Next Step: Administer Tranexamic Acid
After failed manual compression and oxytocin during vaginal delivery with ongoing PPH, immediately administer intravenous tranexamic acid (TXA) 1 g over 10 minutes, followed by intrauterine balloon tamponade (Bakri balloon) if bleeding persists. 1, 2, 3
Immediate Pharmacologic Intervention
- TXA is the critical next step that reduces bleeding-related mortality when given within 3 hours of delivery, with effectiveness declining by approximately 10% for every 15 minutes of delay 1, 2, 3
- Administer TXA 1 g (100 mg/mL) intravenously at 1 mL/min over 10 minutes as part of the first-response bundle 1, 2, 3
- A second dose of 1 g should be given if bleeding continues after 30 minutes or restarts within 24 hours 2, 3
- TXA has demonstrated reduced risk of severe PPH, death from bleeding, and need for laparotomy in international trials 1
Sequential Non-Surgical Intervention
If bleeding persists after TXA administration, proceed immediately to intrauterine balloon tamponade (Answer B: Bakri balloon) before considering surgical options 1, 2, 4
- Balloon tamponade has a success rate of 79.4% to 88.2% in uterine atony cases and should be implemented as a first-line conservative mechanical intervention 3, 4
- This intervention can temporarily control active PPH due to uterine atony that has not responded to medical therapy 4
- The American College of Radiology positions balloon tamponade as the appropriate step after failure of uterotonic medications but before proceeding to interventional radiology or surgery 3
Why Not the Other Options First?
Uterine Artery Ligation (Option C)
- Uterine artery ligation has decreased efficacy due to collateral circulation and can be technically difficult 1
- This should be reserved for cases where balloon tamponade has failed 1, 4
B-Lynch Suture (Option A)
- Compression sutures are surgical interventions that should be considered only if bleeding continues despite medical management and non-surgical approaches like balloon tamponade 2
- These require laparotomy and are more invasive than balloon placement 4
Hysterectomy (Option D)
- Hysterectomy is reserved as the last resort when all other measures have failed 1, 2
- This is the final surgical option for uncontrollable PPH 5
Critical Timing Considerations
- Do not delay TXA administration while arranging other interventions - every 15-minute delay reduces effectiveness by 10% 1, 2, 3
- TXA should not be given beyond 3 hours after birth as it may be potentially harmful 3
- The sequential approach should move from less invasive (TXA → balloon) to more invasive interventions (surgical) as required 3, 5
Concurrent Management
While implementing these interventions, simultaneously:
- Maintain fluid resuscitation with physiologic electrolyte solutions 2, 4
- Monitor fibrinogen levels and consider early replacement with cryoprecipitate if <2-3 g/L with ongoing bleeding 1
- Initiate massive transfusion protocol if blood loss exceeds 1500 mL 2
- Maintain normothermia, as clotting factors function poorly at lower temperatures 2
The correct answer is B (Bakri balloon), but only after TXA administration, which is the most critical immediate next step that was not listed among the options.