What are the current recommendations for prevention and treatment of postpartum hemorrhage, including prophylactic oxytocin dosing, second‑line uterotonics, tranexamic acid administration, and stepwise escalation to balloon tamponade, compression sutures, arterial embolization, or hysterectomy?

Recent Postpartum Hemorrhage Guidelines

Definition and Diagnosis

Postpartum hemorrhage is defined as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section, or any blood loss sufficient to compromise hemodynamic stability. 1

• PPH remains the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1
• Severe persistent PPH is defined as active bleeding >1000 mL within 24 hours following birth that continues despite first-line uterotonic agents and uterine massage 2

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First-Line Prevention: Prophylactic Oxytocin

Administer oxytocin 10 IU intravenously immediately after delivery of the neonate (after anterior shoulder or whole body) and before placental delivery. 3

• If no IV access is available, give oxytocin 10 IU intramuscularly 3
• Higher oxytocin doses (up to 80 IU) are associated with 47% reduction in PPH compared to lower doses (10 IU), with moderate-dose regimens (30 IU) showing intermediate benefit with 43% reduction 1
• Oxytocin is more effective than misoprostol for prevention and treatment of uterine atony and has fewer adverse effects 4

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Prophylactic Tranexamic Acid

Consider adding tranexamic acid 1 g IV over 10 minutes immediately after delivery of the neonate in high-risk patients to prevent PPH. 3

• Combined oxytocin and tranexamic acid prophylaxis reduces postpartum blood loss and need for packed red blood cell transfusions 5
• TXA use before both vaginal and cesarean deliveries reduces postpartum blood loss and should be considered in patients at higher risk for hemorrhage 6

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Treatment of Active PPH: Tranexamic Acid

Administer tranexamic acid 1 g IV over 10 minutes as soon as PPH is diagnosed, but only within 3 hours of birth. 7

Critical Timing Requirements:

• TXA must be given within 3 hours of birth—efficacy decreases by 10% for every 15 minutes of delay, with no benefit after 3 hours 7, 8
• Do not administer TXA beyond 3 hours postpartum as it may be potentially harmful 7, 8
• Give a second dose of 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours of the first dose 7

Indications:

• TXA should be given in all cases of PPH, regardless of whether bleeding is due to genital tract trauma or uterine atony 7
• This represents a broader recommendation than previous guidelines, which advised TXA only after oxytocin and other treatments failed 7

Contraindications:

• Avoid TXA in women with known thromboembolic events during pregnancy 7, 9

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Second-Line Uterotonics

If bleeding continues despite oxytocin and TXA, add second-line uterotonics in the following order:

Methylergonovine:

• Dose: 0.2 mg intramuscularly 8
• Contraindicated in hypertensive patients due to risk of vasoconstriction 1, 8

Misoprostol:

• Dose: 800-1000 mcg rectally or 400 mcg sublingually 8, 3
• Achieves hemorrhage control in 63% of cases within 10 minutes when oxytocin has failed 8
• Can achieve sustained uterine contraction within 3 minutes in patients unresponsive to oxytocin and ergometrine 8

Carboprost:

• Do not delay administration while waiting for laboratory results in active hemorrhage 8

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Mechanical and Non-Surgical Interventions

If pharmacologic measures fail, proceed immediately to mechanical interventions:

• Intrauterine balloon tamponade has 79.4-88.2% success rate for uterine atony and should be first-line conservative mechanical intervention 1, 8
• Bimanual uterine compression 1, 8
• Non-pneumatic antishock garment 1
• External aortic compression 1
• Pelvic pressure packing for acute uncontrolled hemorrhage 8

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Surgical Interventions

Sequential escalation to surgical interventions when mechanical measures fail:

• Uterine compression sutures (B-Lynch or similar) 1, 8
• Arterial ligation 1
• Uterine artery embolization (particularly useful when no single bleeding source is identified) 1, 8
• Hysterectomy as final option 1, 8

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Supportive Care and Monitoring

Initiate massive transfusion protocol if blood loss exceeds 1500 mL 8

• Fluid replacement with physiologic electrolyte solutions and IV fluid resuscitation 1
• Monitor vital signs continuously 1
• Maintain normothermia, as clotting factors function poorly at lower temperatures 8
• Continue hemodynamic monitoring for at least 24 hours after delivery due to significant fluid shifts 1, 8
• Re-dose prophylactic antibiotics if blood loss exceeds 1500 mL 8

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Common Pitfalls to Avoid

• Do not delay TXA administration—every 15 minutes of delay reduces effectiveness by 10% 7, 8
• Never give TXA beyond 3 hours postpartum 7, 8
• Do not use methylergonovine in hypertensive patients 1, 8
• Do not delay carboprost while waiting for laboratory results 8
• Do not perform routine manual removal of placenta except in severe uncontrollable PPH 1
• Avoid routine episiotomy to decrease blood loss risk 4