Step-by-Step Management of Postpartum Hemorrhage (PPH)
The management of postpartum hemorrhage requires immediate recognition, systematic assessment of cause, and a sequential approach starting with medical management and progressing to surgical interventions as needed. This algorithmic approach is critical to reduce maternal morbidity and mortality.
Definition and Initial Assessment
- PPH is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any blood loss sufficient to cause hemodynamic instability 1, 2
- Immediately assess vital signs, estimate blood loss (using collection bags when available), and identify the cause using the "4 T's" mnemonic: Tone (uterine atony), Trauma (lacerations/hematomas), Tissue (retained products), and Thrombin (coagulopathy) 3, 4
First-Line Management
- Simultaneously initiate fluid resuscitation with physiologic electrolyte solutions and call for help 1, 5
- Administer oxytocin 5-10 IU slow IV or IM immediately as first-line uterotonic 1, 5, 2
- Perform uterine massage and bimanual compression for suspected atony 1, 2
- Obtain baseline laboratory tests: complete blood count, coagulation profile (PT, PTT, fibrinogen), and crossmatch for blood products 6
- Maintain patient warmth (temperature >36°C) as clotting factors function poorly at lower temperatures 6
Early Critical Interventions (Within First 30 Minutes)
- Administer tranexamic acid (TXA) 1g IV over 10 minutes as soon as possible and within 3 hours of birth (10% reduction in effectiveness for every 15-minute delay) 1, 5
- If bleeding continues after oxytocin, administer second-line uterotonics:
- Initiate massive transfusion protocol if blood loss exceeds 1500 mL 6, 4
- Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio 6
- Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L 2
Second-Line Interventions (If Bleeding Persists After 30 Minutes)
- Consider second dose of TXA 1g IV if bleeding continues after 30 minutes or restarts within 24 hours 1, 5
- Perform thorough examination to identify and repair genital tract trauma 2, 4
- For retained placenta or products of conception, perform manual removal or surgical evacuation 1, 2
- If atony persists despite uterotonics, proceed to intrauterine balloon tamponade 1, 2, 3
Advanced Interventions (If Second-Line Measures Fail)
- Consider non-pneumatic antishock garment for temporary stabilization while arranging definitive care 1
- Perform imaging studies in hemodynamically stable patients:
- Consider interventional radiology for arterial embolization, particularly when no single source of bleeding can be identified 6, 2
Surgical Management (Last Resort)
- Surgical options include:
- Pelvic pressure packing can be effective for patient stabilization when experiencing acute uncontrolled hemorrhage; may be left in for 24 hours 6
Post-Acute Management
- Continue hemodynamic monitoring for at least 24 hours after delivery 5
- Maintain vigilance for ongoing bleeding and have a low threshold for reoperation if suspected 6
- Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome 6
- Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 6
Common Pitfalls to Avoid
- Delaying TXA administration beyond 3 hours after birth (potentially harmful) 5
- Waiting for laboratory results before initiating treatment for active hemorrhage 6
- Failing to maintain normothermia and normal pH (acidosis impairs clotting) 6
- Overlooking the need for multidisciplinary team activation (obstetrics, anesthesia, blood bank, interventional radiology) 10
- Underestimating blood loss, particularly with vaginal delivery 1, 2