Hemorrhage is defined differently by different texts, but three good general guidelines are these:

• If the bleeding is heavier than the heaviest menstrual period the patient has ever experienced…that is hemorrhage.
• If, when standing, blood is running down her leg and dripping into her shoes…that is hemorrhage.
• If, because of heavy vaginal bleeding, the patient cannot stand upright without feeling light-headed or dizzy…that is hemorrhage.

Vaginal hemorrhage is more often associated with pregnancy complications such as miscarriage or placental abruption, but certainly can occur in the absence of pregnancy.

This is a true medical emergency and a number of precautionary steps should be taken:

• IV access should be established to facilitate fluid resuscitation
• Blood transfusion should be made readily available, if it proves necessary.
• Pregnancy must be excluded as it’s presence may profoundly effect the treatment.
• Bedrest will lead most cases of hemorrhage to slow, regardless of the cause.
• Medical evacuation should be planned as the definitive treatment of uterine hemorrhage not responsive to conservative measures is surgical.

Helpful tips:

Blood counts (hgb or hct) performed during an acute hemorrhage may be falsely reassuring as the hemoconcentration accompanying hemorrhage may take several hours to re-equilibrate in response to your IV fluids.

Elevation of the legs to about 45 degrees will add as much as one unit of fresh, whole blood to the patient’s circulation by eliminating pooling in the lower extremities.

In severe cases of hemorrhage when surgical intervention is not immediately available, vaginal packing can slow and sometimes stop bleeding due to vaginal lacerations or uterine bleeding from many causes.

• After a Foley catheter is inserted in the bladder, a vaginal speculum holds the vaginal walls apart. Tail sponges, long rolls of gauze, 4 X 4’s or any other sterile, gauzelike substance can be packed into the vagina.
• The upper vagina is packed first, with moderate pressure being exerted to insure a tight fit. Then, progressively more packing material is stuffed into the lower vagina, distending the walls.
• Ultimately, the equivalent of a 12-inch or 16-inch softball sized mass of gauze will be packed into the vagina.

Packing of the vagina with gauze has several effects:

1. Any bleeding from the cervix or vagina will have direct compression applied, slowing or stopping the bleeding.
2. The uterus is elevated out of the pelvis by the presence of the vaginal pack, placing the uterine vessels on stretch, slowing blood flow to the uterus and thus slowing or stopping any intrauterine bleeding.
3. By disallowing the egress of blood from the uterus, intrauterine pressure rises to some extent, exerting a tamponade effect on any continuing bleeding within the uterus.

Vaginal packing can be left for 1-3 days, and then carefully removed after the bleeding has stopped or stabilized. Sometimes, only half the packing is removed, followed by the other half the following day. The Foley catheter is very important, both to monitor kidney function (urine output in the presence of hemorrhage) and to allow the patient to urinate (usually impossible without a Foley with the vaginal packing in place).