Postpartum Hemorrhage ConcernAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

511 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Vaginal Discharge Hyperemesis Gravidarum Concern Hypertensive Disorders Of Pregnancy Symptoms Postpartum Hemorrhage Concern Postpartum Infection Concern Sexual Assault Medical Evaluation Overview Pelvic Pain Vaginal Bleeding, Nonpregnant Vaginal Bleeding In Pregnancy Pelvic Pain In Pregnancy Post Procedure Or Post Abortion Complications Concern

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx53

Bleeding characteristics

›Bleeding history

›Timing postpartum

›Primary postpartum hemorrhage within 24 hours

›Secondary postpartum hemorrhage 24 hours to 12 weeks

›Estimated blood loss

›Vaginal delivery greater than 500 mL

›Cesarean delivery greater than 1000 mL

›Bleeding pattern

›Sudden gushes

›Persistent heavy bleeding

OPQRST

›OPQRST for bleeding

›Onset

›Time since delivery

›Time since placental delivery

›Provocation and palliation

›Worse with uterine massage or exam

›Change with breastfeeding or oxytocin exposure

›Quality

›Bright red blood

›Clots

›Region and radiation

›Vaginal bleeding

›Pelvic pressure or pain

›Severity

›Pads per hour

›Soaking bed linens or clothing

›Timing

›Continuous bleeding

›Intermittent heavy episodes

Associated symptoms

›Associated symptoms

›Presyncope or syncope

›Dyspnea

›Chest pain

›Palpitations

›Severe pelvic or abdominal pain

›Fever or rigors

›Headache or visual symptoms

›Reduced urine output

Obstetric and delivery details

›Delivery context

›Mode of delivery

›Spontaneous vaginal delivery

›Operative vaginal delivery

›Cesarean delivery

›Placenta details

›Complete placenta delivered

›Manual placental extraction

›Lacerations or repair

›Perineal tears

›Cervical repair

Prior episodes and baseline

›Prior history

›Prior postpartum hemorrhage

›Baseline anemia

›Bleeding disorder history

02Alarm Features/alarm20

Hemodynamic instability

›Shock features

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 120

›Altered mental status

›Cool clammy skin

›Lactate rising or greater than 4 mmol/L

Ongoing major hemorrhage

›High risk bleeding patterns

›Saturating 1 pad in less than 15 minutes

›Large clots

›Persistent bleeding despite uterine massage

High risk etiologies

›Cannot miss conditions

›Uterine inversion

›Retained placenta

›Genital tract laceration with expanding hematoma

›Placenta accreta spectrum

›Disseminated intravascular coagulation

Escalation triggers

›Immediate activation criteria

›Concern for massive hemorrhage

›Two large bore IVs not achievable quickly

›Any ongoing instability despite initial uterotonic

03Medications/meds30

Current and recent exposures

›Medication and substance exposures

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Low molecular weight heparin

