Management of Postpartum Hemorrhage
Administer tranexamic acid 1 g IV over 10 minutes immediately upon diagnosis of PPH, alongside oxytocin 5-10 IU IV/IM, uterine massage, and fluid resuscitation—but only if you are within 3 hours of birth, as tranexamic acid becomes potentially harmful beyond this window. 1, 2, 3
Immediate First-Line Management (Within Minutes of PPH Diagnosis)
Pharmacologic Interventions
Oxytocin: Administer 5-10 IU slow IV or IM immediately, followed by maintenance infusion of 10-40 units in 1000 mL non-hydrating diluent at a rate necessary to control atony (not to exceed 40 IU cumulative dose) 1, 3, 4
Tranexamic Acid: 1 g IV over 10 minutes (1 mL/min) if within 3 hours of birth 1, 2, 3
- A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours 2, 3
- Critical timing: Effectiveness decreases by 10% for every 15 minutes of delay 1, 2, 5
- Do NOT administer beyond 3 hours postpartum—it may cause harm rather than benefit 1, 2, 5
- Number needed to treat is 276 to prevent one bleeding-related death 1, 2
Physical Maneuvers
- Perform uterine massage and bimanual uterine compression 3, 5, 6
- Conduct manual uterine examination with antibiotic prophylaxis 7
- Perform careful visual assessment of the lower genital tract for lacerations 7
Resuscitation
- Initiate fluid replacement with physiologic electrolyte solutions 1, 3, 4
- Maintain hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 7
- Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 5, 6
Second-Line Pharmacologic Management (If Bleeding Persists After 30 Minutes)
Carboprost tromethamine: For uterine atony not responding to oxytocin 9
- Do not delay administration while waiting for laboratory results in active hemorrhage 5
Rectal misoprostol: 800-1000 mcg for hemorrhage unresponsive to oxytocin in low-resource settings 2, 5
Mechanical Interventions (If Pharmacologic Management Fails)
Intrauterine balloon tamponade: Success rate of 79.4-88.2% for uterine atony 3, 5
Pelvic pressure packing: For acute uncontrolled hemorrhage 5
Definitive Interventions (If Conservative Measures Fail)
Uterine artery embolization: Particularly useful when no single bleeding source is identified 5
- Hospital-to-hospital transfer is possible once hemoperitoneum is ruled out and if hemodynamic condition allows 7
Surgical interventions: Uterine compression sutures (B-Lynch), arterial ligation, or hysterectomy 1, 3
Critical Monitoring and Supportive Care
- Monitor vital signs continuously 1, 3
- Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts 3, 5
- Prevent and treat hypothermia by warming infusion solutions, blood products, and active skin warming 7
- Administer oxygen in severe PPH 7
- Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 5
- Maintain normothermia, as clotting factors function poorly at lower temperatures 5
Common Pitfalls to Avoid
- Do not perform manual removal of placenta routinely except in cases of severe, uncontrollable PPH, as this increases infection and hemorrhage risk 1, 2, 5
- Never administer tranexamic acid beyond 3 hours postpartum—it transitions from beneficial to potentially harmful 1, 2, 5
- Avoid methylergonovine in hypertensive patients due to >10% risk of severe vasoconstriction 3, 5
- Do not delay carboprost administration while waiting for laboratory results during active hemorrhage 5
- Administer RBC, fibrinogen, and FFP without awaiting laboratory results during active hemorrhage 7
The "Four T's" Diagnostic Framework
Use this mnemonic to identify the underlying cause of PPH 6:
- Tone: Uterine atony (most common cause)
- Trauma: Laceration, hematoma, inversion, rupture
- Tissue: Retained placenta or invasive placenta
- Thrombin: Coagulopathy