Postpartum haemorrhage: uterotonic ladder, tranexamic acid, and massive obstetric haemorrhage

Model answer

Resuscitation (4). Help, MOH protocol, O2, large-bore access, bloods including fibrinogen, warm, arterial line if massive, communicate with obstetricians and blood bank.^[12]

Drugs (5). TXA 1 g IV within 3 h; oxytocin slow small bolus then infusion (lower effective doses than historical 5 to 10 IU boluses); ergometrine if not hypertensive; carboprost if not asthmatic; misoprostol adjunct.^{[1][7][10][11]}

Coagulation and surgery (6). Replace fibrinogen early (2 g per litre or less predicts severe bleeding); RBC/plasma/platelets per protocol and ROTEM; balloon, brace sutures, IR, hysterectomy as needed.^[6][12]