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›Uterotonics already given

›Oxytocin

›Methylergonovine

›Carboprost

›Misoprostol

Medication allergies and contraindications

›Contraindications relevant to therapies

›Methylergonovine contraindications

›Hypertension

›Preeclampsia

›Carboprost contraindications

›Asthma

›Significant pulmonary disease

›Tranexamic acid caution

›Active intravascular thrombosis

›Strong thrombotic history

High risk medication interactions

›Interaction traps

›Magnesium sulfate effects

›Uterine atony risk

›Hypotonia and respiratory depression risk

›Sedatives and analgesics

›Hypotension masking shock

›Respiratory depression risk

04Diet/diet9

Intake and hydration

›Intake and hydration context

›Recent oral intake timing

›NPO status

›Vomiting or poor intake

Relevant exposures

›Exposures

›Caffeine and energy drinks

›Herbal products affecting bleeding

›Ginkgo

›Garlic supplements

05Review of Systems/ros17

Bleeding and hematologic

›Hemorrhage related symptoms

›Easy bruising

›Gum bleeding

›Epistaxis

Infectious and inflammatory

›Infection symptoms

›Fever

›Chills

›Uterine tenderness

Cardiopulmonary and neurologic

›Perfusion symptoms

›Dyspnea

›Chest pain

›Confusion

›Severe weakness

Hypertensive disease postpartum

›Preeclampsia related symptoms

›Headache

›Visual changes

›RUQ pain

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral sources

›Partner or family report

›Nursing report

›EMS report

Family history

›Family history risks

›Inherited bleeding disorders

›Von Willebrand disease

›Hemophilia carrier status

›Early cardiovascular disease

›MI before age 55 male relatives

›MI before age 65 female relatives

07Risk Factors/rf27

Obstetric risk factors

›Pregnancy and delivery risks

›Uterine overdistension

›Multiple gestation

›Polyhydramnios

›Macrosomia

›Prolonged labor

›Prolonged first stage

›Prolonged second stage

›Induction or augmentation

›Oxytocin exposure

›Chorioamnionitis

Placental risk factors

›Placental risks

›Placenta previa

›Placenta accreta spectrum

›Retained products risk

›Succenturiate lobe

›Incomplete placenta delivered

Hemorrhage and coagulopathy risks

›Bleeding risks

›Prior postpartum hemorrhage

›Thrombocytopenia

›Gestational thrombocytopenia

›HELLP syndrome

›Anticoagulation therapy

Trauma related risks

›Genital tract trauma risks

›Operative vaginal delivery

›Shoulder dystocia

›Rapid delivery

08Differential Diagnosis/ddx56

Life threatening

›Life threatening causes

›Uterine atony (O72.1)

›Boggy enlarged uterus

›Heavy bleeding without focal laceration source

›Genital tract laceration (O70.0 to O70.3)

›Firm uterus with persistent bleeding

›Bleeding despite uterotonics

›Retained products of conception (O72.0)

›Subinvolution

›Persistent bleeding

›Placenta accreta spectrum (O43.2)

›Difficulty placental separation

›Ongoing hemorrhage after delivery

›Uterine inversion (O71.2)

›Severe pain

›Shock out of proportion to visible blood

›Disseminated intravascular coagulation (D65)

›Oozing from IV sites

›Low fibrinogen

›Uterine rupture (O71.1)

›Severe abdominal pain

›Hemodynamic collapse

Common

›Common causes

›Uterine atony

›Overdistension

›Prolonged labor

›Lacerations

›Cervical

›Vaginal

›Perineal

›Retained placental tissue

›Incomplete placenta

›Placental fragments

Less common

›Less common causes

›Endometritis with secondary hemorrhage (O86.1)

›Fever

›Uterine tenderness

›Subinvolution of placental site

›Delayed postpartum bleeding

›Enlarged uterus

›Uterine artery pseudoaneurysm

›Recurrent delayed heavy bleeding

›Prior uterine instrumentation

›Coagulation disorders

›Von Willebrand disease (D68.0)

›Factor deficiencies

Key distinguishing clues

›Pattern recognition

›Boggy uterus

›Atony more likely

›Responds to uterine massage and uterotonics

›Firm uterus

›Trauma more likely

›Requires speculum exam and repair

›Fever with uterine tenderness

›Infection more likely

›Secondary postpartum hemorrhage pathway

09Past Medical History/pmh12

Obstetric and gynecologic

›Prior obstetric history

›Prior postpartum hemorrhage

›Prior cesarean delivery

›Prior placenta previa or accreta

Medical comorbidities

›Comorbid conditions

›Hypertension and preeclampsia history (O14.9)

