Postpartum hemorrhageMANAGEMENT

OBSTETRIC PRESENTATIONS · 12 SECTIONS

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440 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Eclampsia Ectopic Pregnancy (Ruptured)Ectopic Pregnancy (Unruptured)HELLP Syndrome Hyperemesis gravidarum Placenta previa Placental abruption Postpartum Endometritis Postpartum hemorrhage Postpartum infection Preeclampsia Preeclampsia:eclampsia Preterm labor Spontaneous Abortion (Incomplete)Spontaneous Abortion (Missed)Spontaneous Abortion (Threatened)Threatened:inevitable:incomplete abortion

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp66

Recognition and activation

›Postpartum hemorrhage recognition

›Cumulative blood loss 1000 mL or greater

›ACOG definition

›Any route of delivery

›Blood loss with hypoperfusion

›Tachycardia

›Hypotension

›Traditional thresholds

›Vaginal birth blood loss more than 500 mL

›Cesarean birth blood loss more than 1000 mL

›Hemorrhage activation

›Obstetric hemorrhage protocol

›Massive transfusion protocol

›Hemorrhage cart and uterotonics

›Team roles

›Airway and hemodynamics lead

›Uterine source lead

›Early consultation triggers

›Ongoing bleeding after first line uterotonic

›Shock index 0.9 or greater

Immediate stabilization

›Initial stabilization priorities

›High flow oxygen if hypoxemia

›SpO2 target 94% or greater

›Early airway planning if altered mental status

›Two large bore IV access

›16 gauge or larger

›Intraosseous access if IV delay

›Monitoring

›Continuous ECG

›Noninvasive BP every 2 to 3 minutes

›Warming

›Active forced air warming

›Warmed fluids and blood products

›Hemodynamic targets

›MAP 65 mmHg or greater

›Higher targets for chronic hypertension

›Mental status as perfusion marker

›Urine output 0.5 mL per kg per hour or greater

›Foley catheter

›Hourly output trending

›Lactate trending

›Rising lactate as ongoing shock marker

›Clearance as resuscitation endpoint

Etiology framework

›4T framework

›Tone

›Uterine atony

›Overdistension risk

›Trauma

›Lacerations

›Hematoma

›Tissue

›Retained products of conception

›Placenta accreta spectrum

›Thrombin

›Coagulopathy

›Anticoagulant exposure

Key decision points

›Time critical decision points

›If shock with ongoing bleeding, resuscitation bay

›Parallel uterine source control

›Parallel transfusion

›If persistent hemorrhage after uterotonics and TXA, mechanical tamponade

›Balloon tamponade

›Uterine packing if balloon unavailable

›If hemorrhage persists, definitive procedures

›Uterine artery embolization

›Surgical hemostasis or hysterectomy

02History/hx38

Presentation and timing

›Symptom and timing profile

›Primary postpartum hemorrhage

›Within 24 hours after birth

›Sudden heavy vaginal bleeding

›Secondary postpartum hemorrhage

›After 24 hours to 12 weeks postpartum

›Recurrent heavy bleeding

›Estimated blood loss context

›Pad count and saturation rate

›Clots passage

Risk factors and triggers

›Risk profile

›Uterine atony risks

›Prolonged labor

›Induction or augmentation with oxytocin

›Chorioamnionitis

›Multiple gestation

›Tissue risks

›Retained placenta

›Placenta accreta spectrum history

›Prior uterine surgery

›Trauma risks

›Operative vaginal delivery

›Shoulder dystocia

›Rapid delivery

›Thrombin risks

›Preeclampsia with severe features

›Placental abruption

›Known bleeding disorder

Medication and procedural context

›Peripartum exposures

›Uterotonics already given

›Oxytocin dose and timing

›Misoprostol dose and route

›Anticoagulants and antiplatelets

›Last dose timing

›Indication

›Anesthesia

›Neuraxial placement time

›General anesthesia exposure

