What is the treatment for postpartum hemorrhage (PPH) after a cesarean section (C-section)?

Management of Bleeding After Cesarean Section

The first-line treatment for postpartum hemorrhage (PPH) after cesarean section is uterine massage and administration of oxytocin (5-10 IU slow IV or IM), followed by a maintenance infusion not exceeding a cumulative dose of 40 IU. 1

Initial Management

• Uterine atony is the most common cause of PPH after cesarean section, occurring in >75% of cases 2
• Initial management includes:
  • Manual uterine massage 1
  • Oxytocin administration: 5-10 IU slow IV or IM, followed by maintenance infusion 3, 1
  • Visual assessment of the lower genital tract to identify lacerations or trauma 1
  • Antibiotic prophylaxis if manual exploration is performed 1

Pharmacological Management Algorithm

First-line treatment:

• Oxytocin 5-10 IU slow IV/IM bolus, followed by infusion (10-40 units in 1000 mL of non-hydrating solution) 3, 1
• Higher infusion doses (up to 80 IU/500 mL) appear more effective than lower doses for cesarean deliveries 4
• Bolus administration of oxytocin is more effective than continuous infusion alone 5

Second-line treatment (if bleeding persists after 30 minutes):

• Prostaglandin analogues such as sulprostone or carboprost tromethamine 6, 1
• Carboprost tromethamine (Hemabate) 250 μg IM can be administered when conventional methods including oxytocin have failed 6
• Methergine (ergometrine) can be used for postpartum atony and hemorrhage 7
  • Caution: Ergometrine may cause bronchospasm, particularly with general anesthetics, and should be avoided in women with asthma 2

Third-line treatment:

• Tranexamic acid 1 g IV (over 10 minutes) within 3 hours of bleeding onset 2
• If bleeding continues after 30 minutes or restarts within 24 hours, a second dose of 1 g IV can be given 2

Mechanical and Surgical Interventions

• Intrauterine balloon tamponade if pharmacological management fails 1
• If bleeding continues despite medical management:
  • Uterine compression sutures (during cesarean section) 2, 8
  • Uterine or ovarian artery ligation (during cesarean section) 2, 8
  • Arterial embolization (if patient is stable enough for transfer to interventional radiology) 2, 1
  • Hysterectomy as last resort when all other measures fail 8

Blood Component Therapy

• Fluid resuscitation is recommended for persistent PPH 1
• Maintain hemoglobin concentration >8 g/dL 1
• Maintain fibrinogen level ≥2 g/L during active hemorrhage 1
• For severe bleeding:
  • Red blood cells, fibrinogen, and fresh frozen plasma may be administered without awaiting laboratory results 1
  • If coagulation results are unavailable and bleeding is ongoing after 4 units of RBC, administer 4 units of FFP and maintain 1:1 ratio until coagulation results are available 2
  • Point-of-care testing is recommended in this setting 2

Additional Considerations

• Hypofibrinogenemia (fibrinogen <2 g/L) with ongoing bleeding is associated with progression to massive obstetric hemorrhage 2
• Cell salvage can be used during cesarean section with excessive bleeding (use a leukocyte filter for autotransfusion) 2
• Prevent and treat hypothermia by warming infusion solutions, blood products, and active skin warming 1
• Administer oxygen in women with severe PPH 1

Common Pitfalls and Caveats

• Blood loss during cesarean section is frequently underestimated 8
• Delay in recognizing and treating PPH increases morbidity and mortality 1
• Prostaglandin F2α (carboprost) may cause bronchoconstriction and should be used with caution in women with asthma 2
• Protocol-led use of blood products without laboratory guidance may lead to overtransfusion of FFP in many cases 2
• Consider thromboprophylaxis after bleeding is controlled, especially in women with additional risk factors for VTE 2