What are the RCog (Royal College of Obstetricians and Gynaecologists) guidelines for managing postpartum hemorrhage (PPH)?

RCOG Guidelines for Postpartum Hemorrhage Management

Definition and Initial Recognition

Postpartum hemorrhage is defined as blood loss ≥500 mL after vaginal delivery or ≥1000 mL after caesarean section, or any blood loss sufficient to compromise hemodynamic stability. 1, 2

• PPH is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1
• Early recognition and immediate intervention are critical to prevent progression to severe PPH 3

Immediate First-Line Management (Within Minutes)

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, 4

Tranexamic Acid - Critical Timing

• TXA 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, 4
• Fixed dose of 1 g (100 mg/mL) intravenously at 1 mL/min (over 10 minutes) 1
• A second dose of 1 g should 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) 4
• Contraindicated in women with known thromboembolic event during pregnancy 2

Oxytocin Administration

• Oxytocin 5-10 IU administered slowly IV or IM is the first-line uterotonic 1, 5
• Can be followed by maintenance infusion not to exceed cumulative dose of 40 IU 5
• IV route is more effective than IM for PPH prevention 1

Manual Interventions

• Perform uterine massage and bimanual compression immediately 4, 5
• Bimanual technique: place fist inside vagina against anterior lower uterine segment with counter-pressure from abdominal hand 2
• Manual uterine examination with antibiotic prophylaxis 5
• Careful visual assessment of lower genital tract for trauma 5

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

If oxytocin fails to control bleeding, administer sulprostone within 30 minutes of PPH diagnosis. 5

Alternative Uterotonics

• Prostaglandin analogs (carboprost, sulprostone) are second-line agents when oxytocin fails 6
• Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of vasoconstriction and severe hypertension) 4
• Methylergonovine should be avoided in women with asthma due to bronchospasm risk 4
• Misoprostol remains an option in low-resource settings but has limited effectiveness as independent therapy 6

Mechanical Interventions (Before Surgery or Interventional Radiology)

Intrauterine balloon tamponade should be implemented if pharmacological management fails, with success rates of 79-90% when properly placed. 1, 4

• Balloon tamponade is positioned as first-line conservative mechanical intervention after uterotonic failure 1
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours 2, 4
• Non-pneumatic antishock garment can be used for temporary stabilization while arranging definitive care 2, 4

Resuscitation and Blood Product Management

Initiate massive transfusion protocol if blood loss exceeds 1,500 mL, transfusing packed RBCs, fresh frozen plasma, and platelets in fixed ratio. 2, 4

Transfusion Targets and Timing

• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 4, 5
• Do not delay transfusion waiting for laboratory results in severe bleeding 2, 4
• RBC, fibrinogen, and FFP may be administered without awaiting laboratory results 5
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2, 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, 4, 5
• Administer oxygen in severe PPH 4, 5
• Obtain baseline laboratory tests including complete blood count, coagulation profile, and crossmatch 2

Surgical and Interventional Radiology Options

If bleeding persists despite pharmacological and mechanical interventions, proceed to arterial embolization (if hemodynamically stable) or surgical intervention. 4, 5

Surgical Techniques

• Uterine compression sutures (B-Lynch or similar brace sutures) 4, 5
• Systematic pelvic devascularization including uterine or internal iliac artery ligation 2, 7
• Hysterectomy as last resort 1, 5
• Sequential use of interventions should start with less invasive approaches, moving toward more invasive as required 1

Interventional Radiology

• Arterial embolization is particularly useful when no single bleeding source is identified 2, 4
• Requires hemodynamic stability for transfer 4
• Hospital-to-hospital transfer for embolization is possible once hemoperitoneum is ruled out 5

Etiology-Specific Considerations (The "4 T's")

Tone (Uterine Atony) - Most Common (>75%)

• Treated with uterotonic drugs and uterine massage as described above 4
• Clinical diagnosis; CT can detect focal or diffuse arterial/venous oozing in enlarged uterus 8

Trauma (Lacerations, Rupture, Inversion)

• Requires careful visual inspection and surgical repair 4
• CT with IV contrast useful for localizing bleeding in hemodynamically stable patients 8, 4
• Uterine rupture or inversion requires immediate surgical intervention 2

Tissue (Retained Placenta/Products)

• Manual removal of placenta should not be routinely performed except in severe uncontrollable PPH 8, 1
• Ultrasound can diagnose retained products showing echogenic endometrial mass with vascularity 2, 4
• Surgical evacuation if confirmed 2

Thrombin (Coagulopathy)

• May be inherited or acute (amniotic fluid embolism, HELLP syndrome) 8
• Requires aggressive correction of coagulation parameters 5

Monitoring and Post-Acute Care

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. 1, 4

Complications to Monitor

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

Special Populations

Anticoagulated Patients with Mechanical Heart Valves

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

Critical Pitfalls to Avoid

• Delaying TXA administration beyond 3 hours or waiting to give it—every 15-minute delay reduces effectiveness by 10% 1, 4
• Delaying treatment for active hemorrhage while waiting for laboratory results 2
• Failing to maintain normothermia and normal pH, which impairs clotting 2, 4
• Using methylergonovine in hypertensive patients 4
• Routine manual removal of placenta in non-severe cases 8, 1

Prevention Strategies

• Prophylactic oxytocin administration immediately after delivery (5-10 IU IV or IM) reduces PPH incidence 1, 5
• Active management of third stage of labor is recommended by all major guidelines 3
• Controlled cord traction after caesarean delivery 5