Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Activate PPH protocol; massage uterus; start oxytocin; add uterotonics sequentially; give TXA early.
- Identify cause (4 Ts); perform balloon tamponade if atony persists; repair lacerations; remove retained tissue.
- If refractory → IR embolization or surgical options (B-Lynch, stepwise devascularization, hysterectomy); ICU care.
Clinical Synopsis & Reasoning
PPH is blood loss ≥1000 mL or bleeding with signs of hypovolemia within 24 h of birth. Activate PPH protocol: fundal massage and uterotonics (oxytocin first-line), add tranexamic acid within 3 hours, perform uterine balloon tamponade, and escalate to uterine artery embolization or surgical interventions (B-Lynch, hysterectomy) if refractory.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Quantified blood loss and vitals | Severity | Accurate assessment | Triggers MTP |
| Bedside ultrasound (retained products) | Etiology | Atony vs tissue vs trauma vs thrombin | 4 Ts |
| Coagulation labs/fibrinogen | Coagulopathy | Guide products | Maintain fibrinogen >200 mg/dL |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Blood loss ≥1000 mL or ongoing bleeding with instability | Maternal mortality risk | Activate PPH protocol; massive transfusion |
| Atony not responding to first-line uterotonics | Ongoing hemorrhage | Balloon tamponade; TXA; escalate to IR/surgery |
| Retained placenta or invasive placentation | Source not controlled | Manual removal; OR; multidisciplinary team |
| Coagulopathy or DIC | Failure to clot | Lab-guided products; fibrinogen concentrate/cryoprecipitate |
| Cesarean or operative delivery | Higher risk | Prep resources; early senior help |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Oxytocin infusion; add Methylergonovine 0.2 mg IM (if no HTN), Carboprost 250 µg IM q15–90 min (max 8), Misoprostol 800–1000 µg PR | Uterotonics | Minutes | Atony control | Contraindications apply |
| Tranexamic acid 1 g IV (repeat once) within 3 h | Antifibrinolytic | Minutes | Reduce mortality | Give early |
| Massive transfusion (PRBC:FFP:Platelets) guided by TEG/ROTEM | Hemostatic resuscitation | Minutes | Correct coagulopathy | Calcium repletion |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- WHO/ACOG postpartum hemorrhage bundles and recommendations — Link