›Known bleeding disorder

›Thromboembolic disease

Procedures and devices

›Recent procedures

›Dilation and curettage

›Uterine instrumentation

›Intrauterine balloon placement history

10Physical Exam/exam33

Initial survey and vitals

›General and hemodynamics

›Mental status

›Skin perfusion

›Orthostatic intolerance

›Vital trends

›Tachycardia

›Hypotension

›Tachypnea

›Hypoxia

Abdominal and uterine exam

›Uterus assessment

›Fundal tone

›Boggy

›Firm

›Fundal height

›Enlarged for expected postpartum day

›Tender uterus

›Abdominal guarding or rebound

›Peritonitis concern

›Uterine rupture concern

Pelvic exam

›Genital tract evaluation

›Speculum exam

›Cervical laceration

›Vaginal laceration

›Bimanual exam

›Clots in lower uterine segment

›Uterine inversion findings

›Hematoma assessment

›Vulvar hematoma

›Vaginal hematoma

Cardiopulmonary and neuro

›Shock complication screen

›Pulmonary edema

›New murmur

›Focal neurologic deficits

11Lab Studies/labs30

Initial hemorrhage panel

›Baseline labs for active postpartum hemorrhage

›CBC

›Hemoglobin trend

›Platelet count

›Coagulation studies

›INR

›aPTT

›Fibrinogen

›Low fibrinogen as early marker of severe hemorrhage

›Target thresholds local protocol dependent

›Type and screen

›Crossmatch for anticipated transfusion

›Rh status

Metabolic and end organ perfusion

›Perfusion and organ injury labs

›Lactate

›Trend every 30 to 60 minutes if unstable

›Clearance as resuscitation marker

›Venous blood gas

›pH

›Base deficit

›CMP

›Creatinine

›AST and ALT

Point of care testing and transfusion guidance

›Hemostasis guidance

›POC glucose

›Hypoglycemia as shock marker

›Treatment threshold per local protocol

›Viscoelastic testing

›TEG

›ROTEM

12Imaging/img28

Scoring Systems

›Hemorrhage severity and response tools

›Shock Index

›Heart rate divided by systolic blood pressure

›Greater than 0.9 concerning for significant hemorrhage

›Quantified blood loss approach

›Weighed drapes and sponges

›More reliable than visual estimation

MRI

›MRI role

›Placenta accreta spectrum evaluation

›Usually antepartum planning

›Postpartum use uncommon in acute hemorrhage

›Limitations

›Time and access constraints in unstable patient

›Not first line in acute postpartum hemorrhage

›CT role

›Postpartum hemorrhage with unclear source after stabilization

›Suspected arterial bleeding

›Suspected pelvic hematoma expansion

›CT angiography pelvis

›Target for interventional radiology embolization planning

›Contrast nephropathy risk assessment

Ultrasound

›Ultrasound role

›Transabdominal ultrasound

›Retained products suggested by echogenic material

›Uterine cavity distension by clots

›Doppler ultrasound

›Uterine artery pseudoaneurysm

›Hypervascular retained products caution

13Special Tests/spec21

Bedside maneuvers

›Bedside diagnostics and temporizing actions

›Bimanual uterine compression

›Immediate temporizing maneuver

›Response supports uterine atony

›Uterine sweep

›Removal of clots in lower uterine segment

›Retained tissue suspicion if tissue retrieved

Procedural diagnostics

›Procedural evaluation

›Speculum exam with adequate lighting

›Cervical laceration identification

›Vaginal wall laceration identification

›Examination under anesthesia

›Persistent hemorrhage with inadequate bedside visualization

›Repair and packing capability

Specialty directed tests

›Specialist pathways

›Interventional radiology angiography

›Suspected arterial source

›Candidate for embolization

›Pathology review of placenta

›Incomplete placenta concern

›Accreta spectrum suspicion

14ECG/ecg10

Indications

›ECG indications in postpartum hemorrhage

›Persistent tachycardia out of proportion

›Chest pain

›Syncope

High risk findings

›Concerning patterns

›Ischemic changes in profound anemia

›Arrhythmias during shock

Serial ECG

›Repeat ECG triggers

›Ongoing instability

›New chest pain or dyspnea

15Assessment/ax17

Working diagnosis structure

›Postpartum hemorrhage syndrome

›Primary postpartum hemorrhage

›Atony versus trauma versus tissue versus thrombin framework

›4T approach for causes

›Secondary postpartum hemorrhage

›Retained products

›Infection

›Vascular lesions

Severity and risk stratification

›Severity stratification

›Stable without ongoing heavy bleeding

›Ongoing hemorrhage without shock

›Hemorrhagic shock

Complications to rule out

›High consequence complications

›Coagulopathy and DIC

›Acute kidney injury

›Transfusion reaction

›Pulmonary edema

16Plan/plan94

First 5 minutes

›Immediate stabilization workflow

›Resuscitation bay criteria

›Any hypotension

›Any altered mental status

›Monitoring

›Continuous pulse oximetry

›Continuous cardiac monitoring

›Noninvasive blood pressure every 2 to 3 minutes

