How should postpartum hemorrhage be managed in a patient who has just delivered and is actively bleeding?

Management of Active Postpartum Hemorrhage

Immediately administer tranexamic acid 1 g IV over 10 minutes alongside oxytocin 5-10 IU (IV or IM), initiate uterine massage and bimanual compression, and begin fluid resuscitation—all within 3 hours of birth, as effectiveness decreases by 10% for every 15-minute delay. 1, 2, 3

Immediate First-Line Actions (Within Minutes)

Pharmacological Management

• Tranexamic acid 1 g IV over 10 minutes is critical and must be given within 3 hours of birth—administration beyond 3 hours may be harmful, and each 15-minute delay reduces effectiveness by approximately 10%. 1, 2
• Oxytocin 5-10 IU should be administered slowly IV or IM immediately; the IV route is more effective than IM. 1, 2, 3
• A second dose of tranexamic acid 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours. 1, 4, 2

Physical Interventions

• Perform uterine massage and bimanual compression immediately. 1
• Conduct a 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

Resuscitation

• Begin fluid resuscitation with physiologic electrolyte solutions immediately. 1, 3
• Administer oxygen to achieve arterial saturation ≥95%. 1
• Maintain normothermia by warming all infusion solutions and blood products, and use active skin warming—clotting factors function poorly below 36°C. 6, 1, 2

Second-Line Pharmacological Management (If Bleeding Persists)

• Carboprost (Hemabate) 250 mcg IM is indicated for postpartum hemorrhage due to uterine atony that has not responded to oxytocin and uterine massage. 7
• Methylergonovine 0.2 mg IM can be used as an alternative, but is absolutely contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis). 1, 4, 8
• Avoid methylergonovine and prostaglandin F2α in women with asthma due to risk of bronchospasm. 1, 4
• Rectal misoprostol 800-1000 mcg achieves sustained uterine contraction within 3 minutes with 63% hemorrhage control rate, particularly useful in low-resource settings. 2

Blood Product Management

When to Initiate Massive Transfusion Protocol

• Activate massive transfusion protocol when estimated blood loss exceeds 1,500 mL. 1, 2
• Do not delay transfusion waiting for laboratory results in severe bleeding—treat based on clinical presentation initially. 6, 1

Transfusion Strategy

• For blood loss <4 units RBC: Withhold fresh frozen plasma (FFP) until at least 4 units of packed red blood cells have been transfused, unless early coagulopathy is documented. 1
• After 4 units RBC: Administer 4 units FFP and maintain a 1:1:1 ratio of packed RBCs:FFP:platelets. 6, 1, 2
• Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage. 1, 2

Fibrinogen Replacement

• Hypofibrinogenemia (fibrinogen <2 g/L) is the single most important predictor of severe PPH and should be aggressively corrected. 1, 2
• Administer cryoprecipitate or fibrinogen concentrate when fibrinogen falls below 2 g/L with ongoing bleeding. 1, 2
• Repeat fibrinogen dosing if bleeding persists. 1

Platelet Transfusion

• Platelet transfusion is rarely needed unless blood loss exceeds 5,000 mL or platelet count falls below 75 × 10⁹/L. 1, 4

Laboratory Monitoring

• Obtain baseline complete blood count, coagulation panel (PT/PTT, fibrinogen), blood group and screen, and venous blood gas to detect lactate >2 mmol/L (signals shock). 1
• Use point-of-care testing (viscoelastic hemostatic assays) rather than conventional laboratory analysis for faster turnaround during active hemorrhage. 1, 4
• Monitor fibrinogen levels repeatedly—this is the most critical parameter to follow. 1
• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 6, 1, 2

Mechanical Interventions (If Pharmacological Management Fails)

Intrauterine Balloon Tamponade

• Intrauterine balloon tamponade should be implemented before proceeding to surgery or interventional radiology, with success rates of 79.4-88.2% for uterine atony. 1, 2
• For vaginal delivery: Perform thorough pelvic examination to exclude cervical/vaginal lacerations before balloon insertion. 1
• For cesarean delivery: Introduce deflated balloon directly through hysterotomy before uterine closure. 1
• If balloon tamponade fails, bilateral uterine artery ligation is the next surgical step. 1

Pelvic Pressure Packing

• Pelvic packing is highly effective for acute uncontrolled hemorrhage stabilization and can remain in place for 24 hours (with open abdomen and ventilatory support). 6, 1, 2

Definitive Interventions (If Conservative Measures Fail)

Interventional Radiology

• Arterial embolization is particularly useful when no single bleeding source is identified, but requires hemodynamic stability for transfer. 6, 1, 2
• Rule out hemoperitoneum before hospital-to-hospital transfer for embolization. 5

Surgical Interventions (Sequential Approach)

• Uterine compression sutures (B-Lynch or similar brace sutures). 6, 1, 2
• Bilateral uterine artery ligation. 1
• Hypogastric artery ligation (can be difficult and time-consuming, but effective when performed by experienced surgeons). 6
• Hysterectomy as last resort. 2

Recombinant Factor VIIa

• Consider recombinant activated factor VIIa only for severe refractory bleeding post-hysterectomy with failed standard therapy—carries 3% thrombosis risk. 6, 2

Critical Monitoring and Follow-Up

• Continue intensive 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
• Maintain low threshold for reoperation if ongoing bleeding is suspected. 6
• Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome. 1

Common Pitfalls to Avoid

• Never delay tranexamic acid beyond 3 hours of birth—effectiveness decreases by 10% for every 15 minutes, and late administration may be harmful. 1, 2
• Never use methylergonovine in hypertensive patients—risk of severe vasoconstriction and hypertensive crisis. 1, 4
• Do not routinely perform manual removal of placenta except in cases of severe, uncontrollable PPH—increases infection and hemorrhage risk. 1, 2
• Do not wait for laboratory results before initiating blood component therapy in severe bleeding—treat based on clinical presentation. 6, 1
• Do not rely on visual estimation of blood loss—use calibrated blood collection drapes and volumetric measurement tools. 4
• Do not delay FFP unnecessarily—after 4 units RBC, begin 1:1 ratio transfusion. 1