03Physical Exam/exam33

Vital signs and perfusion

›Hemodynamic assessment

›Shock index

›Heart rate divided by systolic BP

›Threshold 0.9 or greater as concern

›Perfusion markers

›Mental status changes

›Cool clammy skin

›Respiratory status

›Tachypnea

›Hypoxemia

Uterine and pelvic exam

›Source localization

›Uterine tone and fundal height

›Boggy enlarged uterus

›Uterine deviation suggesting bladder distension

›Vaginal and cervical inspection

›Lacerations

›Active bleeding with firm uterus

›Bimanual exam findings

›Atony response to massage

›Uterine inversion concern

›Hematoma assessment

›Vulvar swelling

›Severe pelvic pain with minimal external bleeding

System exam and complications

›Complication screen

›Fever and uterine tenderness

›Endometritis consideration

›Secondary postpartum hemorrhage association

›Disseminated intravascular coagulation clues

›Oozing from IV sites

›Petechiae or ecchymoses

›Abdominal exam

›Uterine rupture concern

›Peritoneal signs

04Differential Diagnosis/ddx29

Life threatening causes

›High risk etiologies

›Uterine atony

›ICD-10 O72.1 postpartum hemorrhage

›Most common cause

›Genital tract trauma

›Cervical laceration

›Vaginal hematoma

›Uterine inversion

›Shock out of proportion to visible bleeding

›Fundus not palpable abdominally

›Placenta accreta spectrum hemorrhage

›Failed placental separation

›Prior cesarean history

›Coagulopathy

›DIC

›Anticoagulant associated bleeding

Mimics and secondary causes

›Other causes of postpartum bleeding

›Retained products of conception

›Secondary postpartum hemorrhage

›Subinvolution

›Endometritis

›Fever

›Malodorous lochia

›Vaginal cuff bleeding after hysterectomy

›Postoperative hemorrhage scenario

›Surgical history dependence

›Nongynecologic bleeding sources

›Lower GI bleeding

›Hematuria

05Laboratory Tests/lt30

Hemorrhage baseline labs

›Initial hemorrhage labs

›CBC for anemia and platelet count

›Hemoglobin trend over time

›Platelet threshold based decisions

›Type and screen

›Crossmatch if ongoing bleeding

›Antibody history

›Coagulation panel

›INR

›aPTT

›Fibrinogen

›Target 2 g/L or greater

›Low fibrinogen as early severe PPH marker

Point of care and shock monitoring

›Shock and metabolic assessment

›Venous blood gas

›pH

›Lactate mmol/L

›Electrolytes and calcium

›Ionized calcium

›Calcium replacement trigger with transfusion

›Glucose

›Hypoglycemia in severe shock

›Hyperglycemia stress response

Additional targeted labs

›Etiology directed labs

›Blood cultures if febrile postpartum bleeding

›Endometritis concern

›Sepsis bundle pathway

›Creatinine

›Acute kidney injury risk with shock

›Contrast planning for CT angiography

06Diagnostic Tests/dt37

Scoring Systems

›Bedside risk stratification

›Shock index

›0.9 or greater as early warning

›1.0 or greater as high risk

›Obstetric early warning tools

›MEOWS triggers

›Escalation for persistent abnormal vitals

›Massive transfusion triggers

›Ongoing bleeding with instability

›Rapid transfusion need assessment

MRI

›MRI role

›Placenta accreta spectrum characterization

›Usually antepartum planning

›Rarely acute postpartum imaging

›Pelvic hematoma characterization when stable

›Soft tissue delineation

›CT alternative considerations

›CT use cases

›CT angiography for ongoing hemorrhage without clear source

›Suspicion of arterial bleeding

›Planning for embolization

›CT for suspected retroperitoneal hematoma

›Severe pain

›Falling hemoglobin with limited vaginal bleeding

›CT contraindication considerations

›Hemodynamic instability without ability to leave resuscitation area

›Contrast allergy planning

Ultrasound (or US)

