What are the criteria for managing postpartum hemorrhage (PPH) following vaginal delivery?

Management of Postpartum Hemorrhage Following Vaginal Delivery

Postpartum hemorrhage (PPH) requires immediate recognition and a systematic approach to management to reduce maternal morbidity and mortality. PPH is defined as blood loss ≥500 mL within 24 hours after vaginal delivery or ≥1000 mL after cesarean delivery 1.

Initial Assessment and Management

Immediate Actions

• Administer oxytocin 5-10 IU slow IV or IM immediately after delivery of the placenta 1, 2
• Establish IV access for medication administration and fluid resuscitation 1
• Position patient in lateral decubitus position to attenuate hemodynamic impact 3
• Monitor vital signs closely, including continuous pulse oximetry and ECG as required 3
• Measure cumulative blood loss using volumetric and gravimetric techniques rather than visual estimation 1

First-Line Medications

• Oxytocin is the first-line treatment for uterine atony 1, 2
  • For postpartum bleeding control: 10-40 units in 1000 mL of non-hydrating solution IV at a rate necessary to control atony 2
  • Higher-dose oxytocin regimens (80 IU/500 mL over 1-4 hours) have been associated with lower rates of PPH compared to lower doses (10-30 IU) 4
  • Alternatively, 10 IU IM can be given after placental delivery 2

Second-Line Medications

• Administer tranexamic acid 1g IV within 1-3 hours of bleeding onset 1
• Consider prostaglandin F analogues (carboprost tromethamine) for treatment of uterine atony that has not responded to oxytocin 5
  • Avoid in women with asthma due to risk of bronchoconstriction 1
• Avoid methylergonovine as it carries a risk (>10%) of vasoconstriction and hypertension 3, 6

Management Based on Etiology (Four T's)

1. Tone (Uterine Atony - 70-80% of PPH cases)

• Perform bimanual uterine massage 7
• Administer uterotonics as described above
• Consider uterine tamponade with balloon catheter if bleeding persists 1

2. Trauma (20% of PPH cases)

• Carefully examine the lower genital tract for lacerations, especially in high-risk situations 1, 8
• Repair any identified lacerations
• Evacuate hematomas if large or expanding

3. Tissue (10% of PPH cases)

• Perform manual removal of placenta if retained 8
• Conduct manual uterine exploration after placental delivery 8
• Consider ultrasound to identify retained placental fragments

4. Thrombin (Coagulopathy - 1% of PPH cases)

• Monitor fibrinogen levels and replace if <2 g/L with ongoing bleeding 1
• Withhold FFP until four units of RBC have been given if coagulation tests are not known, then maintain a 1:1 ratio 1
• Perform point-of-care testing to guide blood product replacement 1

Advanced Interventions for Refractory PPH

Radiological Interventions

• Use CT with IV contrast or CTA to identify bleeding source if conventional treatment fails 3
• Consider uterine artery embolization in hemodynamically stable patients 3, 1

Surgical Interventions

• Consider surgical ligation of uterine/internal iliac arteries if other measures fail 1
• Hysterectomy may be necessary as a life-saving measure in cases of intractable hemorrhage 1

Special Considerations

Anticoagulated Patients

• In patients on therapeutic anticoagulation, PPH risk may be increased 3
• For women on LMWH, consider protamine if emergent delivery is necessary 3
• Monitor closely for at least 24 hours after delivery due to risk of delayed hemorrhage 3

Team-Based Approach

• Immediately alert all concerned professionals (midwife, obstetrician, anesthesiology team) 8
• Implement massive transfusion protocols for blood loss exceeding 1,500 mL 7
• Consider transfer to higher level of care if available for complex cases 1

Prevention Strategies

• Active management of the third stage of labor should be used routinely 7
• Avoid routine episiotomy to decrease blood loss 7
• Medical staff training in simulation centers improves outcomes by enhancing teamwork, accurate blood loss evaluation, and adherence to protocols 9

PPH management requires prompt diagnosis, systematic approach to identifying the cause, and escalating interventions as needed. The standardized approach outlined above can significantly reduce maternal morbidity and mortality associated with this common obstetric emergency.