›IV access

›Two large bore IVs

›Consider intraosseous access if IV failure

›Oxygen

›Target SpO2 at least 94 percent

›Escalate to high flow or ventilation if needed

Hemorrhage control sequence

›Stepwise hemorrhage control

›Uterine massage and bimanual compression

›Immediate attempt

›Continue during medication preparation

›Uterotonics

›Oxytocin IV

›10 units IV bolus slow local protocol dependent

›20 to 40 units in 1 L crystalloid infusion

›Methylergonovine IM

›0.2 mg IM

›Repeat every 2 to 4 hours as needed

›Carboprost IM

›250 mcg IM

›Repeat every 15 to 90 minutes

›Maximum 2 mg total

›Misoprostol

›800 to 1000 mcg rectal

›Alternative sublingual per local protocol

›Tranexamic acid

›1 g IV over 10 minutes

›Repeat 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours

›Best within 3 hours of birth

›Mechanical tamponade

›Intrauterine balloon tamponade

›Uterine packing if balloon unavailable

›Surgical and interventional options

›Uterine curettage for retained tissue

›Uterine artery embolization

›Hysterectomy for refractory hemorrhage

Transfusion and hemostasis

›Massive hemorrhage resuscitation

›Massive transfusion protocol activation

›Ongoing hemorrhage with instability

›Anticipated large volume blood product need

›Balanced transfusion strategy

›PRBC

›Plasma

›Platelets

›Fibrinogen replacement

›Cryoprecipitate dosing per local protocol

›Fibrinogen concentrate dosing per local protocol

›Calcium replacement during transfusion

›Calcium chloride 1 g IV

›Repeat guided by ionized calcium if available

›Warming and hypothermia prevention

›Active warming blankets

›Blood warmer

Etiology specific management

›4T directed actions

›Tone

›Uterotonics escalation ladder

›Balloon tamponade if refractory

›Trauma

›Repair lacerations

›Hematoma management and packing

›Tissue

›Manual removal of retained tissue

›Curettage with OB guidance

›Thrombin

›Correct coagulopathy

›Treat DIC triggers

Reassessment loop

›Reassessment cycle

›Vital signs every 5 minutes until stable

›Bleeding reassessment

›Pad counts and clots

›Fundal tone after each intervention

›Labs reassessment

›Repeat CBC and fibrinogen every 30 to 60 minutes if ongoing bleeding

›Repeat lactate as perfusion marker

Consultation and activation

›Consult triggers

›Obstetrics

›Any suspected postpartum hemorrhage with ongoing bleeding

›Any need for operative management

›Anesthesia

›Hemodynamic instability

›Need for airway or operative intervention

›Interventional radiology

›Suspected arterial bleeding

›Candidate for embolization after stabilization

›Transfusion medicine

›Massive transfusion protocol

›Suspected transfusion reaction

17Disposition/dispo18

ICU and high acuity criteria

›Higher level of care criteria

›Ongoing vasopressor requirement

›Ongoing transfusion requirement

›Persistent lactate elevation despite resuscitation

Admission criteria

›Inpatient admission criteria

›Secondary postpartum hemorrhage requiring IV antibiotics

›Retained products requiring procedure

›Significant anemia requiring transfusion

Observation pathway

›Observation appropriate features

›Bleeding controlled

›Stable vitals for at least 4 to 6 hours

Discharge criteria

›Discharge requirements

›Bleeding minimal and stable

›Hemoglobin stable and symptoms resolved

›Reliable follow up and return precautions understood

Transfer criteria

›Transfer indications

›Need for interventional radiology not available

›Need for surgical capability not available

18Discharge Instructions/di19

Copy discharge instructions

›Postpartum bleeding visit summary

›Heavy bleeding has stopped or improved and your vital signs are stable

›Some bleeding or spotting can be normal after delivery but heavy bleeding is not

›Medications

›Take medications exactly as prescribed

›Avoid aspirin or NSAIDs unless your clinician told you to take them

›Activity

›Avoid heavy lifting until cleared by your obstetric clinician

›Rest and hydrate

›Follow up

›Obstetric follow up within 24 to 72 hours if bleeding was significant

›Earlier follow up if anemia symptoms occur

›Return to emergency care immediately for

›Soaking 1 pad in less than 1 hour

›Passing large clots

›Dizziness or fainting

›Chest pain or trouble breathing

›Fever

›Worsening abdominal or pelvic pain

19References/r6

Guidelines and key sources

›Evidence based references

›American College of Obstetricians and Gynecologists postpartum hemorrhage practice guidance

›World Health Organization recommendations for prevention and treatment of postpartum hemorrhage

›International Federation of Gynecology and Obstetrics postpartum hemorrhage guidance

›Royal College of Obstetricians and Gynaecologists postpartum hemorrhage guideline

