What is the management for postpartum hemorrhage (PPH)?

Management of Postpartum Hemorrhage

When PPH occurs, immediately administer oxytocin 5-10 IU IV or IM alongside uterine massage and bimanual compression, followed by tranexamic acid 1 g IV over 10 minutes if within 3 hours of birth, while simultaneously initiating fluid resuscitation and preparing for escalation to mechanical or surgical interventions if bleeding persists. 1, 2

Immediate First-Line Actions

Pharmacologic Management:

• Administer oxytocin 5-10 IU slow IV or IM immediately as the most effective first-line uterotonic agent 1, 2, 3
• The IV route is more effective than IM for PPH prevention and treatment 1
• For ongoing atony, infuse 10-40 units of oxytocin in 1000 mL of physiologic electrolyte solution at a rate necessary to control bleeding 3

Tranexamic Acid - Critical Timing:

• Administer tranexamic acid 1 g IV over 10 minutes within 3 hours of birth - this is strongly recommended by WHO and ACOG 1, 2, 4
• Effectiveness decreases by 10% for every 15 minutes of delay after birth 1, 2, 4
• Give a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• Do NOT administer TXA beyond 3 hours postpartum - it may be harmful 1, 4
• TXA should be given regardless of whether bleeding is from uterine atony or genital tract trauma 1

Non-Pharmacologic Interventions:

• Perform uterine massage and bimanual compression immediately 1, 2
• Initiate IV fluid resuscitation with physiologic electrolyte solutions 1, 2
• Monitor vital signs continuously to assess hemodynamic stability 1, 2

Second-Line Pharmacotherapy

If bleeding persists despite oxytocin and TXA:

• Methylergonovine 0.2 mg IM - effective second-line agent 4, 5
  • Contraindicated in hypertensive patients due to vasoconstriction risk 1, 4
• Carboprost tromethamine (15-methyl PGF2α) IM - for refractory uterine atony 6
  • Should be used after failure of oxytocin 6
• Rectal misoprostol 800-1000 mcg - alternative if other agents unavailable or failed 4
  • Achieves hemorrhage control in 63% within 10 minutes 4

Mechanical Interventions

When pharmacologic management fails:

• Intrauterine balloon tamponade - first-line conservative mechanical intervention 1, 2
  • Success rate of 79.4-88.2% for uterine atony 1, 4
  • Should be implemented alongside uterotonics 1
• Bimanual uterine compression - place fist inside vagina against anterior lower uterine segment with counter-pressure on abdomen 2
• Pelvic pressure packing - effective for acute uncontrolled hemorrhage, can be left for 24 hours 2, 4

Surgical and Interventional Radiology

For persistent bleeding despite medical and mechanical measures:

• Uterine artery embolization - particularly useful when no single bleeding source identified 2, 4
• Uterine compression sutures (B-Lynch or similar) 4
• Uterine or internal iliac artery ligation - systematic pelvic devascularization 2
• Hysterectomy - definitive last resort 2

Massive Transfusion Protocol

Initiate when blood loss exceeds 1500 mL: 2, 4

• Transfuse packed red blood cells, fresh frozen plasma, and platelets in fixed ratio 2
• Obtain baseline labs: CBC, coagulation profile, crossmatch 2
• Do not delay treatment while waiting for laboratory results 2, 4

Critical Pitfalls to Avoid

• Never delay TXA administration - every 15 minutes reduces effectiveness by 10% 1, 2, 4
• Never give TXA beyond 3 hours postpartum - potentially harmful 1, 4
• Avoid manual removal of placenta outside specialized settings unless severe uncontrolled hemorrhage 7
• Maintain normothermia - clotting factors function poorly at lower temperatures 2, 4
• Avoid methylergonovine in hypertensive patients 1, 4
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 2, 4

Monitoring and Follow-up

• Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts and risk of delayed complications 1, 2, 4
• Monitor for complications including renal failure, liver failure, infection, and Sheehan syndrome 2
• Assess for retained products of conception using ultrasound if indicated 2

The "Four T's" Approach to Etiology

While managing PPH, simultaneously identify the cause using the Four T's mnemonic: 8

• Tone (uterine atony) - most common cause
• Trauma (lacerations, hematomas, uterine rupture/inversion)
• Tissue (retained placenta or invasive placentation)
• Thrombin (coagulopathy)