What are the steps to treat postpartum hemorrhage?

From the Guidelines

Postpartum hemorrhage treatment requires prompt identification and a stepwise approach, with the administration of intravenous tranexamic acid within 3 hours of birth, in addition to standard care, as recommended by the WHO 1. The steps to treat postpartum hemorrhage include:

• Assessing the cause using the "4 Ts": Tone (uterine atony), Trauma, Tissue (retained placenta), and Thrombin (coagulation disorders)
• For uterine atony, which causes 70-80% of cases, beginning with uterine massage and bimanual compression, and administering oxytocin 10-40 units IV infusion or 10 units IM as first-line medication
• If bleeding continues, using second-line medications: methylergonovine 0.2mg IM (avoid in hypertensive patients), carboprost (Hemabate) 250mcg IM every 15-90 minutes up to 8 doses, or misoprostol 800-1000mcg rectally
• Ensuring IV access with two large-bore catheters and starting crystalloid fluid resuscitation
• Monitoring vital signs closely and preparing blood products if needed
• For trauma, repairing lacerations
• For retained tissue, performing manual removal or curettage
• For coagulation issues, replacing specific factors
• If medical management fails, proceeding to surgical interventions like uterine balloon tamponade (Bakri balloon), compression sutures (B-Lynch), uterine artery ligation, or hysterectomy as a last resort, as recommended by the ACR Appropriateness Criteria 1. Early recognition and aggressive management are crucial as postpartum hemorrhage can rapidly lead to shock, organ failure, and death. The use of tranexamic acid has been shown to reduce maternal death due to bleeding in women with clinically diagnosed post-partum haemorrhage, and early treatment appears to optimize benefits 1.

From the FDA Drug Label

To control postpartum bleeding, 10 to 40 units of oxytocin may be added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony Intramuscular Administration – 1 mL (10 units) of oxytocin can be given after delivery of the placenta. Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management. An initial dose of 250 micrograms of carboprost tromethamine injection (1 mL of carboprost tromethamine injection) is to be given deep, intramuscularly.

The steps to treat postpartum hemorrhage include:

• Initial Management: Administer oxytocin intravenously, with 10 to 40 units added to 1,000 mL of a nonhydrating diluent, at a rate necessary to control uterine atony 2.
• Alternative Administration: Give 1 mL (10 units) of oxytocin intramuscularly after delivery of the placenta 2.
• Second-Line Treatment: If postpartum hemorrhage persists, consider administering carboprost tromethamine injection, starting with an initial dose of 250 micrograms (1 mL) deep intramuscularly 3 3.
• Ongoing Management: The need for additional injections and the interval at which these should be given can be determined only by the attending physician, as dictated by the course of clinical events 3.

From the Research

Steps to Treating Postpartum Hemorrhage

The treatment of postpartum hemorrhage (PPH) involves several steps, including:

• Identifying the underlying cause of the hemorrhage, using the Four T's mnemonic: Tone (uterine atony), Trauma (laceration, hematoma, inversion, rupture), Tissue (retained tissue or invasive placenta), and Thrombin (coagulopathy) 4, 5
• Estimating the blood loss and initiating a resuscitation protocol with fluid replacement, blood transfusion, and close monitoring of the woman 5
• Using uterotonics, such as oxytocin, to stimulate uterine contractions and reduce bleeding 4, 6
• Performing uterine massage and bimanual uterine compression to help control bleeding 5
• Using intrauterine balloon tamponade or other surgical interventions if uterotonics and uterine massage are ineffective 5

Prevention of Postpartum Hemorrhage

Prevention of PPH is also crucial, and can be achieved through:

• Active management of the third stage of labor, including the use of oxytocin after delivery of the anterior shoulder 4, 5
• Avoiding routine episiotomy to decrease blood loss and the risk of anal laceration 4
• Using ergometrine combined with oxytocin for prevention of PPH at cesarean section, as it has been shown to reduce blood loss compared to oxytocin alone 7

Management of Postpartum Hemorrhage

The management of PPH requires a team-based approach, with rapid response to hemorrhages exceeding 1,500 mL of blood loss, and the use of massive transfusion protocols 4, 5

• The National Partnership for Maternal Safety has developed an obstetric hemorrhage consensus bundle of 13 patient- and systems-level recommendations to reduce morbidity and mortality from PPH 4
• The use of uterotonics, such as methylergonovine and carboprost, as second-line agents for the treatment of uterine atony, with severe potential side effects 6