›WOMAN Trial tranexamic acid in postpartum hemorrhage

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Postpartum Hemorrhage ConcernAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

511 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx53

Bleeding characteristics

›Bleeding history

›Timing postpartum

›Primary postpartum hemorrhage within 24 hours

›Secondary postpartum hemorrhage 24 hours to 12 weeks

›Estimated blood loss

›Vaginal delivery greater than 500 mL

›Cesarean delivery greater than 1000 mL

›Bleeding pattern

›Sudden gushes

›Persistent heavy bleeding

OPQRST

›OPQRST for bleeding

›Onset

›Time since delivery

›Time since placental delivery

›Provocation and palliation

›Worse with uterine massage or exam

›Change with breastfeeding or oxytocin exposure

›Quality

›Bright red blood

›Clots

›Region and radiation

›Vaginal bleeding

›Pelvic pressure or pain

›Severity

›Pads per hour

›Soaking bed linens or clothing

›Timing

›Continuous bleeding

›Intermittent heavy episodes

Associated symptoms

›Associated symptoms

›Presyncope or syncope

›Dyspnea

›Chest pain

›Palpitations

›Severe pelvic or abdominal pain

›Fever or rigors

›Headache or visual symptoms

›Reduced urine output

Obstetric and delivery details

›Delivery context

›Mode of delivery

›Spontaneous vaginal delivery

›Operative vaginal delivery

›Cesarean delivery

›Placenta details

›Complete placenta delivered

›Manual placental extraction

›Lacerations or repair

›Perineal tears

›Cervical repair

Prior episodes and baseline

›Prior history

›Prior postpartum hemorrhage

›Baseline anemia

›Bleeding disorder history

02Alarm Features/alarm20

Hemodynamic instability

›Shock features

›Systolic blood pressure less than 90 mmHg

›Heart rate greater than 120

›Altered mental status

›Cool clammy skin

›Lactate rising or greater than 4 mmol/L

Ongoing major hemorrhage

›High risk bleeding patterns

›Saturating 1 pad in less than 15 minutes

›Large clots

›Persistent bleeding despite uterine massage

High risk etiologies

›Cannot miss conditions

›Uterine inversion

›Retained placenta

›Genital tract laceration with expanding hematoma

›Placenta accreta spectrum

›Disseminated intravascular coagulation

Escalation triggers

›Immediate activation criteria

›Concern for massive hemorrhage

›Two large bore IVs not achievable quickly

›Any ongoing instability despite initial uterotonic

03Medications/meds30

Current and recent exposures

›Medication and substance exposures

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Low molecular weight heparin

