Postpartum Hemorrhage
The leading preventable cause of maternal death worldwide
Definition (ACOG)
Cumulative blood loss ≥1,000 mL, or blood loss with signs of hypovolemia, within 24 h of birth, by any route of delivery.
- Primary: first 24 h. Secondary: 24 h to 12 weeks.
- Measure, don't guess: quantitative blood loss (weigh pads: 1 g ≈ 1 mL).
- Vital signs change late in young healthy patients. A shock index (HR ÷ systolic BP) >0.9 is an early warning.
Causes: the 4 Ts
| Tone | Uterine atony (most common): overdistended uterus (twins, big baby, polyhydramnios), long labor, oxytocin, infection, magnesium |
| Trauma | Lacerations, hematoma, uterine inversion or rupture. Bleeding with a firm uterus → think trauma |
| Tissue | Retained placenta or clots; placenta accreta |
| Thrombin | Clotting disorders, DIC (abruption, preeclampsia/HELLP, sepsis) |
First actions
- Fundal massage (support the lower uterus above the pubic bone with the other hand).
- Call for help; activate the hemorrhage protocol.
- Empty the bladder (a full bladder pushes the uterus up and to the right).
- Two large-bore IVs; fluids; oxygen; legs raised.
- Labs: CBC, type and crossmatch, coagulation, fibrinogen.
- Uterotonics and TXA as ordered; keep counting blood loss.
Tranexamic acid (TXA) Must know
1 g IV over 10 min, as soon as possible and within 3 hours of birth, given alongside uterotonics. A second 1 g dose if bleeding continues after 30 min or restarts within 24 h.
Reduces death from bleeding (WOMAN trial; endorsed by ACOG). Less effective the later it's given.
Uterotonic drugs
| Drug | Usual dose | Watch for / avoid |
|---|---|---|
| Oxytocin | IV infusion (10–40 units in 500–1,000 mL) or 10 units IM | First-line. Never undiluted IV push (hypotension) |
| Methylergonovine | 0.2 mg IM every 2–4 h | Avoid in hypertension or preeclampsia (vasoconstriction). Refrigerate |
| Carboprost | 250 mcg IM every 15–90 min (max 8 doses) | Avoid in asthma (bronchospasm). Diarrhea, fever. Refrigerate |
| Misoprostol | 600–1,000 mcg oral, sublingual or rectal | Fever, shivering; diarrhea |
If bleeding continues
Uterine balloon tamponade, uterine artery embolization, compression sutures, hysterectomy. Massive transfusion protocol (red cells, plasma, platelets, fibrinogen/cryo).
Hematoma
Severe perineal or rectal pain and pressure, swelling, signs of blood loss with little visible bleeding.
Priority
A boggy uterus + heavy bleeding → massage first. Uterus firm but bright red bleeding continues → laceration: notify.
Saturating a pad in ≤1 hour, or clots larger than an egg, is excessive bleeding.
Saturating a pad in ≤1 hour, or clots larger than an egg, is excessive bleeding.