Critical Alerts

• PPH is the leading cause of maternal mortality worldwide
• Uterine atony accounts for 70-80% of PPH cases
• 4 T's mnemonic: Tone (atony), Trauma, Tissue (retained), Thrombin (coagulopathy)
• Massive hemorrhage (>1000 mL) requires immediate intervention
• Early recognition and treatment significantly reduces mortality

Key Diagnostics

• Direct observation and measurement of blood loss
• Fundal assessment (boggy = atony)
• Cervical and vaginal inspection for lacerations
• Placental examination (completeness, abnormalities)
• Coagulation profile, CBC, Type & Crossmatch

Emergency Treatments

• Uterine massage: First-line for suspected atony
• Oxytocin: 20-40 units in 1L crystalloid IV
• Ergometrine: 0.2-0.5 mg IM/IV (avoid in hypertension)
• Carboprost: 250 mcg IM q15-90min (avoid in asthma)
• Misoprostol: 800-1000 mcg SL/rectal
• TXA: 1g IV (give within 3 hours of delivery)
• Massive transfusion protocol: 1:1:1 ratio pRBCs:FFP:Platelets

Postpartum hemorrhage (PPH) is defined as excessive blood loss following childbirth. The traditional definition of blood loss ≥500 mL after vaginal delivery or ≥1000 mL after cesarean section has been updated, with many organizations now using ≥1000 mL or blood loss with signs of hypovolemia as the threshold for action.

Classification

Severity Classification

Epidemiology

• Incidence: 1-6% of deliveries (primary PPH)
• Maternal mortality: Leading direct cause worldwide
• Trends: Increasing in developed countries (obesity, cesarean rates)

Critical Warning Signs

Shock Index (SI)

SI = Heart Rate / Systolic Blood Pressure

Causes by the 4 T's

Tone (Uterine Atony)

• Most common cause (70-80%)
• Boggy, enlarged uterus
• Responds to massage and uterotonics

Trauma

Tissue

Thrombin (Coagulopathy)

• Blood not clotting on swab
• Bleeding from IV sites, mucous membranes
• Prolonged PT/PTT, low fibrinogen

Initial Assessment

ABCDE Approach

• A: Airway patent
• B: Breathing adequate (tachypnea)
• C: Circulation (volume status, hemorrhage control)
• D: Disability (level of consciousness)
• E: Exposure (quantify blood loss, examine for source)

Laboratory Studies

Bedside Clot Test

• Place 5-10 mL blood in red-top tube
• Observe for clot formation at 7-10 minutes
• No clot or rapid lysis suggests coagulopathy

Point-of-Care Testing

• TEG/ROTEM if available for real-time coagulation assessment
• Guides targeted blood product replacement

ICU Admission Criteria

• Massive transfusion (>4 units pRBCs)
• Hemodynamic instability despite resuscitation
• Ongoing hemorrhage
• DIC
• Multi-organ dysfunction
• Post-hysterectomy

Labor & Delivery Admission Criteria

• Controlled PPH requiring observation
• Minor PPH that has resolved
• Ongoing monitoring needs

Discharge Criteria (After Resolution)

• Hemodynamically stable >24 hours
• No ongoing bleeding
• Hemoglobin stable (may discharge Hb >7 with iron supplementation)
• Able to care for newborn
• Follow-up arranged

Follow-up Recommendations

Understanding PPH

• Postpartum hemorrhage is excessive bleeding after delivery
• It is a serious but treatable condition
• Multiple interventions may be needed
• Most women recover fully with prompt treatment

Warning Signs After Discharge

Return Immediately If:

• Heavy bleeding (soaking >1 pad/hour for >2 hours)
• Passing large clots (golf ball sized or larger)
• Dizziness, lightheadedness, fainting
• Racing heart
• Fever or chills
• Foul-smelling vaginal discharge

Recovery

• Fatigue is normal and may last weeks
• Iron supplementation if prescribed
• Adequate hydration and nutrition
• Rest when possible
• Gradual return to activities

Future Pregnancies

• Risk of recurrence is 10-15%
• Early OB consultation recommended
• May need active management of third stage
• Close monitoring during labor
• Delivery at facility with blood products available

Secondary PPH (>24 hours postpartum)

Common Causes

• Retained products of conception
• Endometritis
• Subinvolution of placental site

Management

• Ultrasound to assess for retained products
• Antibiotics if infection suspected
• Curettage if retained tissue confirmed
• Uterotonics for subinvolution

Cesarean Section PPH

• Higher baseline blood loss (average 1000 mL)
• May be internal/concealed
• B-Lynch suture often effective
• Lower threshold for uterine artery ligation

Coagulation Disorders

Pre-existing

• Von Willebrand disease
• Factor deficiencies
• Platelet disorders

Management

• Pre-delivery planning with hematology
• Factor replacement available
• Desmopressin (DDAVP) for vWD
• Platelet transfusion as needed

Uterine Inversion

Recognition

• Profound shock (neurogenic + hemorrhagic)
• Fundus not palpable abdominally
• May see fundus at or protruding through cervix

Management

• Immediate replacement manually
• Stop uterotonics (relax uterus first)
• Consider terbutaline, nitroglycerin, or general anesthesia
• Once replaced, give uterotonics
• Surgical if manual fails

Performance Indicators

Documentation Requirements

• Quantified blood loss (not just "EBL")
• Time of interventions
• Medications given with doses and timing
• Blood products transfused
• Procedures performed
• Patient response
• Disposition and follow-up plan

Prevention Pearls

1. Active management of third stage reduces PPH by 50%
2. Risk stratification on admission guides preparation
3. Quantitative blood loss is more accurate than estimation
4. Have uterotonics drawn up before high-risk deliveries
5. Type and screen early for high-risk patients

Treatment Pearls

1. Uterine massage is first-line - don't skip it
2. TXA works best within 3 hours - give early
3. Don't wait for "target" Hb to transfuse - use clinical judgment
4. Warm all blood products - hypothermia worsens coagulopathy
5. Replace calcium - massive transfusion causes hypocalcemia

Disposition Pearls

1. Stay with the patient - PPH can recur
2. Check fundus frequently after stabilization
3. Repeat hemoglobin before discharge
4. Document clearly for medicolegal purposes
5. Debrief the team - improves future responses