What is the most appropriate initial step in managing a postpartum hemorrhage (PPH) in a patient with a soft uterus and ongoing bleeding despite uterine massage, with symptoms of tachycardia and normal blood pressure, following a vaginal delivery with oxytocin (Pitocin) infusion?

From the Guidelines

The most appropriate initial step in management for this patient with postpartum hemorrhage is to administer tranexamic acid, as it is recommended by the WHO for the treatment of post-partum haemorrhage, in addition to standard care, which in this case includes the already initiated oxytocin infusion and fluid administration. This patient is experiencing significant bleeding, with heavy vaginal bleeding and clots, and a soft uterus, indicating uterine atony. The WHO strongly recommends the early use of intravenous tranexamic acid (within 3 hours of birth) for women with clinically diagnosed post-partum haemorrhage, with a fixed dose of 1 g intravenously at 1 mL/min, and a second dose of 1 g intravenously if bleeding continues after 30 minutes, or if bleeding restarts within 24 hours of completing the first dose 1. While increasing the oxytocin infusion (option C) may be considered, the addition of tranexamic acid is crucial in the management of postpartum hemorrhage, as it has been shown to reduce the risk of death from bleeding. The other options, such as transfusing fresh frozen plasma (option A), placing compression sutures (option B), administering misoprostol (option D), performing intrauterine tamponade (option E), or administering methylergonovine (option F), may be considered if the bleeding continues despite the initial management with oxytocin and tranexamic acid.

Some key points to consider in the management of this patient include:

• The patient's bleeding is significant, with heavy vaginal bleeding and clots, and a soft uterus, indicating uterine atony.
• The patient has risk factors for postpartum hemorrhage, including polyhydramnios, prolonged rupture of membranes, and delivery of a large infant.
• The WHO recommends the early use of intravenous tranexamic acid for the treatment of post-partum haemorrhage, in addition to standard care.
• Oxytocin infusion has already been initiated, and increasing the dose may be considered, but the addition of tranexamic acid is crucial in the management of postpartum hemorrhage.

The patient's management should prioritize the reduction of bleeding and the maintenance of hemodynamic stability, with the use of tranexamic acid, oxytocin, and fluid administration, and the consideration of other options if the bleeding continues.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... Control of Postpartum Uterine Bleeding Intravenous Infusion (Drip Method) – 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 The most appropriate initial step in management is to Increase oxytocin infusion as the patient is already on an oxytocin infusion for active management of the third stage of labor and is experiencing heavy vaginal bleeding with clots, indicating possible uterine atony. The drug label supports the use of oxytocin to control postpartum uterine bleeding 2.

From the Research

Management of Postpartum Hemorrhage

The patient is experiencing heavy vaginal bleeding with clots after delivery, despite bimanual uterine massage and manual removal of intrauterine clots. The most appropriate initial step in management would be to increase the oxytocin infusion, as oxytocin is the first-line uterotonic agent for preventing postpartum hemorrhage 3, 4, 5.

Uterotonic Agents

• Oxytocin is the first-line agent for preventing postpartum hemorrhage 3, 4, 5
• Methylergonovine and carboprost are highly effective second-line agents, but have severe potential side effects 4
• Misoprostol is a useful therapeutic in resource-limited practice environments, but its effectiveness as an adjunct to other uterotonic agents has been called into question 4, 6, 7

Treatment Options

• Increasing the oxytocin infusion is a suitable initial step in managing postpartum hemorrhage, as it is the first-line uterotonic agent 3, 4, 5
• Administering methylergonovine or misoprostol may be considered as second-line agents, but their use should be carefully evaluated due to potential side effects and varying effectiveness 4, 6, 7
• Other options, such as transfusing fresh frozen plasma, placing compression sutures, performing intrauterine tamponade, or administering other uterotonics, may be considered based on the patient's specific condition and response to initial treatment.