What is the management of postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

Immediate First-Line Management

Administer intravenous tranexamic acid 1 g over 10 minutes within 3 hours of birth alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation with physiologic electrolyte solutions. 1, 2, 3

Critical Time-Sensitive Actions

• Tranexamic acid must be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful 1, 2
• A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 4
• TXA should be administered in all cases of PPH regardless of etiology (uterine atony, trauma, retained tissue) 1

Oxytocin Administration Protocol

• First-line uterotonic: Oxytocin 5-10 IU slow IV or IM immediately after placental delivery 1, 2, 3
• For ongoing bleeding control: 10-40 units oxytocin in 1,000 mL non-hydrating diluent, infused at rate necessary to control atony (not exceeding 40 IU cumulative dose) 2, 3
• Slow IV infusion (<2 U/min) prevents systemic hypotension 5

Simultaneous Non-Pharmacological Interventions

• Perform uterine massage and bimanual compression (fist in vagina against anterior lower uterine segment with abdominal counter-pressure) 2
• Manual uterine examination with antibiotic prophylaxis 6
• Careful visual assessment of lower genital tract for lacerations 6
• Use calibrated blood collection drape for accurate measurement—visual estimation is unreliable 4

Second-Line Pharmacological Management

If oxytocin fails to control bleeding within 30 minutes:

• Carboprost tromethamine (prostaglandin F2α): Indicated for uterine atony unresponsive to oxytocin and uterine massage 7
• Methylergonovine 0.2 mg IM: For routine management of uterine atony 8
  • CONTRAINDICATED in hypertensive patients (>10% risk of vasoconstriction and severe hypertension) 5, 1
  • Avoid in women with asthma due to bronchospasm risk 4

Mechanical and Surgical Interventions

Non-Surgical Approaches (if pharmacological management fails)

• Intrauterine balloon tamponade: Implement before proceeding to surgery or interventional radiology 1, 2, 6
• Pelvic pressure packing: Effective for acute uncontrolled hemorrhage stabilization, can remain for 24 hours 2
• Non-pneumatic antishock garment: For temporary stabilization while arranging definitive care 1

Surgical and Interventional Options

• Uterine compression sutures (B-Lynch or similar brace sutures) 1, 2
• Arterial embolization: Particularly useful when no single bleeding source identified, requires hemodynamic stability for transfer 5, 2
• Uterine or internal iliac artery ligation 1, 2
• Hysterectomy: Last resort when all other measures fail 1, 2

Resuscitation and Blood Product Management

Fluid and Transfusion Protocol

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 2, 9
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 2
• Do not delay transfusion waiting for laboratory results in severe bleeding 2, 4, 6
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 2, 6

Critical Laboratory Monitoring

• Obtain baseline CBC, coagulation profile, fibrinogen level, and crossmatch 2
• Hypofibrinogenemia (fibrinogen <2 g/L) is the most common factor deficiency and predicts progression to massive hemorrhage 4, 6
• Point-of-care viscoelastic testing (FIBTEM A5 <12 mm) can predict severe hemorrhage 4
• Platelet transfusion rarely required unless PPH exceeds 5,000 mL or platelet count <75 × 10⁹/L 4

Essential Supportive Measures

• Maintain normothermia: Warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures) 2, 6
• Administer oxygen in severe PPH 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2
• Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts that may precipitate heart failure in women with structural heart disease 5, 1

Common Pitfalls to Avoid

• Delaying TXA administration: Every 15-minute delay reduces effectiveness by 10% 1, 2
• Visual estimation of blood loss: Consistently underestimates actual loss—use calibrated measurement tools 4
• Waiting for laboratory results before initiating blood products: In severe bleeding, transfuse empirically 2, 4
• Failing to maintain normothermia and normal pH: Impairs clotting cascade 2
• Using methylergonovine in hypertensive patients: High risk of severe vasoconstriction 5, 1
• Manual placental removal without severe indication: Should not be routine except in severe uncontrollable PPH 1

Special Considerations

Anticoagulated Patients with Mechanical Heart Valves

• Switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation 5
• Discontinue UFH 4-6 hours before planned delivery 5
• If emergent delivery required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 5
• Caesarean delivery preferred to reduce fetal intracranial hemorrhage risk 5

Post-Acute Monitoring

• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 2
• Early ambulation with elastic support stockings to reduce thromboembolism risk 5
• Consider thromboprophylaxis after bleeding controlled, especially with additional VTE risk factors 4