›Antiplatelets

›Aspirin

›P2Y12 inhibitors

›Uterotonics already given

›Oxytocin

›Methylergonovine

›Carboprost

›Misoprostol

Medication allergies and contraindications

›Contraindications relevant to therapies

›Methylergonovine contraindications

›Hypertension

›Preeclampsia

›Carboprost contraindications

›Asthma

›Significant pulmonary disease

›Tranexamic acid caution

›Active intravascular thrombosis

›Strong thrombotic history

High risk medication interactions

›Interaction traps

›Magnesium sulfate effects

›Uterine atony risk

›Hypotonia and respiratory depression risk

›Sedatives and analgesics

›Hypotension masking shock

›Respiratory depression risk

04Diet/diet9

Intake and hydration

›Intake and hydration context

›Recent oral intake timing

›NPO status

›Vomiting or poor intake

Relevant exposures

›Exposures

›Caffeine and energy drinks

›Herbal products affecting bleeding

›Ginkgo

›Garlic supplements

05Review of Systems/ros17

Bleeding and hematologic

›Hemorrhage related symptoms

›Easy bruising

›Gum bleeding

›Epistaxis

Infectious and inflammatory

›Infection symptoms

›Fever

›Chills

›Uterine tenderness

Cardiopulmonary and neurologic

›Perfusion symptoms

›Dyspnea

›Chest pain

›Confusion

›Severe weakness

Hypertensive disease postpartum

›Preeclampsia related symptoms

›Headache

›Visual changes

›RUQ pain

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral sources

›Partner or family report

›Nursing report

›EMS report

Family history

›Family history risks

›Inherited bleeding disorders

›Von Willebrand disease

›Hemophilia carrier status

›Early cardiovascular disease

›MI before age 55 male relatives

›MI before age 65 female relatives

07Risk Factors/rf27

Obstetric risk factors

›Pregnancy and delivery risks

›Uterine overdistension

›Multiple gestation

›Polyhydramnios

›Macrosomia

›Prolonged labor

›Prolonged first stage

›Prolonged second stage

›Induction or augmentation

›Oxytocin exposure

›Chorioamnionitis

Placental risk factors

›Placental risks

›Placenta previa

›Placenta accreta spectrum

›Retained products risk

›Succenturiate lobe

›Incomplete placenta delivered

Hemorrhage and coagulopathy risks

›Bleeding risks

›Prior postpartum hemorrhage

›Thrombocytopenia

›Gestational thrombocytopenia

›HELLP syndrome

›Anticoagulation therapy

Trauma related risks

›Genital tract trauma risks

›Operative vaginal delivery

›Shoulder dystocia

›Rapid delivery

08Differential Diagnosis/ddx56

Life threatening

›Life threatening causes

›Uterine atony (O72.1)

›Boggy enlarged uterus

›Heavy bleeding without focal laceration source

›Genital tract laceration (O70.0 to O70.3)

›Firm uterus with persistent bleeding

›Bleeding despite uterotonics

›Retained products of conception (O72.0)

›Subinvolution

›Persistent bleeding

›Placenta accreta spectrum (O43.2)

›Difficulty placental separation

›Ongoing hemorrhage after delivery

›Uterine inversion (O71.2)

›Severe pain

›Shock out of proportion to visible blood

›Disseminated intravascular coagulation (D65)

›Oozing from IV sites

›Low fibrinogen

›Uterine rupture (O71.1)

›Severe abdominal pain

›Hemodynamic collapse

Common

›Common causes

›Uterine atony

›Overdistension

›Prolonged labor

›Lacerations

›Cervical

›Vaginal

›Perineal

›Retained placental tissue

›Incomplete placenta

›Placental fragments

Less common

›Less common causes

›Endometritis with secondary hemorrhage (O86.1)

›Fever

›Uterine tenderness

›Subinvolution of placental site

›Delayed postpartum bleeding

›Enlarged uterus

›Uterine artery pseudoaneurysm

›Recurrent delayed heavy bleeding

›Prior uterine instrumentation

›Coagulation disorders

›Von Willebrand disease (D68.0)

›Factor deficiencies

Key distinguishing clues

›Pattern recognition

›Boggy uterus

›Atony more likely

›Responds to uterine massage and uterotonics

›Firm uterus

›Trauma more likely

›Requires speculum exam and repair

›Fever with uterine tenderness

›Infection more likely

›Secondary postpartum hemorrhage pathway

09Past Medical History/pmh12

Obstetric and gynecologic

›Prior obstetric history

›Prior postpartum hemorrhage

›Prior cesarean delivery

›Prior placenta previa or accreta

Medical comorbidities

›Comorbid conditions

›Hypertension and preeclampsia history (O14.9)

