What is the immediate treatment for a postpartum woman experiencing postpartum hemorrhage (PPH)?

Immediate Treatment of Postpartum Hemorrhage

Administer tranexamic acid 1 g IV 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, 2

Critical Time-Sensitive Interventions

Tranexamic Acid Administration (MUST BE FIRST-LINE)

• Give tranexamic acid 1 g IV over 10 minutes immediately—this is now a WHO strong recommendation and must be administered within 3 hours of birth 1, 2
• Effectiveness decreases by approximately 10% for every 15-minute delay, and administration beyond 3 hours may be harmful 1, 2
• A second dose of 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2
• TXA should be administered in all cases of PPH regardless of etiology (uterine atony, trauma, retained tissue) 1, 2

Oxytocin Administration

• Administer oxytocin 5-10 IU slow IV or IM immediately 3, 1, 2, 4
• The IV route is more effective than IM for PPH treatment—IV infusion reduces mean blood loss by 5.9% compared to IM, and IV bolus reduces it by 11.1% 5, 6
• Follow with maintenance infusion not exceeding 40 IU total cumulative dose 7
• Higher oxytocin doses (up to 80 IU) are associated with 47% reduction in PPH compared to lower doses (10 IU), with moderate doses (30 IU) showing 43% reduction 2, 8

Immediate Physical Interventions

Manual Examination and Massage

• Perform manual uterine examination with antibiotic prophylaxis 7
• Initiate immediate uterine massage and bimanual compression 1
• Conduct careful visual assessment of the lower genital tract for lacerations or trauma 1, 7

Fluid Resuscitation

• Begin aggressive fluid resuscitation with physiologic electrolyte solutions 1, 2
• Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1

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

Additional Uterotonics

• Administer sulprostone within 30 minutes of PPH diagnosis if oxytocin fails 7
• Alternatively, carboprost tromethamine (prostaglandin F2α) 250 μg IM can be used for refractory uterine atony 9
• CRITICAL CONTRAINDICATIONS: Avoid prostaglandin F2α in women with asthma (risk of bronchoconstriction) 1, 9
• Avoid methylergonovine in hypertensive patients (>10% risk of severe vasoconstriction and hypertension) 1, 2
• Methylergonovine should also be avoided in women with asthma due to bronchospasm risk 1

Mechanical Interventions (Before Surgery or Interventional Radiology)

Intrauterine Balloon Tamponade

• Implement intrauterine balloon tamponade if pharmacological treatments fail—this has a 79.4-88.2% success rate in uterine atony cases 1, 2, 7
• This should be performed before proceeding to surgery or interventional radiology 1, 2
• Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours 1

Surgical and Interventional Options

• Uterine compression sutures (B-Lynch or similar brace sutures) can control bleeding 1
• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer 1, 7

Resuscitation and Blood Product Management

Transfusion Thresholds and Targets

• Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 1
• Do not delay transfusion waiting for laboratory results in severe bleeding 1
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1, 7
• Maintain fibrinogen level ≥2 g/L during active hemorrhaging 7

Essential Supportive Measures

• Maintain normothermia: Warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures) 1, 7
• Administer oxygen to achieve arterial oxygen saturation ≥95% in severe PPH 3, 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1

Monitoring and Follow-Up

• 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, 2
• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 1

Special Considerations

Manual Removal of Placenta

• Manual removal of placenta should NOT be routinely performed except in cases of severe and uncontrollable PPH 3, 2

Anticoagulated Patients

• Active management of third stage with oxytocin is critical in anticoagulated patients, as primary hemostasis mechanism is myometrial contraction, not coagulation 1, 2
• If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 1

Imaging for Hemodynamically Stable Patients

• CT with IV contrast is useful in hemodynamically stable patients to localize bleeding sources, particularly for intra-abdominal hemorrhage 1
• Ultrasound can be used to diagnose retained products of conception 1