›Ultrasound evaluation

›Bedside pelvic ultrasound

›Retained products concern

›Endometrial thickening or echogenic material

›Uterine tone and cavity assessment adjunct

›Clot burden

›Uterine inversion exclusion support

›FAST style assessment if shock unclear source

›Free fluid

›Alternative bleeding source consideration

07Disposition/dispo24

Level of care

›Admission level criteria

›ICU level care

›Ongoing transfusion requirement

›Vasopressors for persistent hypotension

›Operating room activation

›Failure of medical therapy

›Suspected uterine rupture or inversion

›Interventional radiology pathway

›Persistent bleeding with suspected arterial source

›Hemodynamic stability sufficient for transport

Transfer and follow up

›Transfer criteria

›Lack of blood bank or massive transfusion capability

›Early transfer coordination

›En route hemorrhage control plan

›Need for embolization or subspecialty surgery

›Uterine artery embolization access

›Gynecologic oncology for accreta spectrum

›Discharge considerations

›Resolved mild secondary bleeding with stable hemoglobin

›Reliable follow up within 24 to 72 hours

›Clear return precautions

›Postpartum anemia management plan

›Oral iron strategy when appropriate

›Transfusion thresholds individualized

08Treatment/t87

First line measures

›Immediate uterine source control

›Uterine massage

›Bimanual compression if atony

›Response assessment within minutes

›Bladder decompression

›Foley catheter placement

›Uterine displacement improvement

›Quantitative blood loss methods

›Weighing pads and drapes

›Calibrated suction canister

Uterotonics and pharmacotherapy

›Uterotonic therapy sequence

›Oxytocin IV

›Initiate infusion 10 to 40 units in 1 L crystalloid

›Titrate rate to uterine tone and bleeding

›Methylergonovine IM

›0.2 mg IM every 2 to 4 hours as needed

›Contraindicated in hypertension and preeclampsia

›Carboprost IM

›250 mcg IM every 15 to 90 minutes as needed

›Maximum 2 mg total dose

›Contraindicated in severe asthma

›Misoprostol

›800 to 1000 mcg rectal

›Alternative 600 to 800 mcg sublingual

›Antifibrinolytic therapy

›Tranexamic acid

›1 g IV over 10 minutes

›If bleeding continues after 30 minutes, second dose 1 g IV

›If bleeding restarts within 24 hours, second dose 1 g IV

›If more than 3 hours since bleeding onset, reduced benefit

›Antibiotics when indicated

›Endometritis suspected

›Broad spectrum postpartum regimen per local protocol

›Blood cultures before antibiotics if feasible

Transfusion and hemostasis

›Resuscitation with blood products

›Packed red blood cells

›Early uncrossmatched O negative or O positive per protocol

›Transition to crossmatched as available

›Balanced component therapy

›RBC to plasma to platelets ratio 1 to 1 to 1 as massive transfusion strategy

›Adjust based on coagulation testing

›Fibrinogen replacement

›Cryoprecipitate

›Target fibrinogen 2 g/L or greater

›Early use if fibrinogen low or rapidly falling

›Fibrinogen concentrate if available

›Dose per local protocol and fibrinogen level

›Faster administration than cryoprecipitate

›Calcium replacement

›Calcium chloride 1 g IV for ionized hypocalcemia or massive transfusion

›Repeat dosing based on ionized calcium

›Adjunctive hemostatic strategies

›Uterine balloon tamponade

›If refractory bleeding after uterotonics and TXA

›Confirm intrauterine source by reduced bleeding after placement

›External aortic compression or nonpneumatic antishock garment

›Bridge to definitive therapy when resources limited

›Use with continuous monitoring

Definitive procedures and escalation

›Procedural and surgical escalation

›Manual removal of retained tissue

›Suspected retained placenta

›Adequate analgesia and uterotonic support

›Curettage or hysteroscopy

›Retained products confirmed or strongly suspected

›Antibiotic prophylaxis per protocol

›Uterine artery embolization

›Persistent hemorrhage with stable enough transport

›Fertility preservation goal