›Known bleeding disorder

›Thromboembolic disease

Procedures and devices

›Recent procedures

›Dilation and curettage

›Uterine instrumentation

›Intrauterine balloon placement history

10Physical Exam/exam33

Initial survey and vitals

›General and hemodynamics

›Mental status

›Skin perfusion

›Orthostatic intolerance

›Vital trends

›Tachycardia

›Hypotension

›Tachypnea

›Hypoxia

Abdominal and uterine exam

›Uterus assessment

›Fundal tone

›Boggy

›Firm

›Fundal height

›Enlarged for expected postpartum day

›Tender uterus

›Abdominal guarding or rebound

›Peritonitis concern

›Uterine rupture concern

Pelvic exam

›Genital tract evaluation

›Speculum exam

›Cervical laceration

›Vaginal laceration

›Bimanual exam

›Clots in lower uterine segment

›Uterine inversion findings

›Hematoma assessment

›Vulvar hematoma

›Vaginal hematoma

Cardiopulmonary and neuro

›Shock complication screen

›Pulmonary edema

›New murmur

›Focal neurologic deficits

11Lab Studies/labs30

Initial hemorrhage panel

›Baseline labs for active postpartum hemorrhage

›CBC

›Hemoglobin trend

›Platelet count

›Coagulation studies

›INR

›aPTT

›Fibrinogen

›Low fibrinogen as early marker of severe hemorrhage

›Target thresholds local protocol dependent

›Type and screen

›Crossmatch for anticipated transfusion

›Rh status

Metabolic and end organ perfusion

›Perfusion and organ injury labs

›Lactate

›Trend every 30 to 60 minutes if unstable

›Clearance as resuscitation marker

›Venous blood gas

›pH

›Base deficit

›CMP

›Creatinine

›AST and ALT

Point of care testing and transfusion guidance

›Hemostasis guidance

›POC glucose

›Hypoglycemia as shock marker

›Treatment threshold per local protocol

›Viscoelastic testing

›TEG

›ROTEM

12Imaging/img28

Scoring Systems

›Hemorrhage severity and response tools

›Shock Index

›Heart rate divided by systolic blood pressure

›Greater than 0.9 concerning for significant hemorrhage

›Quantified blood loss approach

›Weighed drapes and sponges

›More reliable than visual estimation

MRI

›MRI role

›Placenta accreta spectrum evaluation

›Usually antepartum planning

›Postpartum use uncommon in acute hemorrhage

›Limitations

›Time and access constraints in unstable patient

›Not first line in acute postpartum hemorrhage

›CT role

›Postpartum hemorrhage with unclear source after stabilization

›Suspected arterial bleeding

›Suspected pelvic hematoma expansion

›CT angiography pelvis

›Target for interventional radiology embolization planning

›Contrast nephropathy risk assessment

Ultrasound

›Ultrasound role

›Transabdominal ultrasound

›Retained products suggested by echogenic material

›Uterine cavity distension by clots

›Doppler ultrasound

›Uterine artery pseudoaneurysm

›Hypervascular retained products caution

13Special Tests/spec21

Bedside maneuvers

›Bedside diagnostics and temporizing actions

›Bimanual uterine compression

›Immediate temporizing maneuver

›Response supports uterine atony

›Uterine sweep

›Removal of clots in lower uterine segment

›Retained tissue suspicion if tissue retrieved

Procedural diagnostics

›Procedural evaluation

›Speculum exam with adequate lighting

›Cervical laceration identification

›Vaginal wall laceration identification

›Examination under anesthesia

›Persistent hemorrhage with inadequate bedside visualization

›Repair and packing capability

Specialty directed tests

›Specialist pathways

›Interventional radiology angiography

›Suspected arterial source

›Candidate for embolization

›Pathology review of placenta

›Incomplete placenta concern

›Accreta spectrum suspicion

14ECG/ecg10

Indications

›ECG indications in postpartum hemorrhage

›Persistent tachycardia out of proportion

›Chest pain

›Syncope

High risk findings

›Concerning patterns

›Ischemic changes in profound anemia

›Arrhythmias during shock

Serial ECG

›Repeat ECG triggers

›Ongoing instability

›New chest pain or dyspnea

15Assessment/ax17

Working diagnosis structure

›Postpartum hemorrhage syndrome

›Primary postpartum hemorrhage

›Atony versus trauma versus tissue versus thrombin framework

›4T approach for causes

›Secondary postpartum hemorrhage

›Retained products

›Infection

›Vascular lesions

Severity and risk stratification

›Severity stratification

›Stable without ongoing heavy bleeding

›Ongoing hemorrhage without shock

›Hemorrhagic shock

Complications to rule out

›High consequence complications

›Coagulopathy and DIC

›Acute kidney injury

›Transfusion reaction

›Pulmonary edema

16Plan/plan94

First 5 minutes

›Immediate stabilization workflow

›Resuscitation bay criteria

›Any hypotension

›Any altered mental status

›Monitoring

›Continuous pulse oximetry

›Continuous cardiac monitoring

›Noninvasive blood pressure every 2 to 3 minutes

›IV access

›Two large bore IVs

›Consider intraosseous access if IV failure

›Oxygen

›Target SpO2 at least 94 percent

›Escalate to high flow or ventilation if needed

Hemorrhage control sequence

›Stepwise hemorrhage control

›Uterine massage and bimanual compression

›Immediate attempt

›Continue during medication preparation

›Uterotonics

›Oxytocin IV

›10 units IV bolus slow local protocol dependent

›20 to 40 units in 1 L crystalloid infusion

›Methylergonovine IM

›0.2 mg IM

›Repeat every 2 to 4 hours as needed

›Carboprost IM

›250 mcg IM

›Repeat every 15 to 90 minutes

›Maximum 2 mg total

›Misoprostol

›800 to 1000 mcg rectal

›Alternative sublingual per local protocol

›Tranexamic acid

›1 g IV over 10 minutes

›Repeat 1 g IV if bleeding continues after 30 minutes or restarts within 24 hours

