What is the treatment for postpartum (post-partum) hemorrhage or postpartum complications?

From the Guidelines

The treatment for postpartum hemorrhage should include the early use of intravenous tranexamic acid, in addition to standard care, with a recommended dose of 1 g intravenously given over 10 minutes, and a second dose of 1 g if bleeding continues or restarts within 24 hours. This recommendation is based on the updated WHO guidelines from 2018, which strongly support the use of tranexamic acid for the treatment of post-partum haemorrhage following vaginal birth or caesarean section 1. The guidelines define clinically diagnosed post-partum haemorrhage as a clinically estimated blood loss of more than 500 mL after vaginal birth or 1000 mL after caesarean section, or any blood loss that compromises haemodynamic stability.

Key points to consider in the treatment of postpartum hemorrhage include:

• The use of tranexamic acid should not be delayed, and it should be given within 3 hours of birth 1
• The treatment should be given regardless of the cause of the bleeding, including genital tract trauma or uterine atony 1
• A second dose of tranexamic acid may be given if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1
• Standard care for postpartum hemorrhage should also be provided, in addition to tranexamic acid 1

It is essential to note that the updated recommendation from 2018 is broader than the previous recommendation, and it advises the use of tranexamic acid in all cases of post-partum haemorrhage, regardless of the effectiveness of other treatments like oxytocin 1. This approach prioritizes the reduction of morbidity, mortality, and improvement of quality of life for women experiencing postpartum hemorrhage.

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 Oxytocin Injection, USP (synthetic) is indicated to produce uterine contractions during the third stage of labor and to control postpartum bleeding or hemorrhage. Carboprost tromethamine injection is indicated for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management.

The treatment for postpartum hemorrhage or postpartum complications includes:

• Oxytocin (IV): 10 to 40 units added to 1,000 mL of a nonhydrating diluent and run at a rate necessary to control uterine atony 2
• Oxytocin (IV): to produce uterine contractions during the third stage of labor and to control postpartum bleeding or hemorrhage 2
• Carboprost tromethamine (IM): for the treatment of postpartum hemorrhage due to uterine atony which has not responded to conventional methods of management, including oxytocin, manipulative techniques, and ergot preparations 3

From the Research

Treatment for Postpartum Hemorrhage

• The first-line preventative therapy for postpartum hemorrhage is pharmacotherapy, which may include single or combination therapies such as oxytocin, carbetocin, methylergonovine, ergometrine, misoprostol, prostaglandin analogs, or tranexamic acid 4.
• Combined therapy rather than oxytocin alone is recommended for preventing postpartum hemorrhage, as it has an additive or synergistic effect and a greater risk reduction for postpartum hemorrhage prevention compared with oxytocin alone 4.
• Tranexamic acid has been found to be both effective and safe for decreasing maternal mortality in women with postpartum hemorrhage, and prophylactic use of tranexamic acid may decrease the need for packed red blood cell transfusions and/or uterotonics 4.

Management of Postpartum Pain

• The goal of postpartum pain management is to achieve the right complement and dosing schedule of medications and nonpharmacologic comfort measures to successfully relieve pain, while allowing the woman to remain fully awake and aware to care for her newborn 5.
• Evidence-based pain management strategies include both pharmacologic and nonpharmacologic methods, such as ibuprofen and acetaminophen 6.
• The first-line use of ibuprofen rather than acetaminophen for postpartum pain did not lengthen the duration of severe-range hypertension in women with preeclampsia with severe features 6.

Uterotonic Medications

• Oxytocin is the first-line agent for preventing and treating uterine atony, a common cause of primary postpartum hemorrhage 7.
• Methylergonovine and carboprost are highly effective second-line agents with severe potential side effects, while misoprostol remains a useful therapeutic in resource-limited practice environments 7.

Best Practices in Postpartum Care

• Inadequate pain relief in the hours to months following childbirth can interfere with maternal-newborn bonding and feeding, and increase the risk of postpartum complications 8.
• Recommendations for pain management based on available evidence are outlined, including considerations for pain management in lactating women and for hospital discharge 8.