What is the management of postpartum bleeding?

Management of Postpartum Hemorrhage

Immediately administer tranexamic acid 1 g IV 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

Initial Assessment and Immediate Actions

Postpartum hemorrhage is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability. 1

First-Line Pharmacological Management (Within Minutes)

• Tranexamic acid 1 g IV over 10 minutes is the priority medication and 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

• Administer TXA in all cases of PPH regardless of etiology (uterine atony, genital tract trauma, retained placental tissue). 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, 2

• Oxytocin 5-10 IU should be administered slowly IV or IM immediately, followed by maintenance infusion not exceeding a cumulative dose of 40 IU. 1, 3, 4

• Oxytocin is the first-line uterotonic agent and is more effective than misoprostol with fewer adverse effects. 5

Immediate Physical Interventions

• Perform uterine massage and bimanual compression immediately. 1, 2
• Conduct manual uterine examination with antibiotic prophylaxis to identify retained placental tissue or uterine atony. 4
• Perform careful visual inspection of the lower genital tract to identify lacerations, hematomas, or cervical tears requiring surgical repair. 2, 4
• Empty the bladder to optimize uterine contraction. 4

Second-Line Management (If Bleeding Persists After 30 Minutes)

Additional Pharmacological Options

• Sulprostone should be administered within 30 minutes of PPH diagnosis if oxytocin fails to control bleeding. 4
• Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertension) and should be avoided in women with asthma due to bronchospasm risk. 2, 6, 7
• Carbetocin may be preferable in cardiac patients as it shows better hemodynamic stability than oxytocin with less significant drops in blood pressure. 6

Mechanical Interventions

• Intrauterine balloon tamponade should be implemented if sulprostone fails and before proceeding to surgery or interventional radiology, with a success rate of 79.4% to 88.2% in uterine atony cases. 1, 2
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours. 2
• Non-pneumatic antishock garment can be used for temporary stabilization while arranging definitive care. 2

Resuscitation Protocol

Fluid and Blood Product Management

• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL. 2
• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio. 2
• Do not delay transfusion waiting for laboratory results in severe bleeding—RBC, fibrinogen, and FFP may be administered without awaiting laboratory results. 2, 4
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 2, 4

Essential Supportive Measures

• Maintain normothermia by warming all infusion solutions and blood products and using active skin warming, as clotting factors function poorly at lower temperatures. 2, 4
• Administer oxygen in severe PPH. 2, 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 2

Invasive Interventions (If Conservative Measures Fail)

Surgical and Interventional Radiology Options

• Uterine compression sutures (B-Lynch or similar brace sutures) can be used to control bleeding when medical and balloon tamponade measures fail. 2
• Arterial embolization is particularly useful when no single bleeding source is identified and requires hemodynamic stability for transfer, with success rates exceeding 90% in controlling PPH unresponsive to other therapies. 2, 8
• Stepwise uterine devascularization or hypogastric artery ligation may be considered in severe uncontrollable bleeding. 9
• Hysterectomy remains a life-saving intervention in cases of intractable bleeding. 8

Diagnostic Imaging Considerations

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage. 2
• A bladder flap hematoma >5 cm should raise suspicion for uterine dehiscence. 2
• Ultrasound can be used to diagnose retained products of conception. 2

Special Populations and Considerations

Anticoagulated Patients

• Anticoagulated patients with mechanical heart valves should switch from oral anticoagulants to LMWH/UFH from 36 weeks gestation. 2
• Discontinue UFH 4-6 hours before planned delivery. 2
• If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH). 2
• Caesarean delivery is preferred to reduce fetal intracranial hemorrhage risk. 2

Post-Hemorrhage Monitoring

• 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. 10, 2
• Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome. 2
• Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors such as BMI ≥30 kg/m², emergency cesarean section, or postpartum blood loss >1 L. 10
• Early ambulation with elastic support stockings can reduce thromboembolism risk. 2

Common Pitfalls to Avoid

• Do not use ergometrine (methylergonovine) in hypertensive patients or those with cardiac disease due to severe vasoconstriction risk. 10, 2
• Do not delay TXA administration—it must be given within 3 hours of birth and should not be given beyond this window. 1, 2
• Do not routinely perform manual removal of placenta except in cases of severe and uncontrollable PPH. 1
• Prostaglandin F2α should not be used in women with asthma due to bronchoconstriction risk. 10