›Best within 3 hours of birth

›Mechanical tamponade

›Intrauterine balloon tamponade

›Uterine packing if balloon unavailable

›Surgical and interventional options

›Uterine curettage for retained tissue

›Uterine artery embolization

›Hysterectomy for refractory hemorrhage

Transfusion and hemostasis

›Massive hemorrhage resuscitation

›Massive transfusion protocol activation

›Ongoing hemorrhage with instability

›Anticipated large volume blood product need

›Balanced transfusion strategy

›PRBC

›Plasma

›Platelets

›Fibrinogen replacement

›Cryoprecipitate dosing per local protocol

›Fibrinogen concentrate dosing per local protocol

›Calcium replacement during transfusion

›Calcium chloride 1 g IV

›Repeat guided by ionized calcium if available

›Warming and hypothermia prevention

›Active warming blankets

›Blood warmer

Etiology specific management

›4T directed actions

›Tone

›Uterotonics escalation ladder

›Balloon tamponade if refractory

›Trauma

›Repair lacerations

›Hematoma management and packing

›Tissue

›Manual removal of retained tissue

›Curettage with OB guidance

›Thrombin

›Correct coagulopathy

›Treat DIC triggers

Reassessment loop

›Reassessment cycle

›Vital signs every 5 minutes until stable

›Bleeding reassessment

›Pad counts and clots

›Fundal tone after each intervention

›Labs reassessment

›Repeat CBC and fibrinogen every 30 to 60 minutes if ongoing bleeding

›Repeat lactate as perfusion marker

Consultation and activation

›Consult triggers

›Obstetrics

›Any suspected postpartum hemorrhage with ongoing bleeding

›Any need for operative management

›Anesthesia

›Hemodynamic instability

›Need for airway or operative intervention

›Interventional radiology

›Suspected arterial bleeding

›Candidate for embolization after stabilization

›Transfusion medicine

›Massive transfusion protocol

›Suspected transfusion reaction

17Disposition/dispo18

ICU and high acuity criteria

›Higher level of care criteria

›Ongoing vasopressor requirement

›Ongoing transfusion requirement

›Persistent lactate elevation despite resuscitation

Admission criteria

›Inpatient admission criteria

›Secondary postpartum hemorrhage requiring IV antibiotics

›Retained products requiring procedure

›Significant anemia requiring transfusion

Observation pathway

›Observation appropriate features

›Bleeding controlled

›Stable vitals for at least 4 to 6 hours

Discharge criteria

›Discharge requirements

›Bleeding minimal and stable

›Hemoglobin stable and symptoms resolved

›Reliable follow up and return precautions understood

Transfer criteria

›Transfer indications

›Need for interventional radiology not available

›Need for surgical capability not available

18Discharge Instructions/di19

Copy discharge instructions

›Postpartum bleeding visit summary

›Heavy bleeding has stopped or improved and your vital signs are stable

›Some bleeding or spotting can be normal after delivery but heavy bleeding is not

›Medications

›Take medications exactly as prescribed

›Avoid aspirin or NSAIDs unless your clinician told you to take them

›Activity

›Avoid heavy lifting until cleared by your obstetric clinician

›Rest and hydrate

›Follow up

›Obstetric follow up within 24 to 72 hours if bleeding was significant

›Earlier follow up if anemia symptoms occur

›Return to emergency care immediately for

›Soaking 1 pad in less than 1 hour

›Passing large clots

›Dizziness or fainting

›Chest pain or trouble breathing

›Fever

›Worsening abdominal or pelvic pain

19References/r6

Guidelines and key sources

›Evidence based references

›American College of Obstetricians and Gynecologists postpartum hemorrhage practice guidance

›World Health Organization recommendations for prevention and treatment of postpartum hemorrhage

›International Federation of Gynecology and Obstetrics postpartum hemorrhage guidance

›Royal College of Obstetricians and Gynaecologists postpartum hemorrhage guideline

›WOMAN Trial tranexamic acid in postpartum hemorrhage

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.