What is the immediate management of postpartum hemorrhage?

Immediate Management of Postpartum Hemorrhage

Activate your massive hemorrhage protocol immediately, establish large-bore IV access, begin uterine massage and bimanual compression, administer oxytocin 5-10 IU IV/IM, give tranexamic acid 1 g IV over 10 minutes, measure blood loss with a collection bag, obtain baseline labs including Clauss fibrinogen, and prepare for blood product transfusion while simultaneously identifying and treating the bleeding source. 1, 2

Initial Resuscitation and Team Activation

• Declare the massive hemorrhage situation and activate your major hemorrhage protocol with a designated team leader coordinating all interventions 3
• Assign specific roles: communications lead for laboratory coordination, personnel for blood product transport, and a team member dedicated to securing vascular access 3
• Establish large-bore IV access immediately (ideally 8-Fr central access in adults; consider intra-osseous or surgical access if peripheral attempts fail) 3
• Administer high-flow oxygen to maintain tissue perfusion 3

Immediate Pharmacologic Interventions

First-Line Uterotonic Therapy

• Administer oxytocin 5-10 IU slow IV or IM injection immediately as the first-line uterotonic agent 2, 4
• For ongoing bleeding, add oxytocin 10-40 units to 1,000 mL non-hydrating diluent and infuse at a rate necessary to control uterine atony (not to exceed cumulative dose of 40 IU) 4, 5

Tranexamic Acid Administration

• Give tranexamic acid 1 g IV over 10 minutes within 3 hours of delivery - effectiveness declines by approximately 10% for every 15 minutes of delay 3, 1, 2
• Administer a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours 2
• This intervention reduces bleeding-related mortality and progression to severe PPH in international trials 3, 1

Mechanical Interventions

• Perform immediate uterine massage and bimanual compression while pharmacologic agents take effect 2
• Conduct manual uterine examination to identify retained placenta or tissue, with antibiotic prophylaxis 5
• Carefully inspect the lower genital tract for lacerations or trauma requiring repair 5

Blood Loss Measurement and Laboratory Assessment

• Place a calibrated blood collection bag immediately to measure cumulative blood loss accurately (volumetric/gravimetric techniques) 3, 2
• Obtain baseline labs urgently: complete blood count, PT, aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and crossmatch for at least 4-6 units of packed RBCs 3, 2
• Consider point-of-care testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available 3

Fluid Resuscitation and Blood Product Strategy

Initial Resuscitation

• Begin aggressive fluid resuscitation with warmed physiologic electrolyte solutions 3, 2
• Actively warm the patient and all transfused fluids - hypothermia severely impairs clotting factor function 3, 2
• Maintain temperature >36°C and avoid acidosis, as both impair coagulation 2, 6

Blood Product Transfusion

• Activate massive transfusion protocol if blood loss exceeds 1,500 mL 2, 6
• For severe ongoing bleeding, transfuse in a 4:4:1 ratio (RBC:FFP:platelets) or 1:1:1 ratio depending on your institutional protocol 3, 7, 6
• Maintain hemoglobin >8 g/dL as the transfusion threshold 5
• In obstetric PPH, withhold FFP until 4 units of RBC have been given unless early coagulopathy is documented, as most atonic/traumatic bleeds don't initially cause coagulopathy 3

Fibrinogen Management - Critical in Obstetrics

• Hypofibrinogenemia (Clauss fibrinogen <2 g/L) occurs in 17% of PPH cases with blood loss >2,500 mL and is the most common factor deficiency 3, 1
• Fibrinogen <3 g/L (especially <2 g/L) with ongoing bleeding predicts progression to massive obstetric hemorrhage 3
• Administer cryoprecipitate or fibrinogen concentrate early if fibrinogen <2-3 g/L with ongoing bleeding - may need to give before RBCs in cases of severe early hypofibrinogenemia (abruption, amniotic fluid embolus, sepsis with pre-eclampsia) 3, 1
• Maintain fibrinogen ≥2 g/L during active hemorrhage 5
• Platelet transfusion rarely needed unless blood loss >5,000 mL or platelet count <75 × 10⁹/L 3

Escalation of Uterotonic Therapy

• If oxytocin fails within 30 minutes, administer second-line uterotonics (sulprostone where available, or methylergonovine if no hypertension, or carboprost) 5
• Avoid methylergonovine in hypertensive patients due to vasoconstriction risk 2

Mechanical Tamponade

• Implement intrauterine balloon tamponade if pharmacologic management fails and before proceeding to surgery or interventional radiology 2, 5
• This is particularly effective for uterine atony unresponsive to uterotonics 5

Surgical and Interventional Options

When to Escalate

• Proceed to definitive interventions if bleeding continues despite initial measures (uterotonics, tranexamic acid, balloon tamponade) 1, 2

Interventional Radiology

• Uterine artery embolization is particularly useful when no single identifiable bleeding source exists and the patient is hemodynamically stable 1, 2
• Consider imaging (ultrasound, CT with IV contrast) in stable patients to localize bleeding source before embolization 1, 2

Surgical Hierarchy

• Uterine compression sutures (B-Lynch or similar) for persistent bleeding 2, 6
• Uterine or internal iliac artery ligation (though efficacy decreased due to collateral circulation) 1, 6
• Hysterectomy as last resort when all other measures fail 1, 2

Critical Pitfalls to Avoid

• Do not delay tranexamic acid administration - benefit decreases 10% for every 15 minutes of delay 1, 2
• Do not wait for laboratory results to initiate transfusion in active severe hemorrhage - transfuse empirically 2
• Do not use derived fibrinogen levels - only Clauss fibrinogen is accurate 3
• Do not allow hypothermia or acidosis - both severely impair coagulation 3, 2, 6
• Do not transfuse FFP routinely in obstetric PPH until 4 units RBC given, unless documented early coagulopathy 3
• Avoid vasopressors during active bleeding - focus on volume resuscitation and bleeding control 3

Ongoing Monitoring

• Continuously assess vital signs (heart rate, blood pressure, capillary refill, conscious level, skin color) 3
• Monitor for visible blood loss (on floor, in drains, on clothing) and signs of internal bleeding 3
• Continue hemodynamic monitoring for at least 24-48 hours postpartum in severe cases, preferably in ICU setting 2, 6
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2, 6
• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 2