sharp curettage that could perforate the thinned cesarean scar if RPOC removal is needed, according to the American College of Radiology 2

If normal menstrual return is diagnosed, counsel that menstrual patterns may differ from pre-pregnancy patterns, as recommended by the American College of Radiology 1
If RPOC is treated, maintain close hemodynamic monitoring for 24-48 hours, serial hemoglobin checks, and watch for delayed complications, according to the American College of Radiology 2