What is the management of postpartum hemorrhage (PPH) in a recently postpartum female patient?

Postpartum Hemorrhage: A Simple Guide

What Is It?

Postpartum hemorrhage (PPH) is excessive bleeding after delivery—defined as blood loss ≥500 mL after vaginal birth or ≥1,000 mL after cesarean section, or any bleeding that makes the mother unstable. 1 It's the leading cause of maternal death worldwide, with most deaths occurring in the first 24 hours after birth. 1

Why Does It Happen? (The "Four T's")

The causes can be remembered as the Four T's: 2

• Tone (Uterine Atony) - The uterus doesn't contract properly after delivery. This is the most common cause, responsible for over 75% of cases. 3, 4 Think of the uterus as a muscle that needs to squeeze down to stop bleeding from where the placenta was attached.

• Trauma - Tears in the vagina, cervix, or uterus; or the uterus turning inside-out (rare). 2

• Tissue - Pieces of placenta or membranes left inside the uterus. 2

• Thrombin (Clotting Problems) - The blood doesn't clot properly due to underlying conditions or massive blood loss. 2

How to Prevent It

Every woman should receive oxytocin immediately after delivery to prevent PPH. 3, 2 This medication helps the uterus contract and is given as 5-10 units either into a vein (IV) or muscle (IM). 5 This simple step significantly reduces bleeding risk regardless of whether delivery was vaginal or cesarean. 6

Immediate Treatment When PPH Occurs

First Actions (Do These Right Away)

The moment PPH is recognized, give tranexamic acid (TXA) 1 gram IV over 10 minutes within 3 hours of birth, alongside oxytocin 5-10 units, start uterine massage, and begin fluid resuscitation. 3, 1 This is critical because:

• TXA must be given within 3 hours—its effectiveness drops by 10% every 15 minutes you wait, and giving it after 3 hours may actually be harmful. 3, 1
• TXA works by preventing blood clots from breaking down too quickly. 7
• A second 1-gram dose can be given if bleeding continues after 30 minutes or restarts within 24 hours. 3, 1

Physical Maneuvers

• Uterine massage - Firmly massage the uterus through the abdomen to stimulate contractions. 3, 8
• Bimanual compression - One hand inside the vagina pushes up on the uterus while the other hand pushes down from the abdomen. 3
• Manual examination of the uterus - Check inside for retained placental pieces (give antibiotics first). 8
• Inspect for tears - Carefully look at the vagina, cervix, and perineum for lacerations that need repair. 8

Additional Medications (If Bleeding Continues)

If oxytocin alone doesn't work: 8

• Methylergonovine 0.2 mg IM - BUT avoid this if the woman has high blood pressure (can cause dangerous spikes) or asthma (can cause breathing problems). 3, 4
• Prostaglandin F2α - Also avoid in women with asthma due to breathing problems. 3

When Bleeding Doesn't Stop

Balloon Tamponade

If medications fail, place an intrauterine balloon to apply pressure from inside the uterus. 3, 1 This works in 79-90% of cases when properly placed and should be tried before surgery. 1

Blood Transfusion

Start massive transfusion protocol if blood loss exceeds 1,500 mL. 3, 1 This means giving:

• Packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio. 7
• Don't wait for lab results in severe bleeding—start transfusing immediately. 3, 4, 1
• Target: Keep hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active bleeding. 3, 1

The most important clotting factor to watch is fibrinogen—levels below 2 g/L predict severe hemorrhage. 7, 4

Surgical Options (Last Resort)

If everything else fails: 8

• Arterial embolization - A radiologist blocks the bleeding blood vessels (patient must be stable enough to transfer). 3, 1
• Uterine compression sutures - Special stitches that compress the uterus. 3
• Hysterectomy - Removing the uterus as a life-saving measure. 8

Critical Things to Remember

• Keep the mother warm - Warm all IV fluids and blood products, and use warming blankets. Cold temperatures prevent blood from clotting properly. 3, 1
• Give oxygen in severe PPH. 3, 8
• Monitor closely for 24 hours after delivery, as complications can develop. 3, 1
• Visual estimation of blood loss is notoriously inaccurate—use collection bags and measurement tools when possible. 4, 8

Common Mistakes to Avoid

• Delaying TXA—every 15 minutes counts. 3, 1
• Waiting for lab results before transfusing in severe bleeding. 3, 1
• Giving methylergonovine to women with high blood pressure or asthma. 3, 4
• Underestimating blood loss because it "doesn't look that bad." 4
• Not maintaining body temperature—hypothermia makes bleeding worse. 3, 1