›Operative hemostasis

›Uterine compression sutures

›Uterine artery ligation

›Peripartum hysterectomy

›Life threatening hemorrhage refractory to other measures

›Placenta accreta spectrum with uncontrolled bleeding

Evidence level anchors

›Evidence and guideline anchors

›Tranexamic acid within 3 hours

›Class I recommendation based on high quality trial evidence and WHO guidance

›Dose 1 g IV with repeat dosing criteria

›Uterine balloon tamponade for refractory bleeding

›Class IIa recommendation based on guideline consensus and observational outcomes

›Earlier placement before profound shock improves success

›Balanced massive transfusion strategy

›Class IIa recommendation based on hemorrhage resuscitation principles

›Targeted by labs and viscoelastic testing when available

›Emergency department management pathway

›ACEP Level C consensus style support for rapid stabilization and multidisciplinary activation

›Parallel evaluation for 4T etiologies

09Special Populations/sp24

Pregnancy

›Ongoing pregnancy or intrapartum hemorrhage overlap

›Placenta previa and accreta spectrum risk

›Prior cesarean with placenta previa as high risk profile

›Early surgical planning

›Hypertensive disorders

›Avoid methylergonovine

›Magnesium exposure and uterine tone considerations

›Thromboembolism prophylaxis exposure

›Recent anticoagulant dosing

›Neuraxial anesthesia safety coordination

Geriatric

›Advanced maternal age considerations

›Higher accreta spectrum risk with prior surgery

›Lower threshold for early definitive management

›Higher transfusion likelihood

›Cardiovascular reserve limitations

›Earlier decompensation with blood loss

›Lower threshold for ICU level monitoring

Pediatrics

›Adolescent postpartum considerations

›Weight based medication safety checks

›Dosing verification for antibiotics and analgesia

›Smaller circulating volume and faster shock progression

›Social safety and follow up barriers

›Discharge planning complexity

›Early involvement of support services when appropriate

10Background/b33

Epidemiology

›Epidemiologic overview

›Leading cause of maternal morbidity

›Major contributor to maternal mortality worldwide

›Incidence varies by definition and setting

›Severe hemorrhage markers

›Blood loss 1000 mL or greater

›Transfusion requirement as severity surrogate

Pathophysiology

›Mechanisms by 4T

›Tone mechanism

›Failure of myometrial contraction

›Open uterine sinuses bleeding

›Trauma mechanism

›Lacerations bleeding despite firm uterus

›Hematoma as concealed blood loss

›Tissue mechanism

›Retained chorionic tissue

›Persistent uterine subinvolution

›Thrombin mechanism

›Consumptive coagulopathy

›Dilutional coagulopathy with large volume fluids

Therapeutic Considerations

›Treatment principles

›Uterotonics

›Restore uterine tone

›Stepwise escalation based on contraindications

›Tranexamic acid

›Inhibits fibrinolysis

›Greatest effect when early after onset

›Fibrinogen as early limiting factor

›Early fall in severe obstetric hemorrhage

›Target 2 g/L or greater

›Hypothermia and acidosis avoidance

›Coagulopathy amplification

›Warming and balanced resuscitation

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Discharge instructions for resolved bleeding scenario

›Expected postpartum bleeding pattern education

›Gradual decrease over days to weeks

›Intermittent small clots can occur

›Return immediately for heavy bleeding

›Soaking 1 pad in 1 hour for 2 consecutive hours

›Large clots or sudden gushes

›Return immediately for shock symptoms

›Fainting or near fainting

›Chest pain or shortness of breath

›Return immediately for infection symptoms

›Fever

›Worsening pelvic pain

›Medication instructions

›Iron supplementation plan if prescribed

›Avoid NSAIDs if advised due to bleeding risk

›Follow up plan

›Obstetric follow up within 24 to 72 hours if recent hemorrhage

›Repeat hemoglobin check if symptomatic

12References/r20

Clinical guidelines and key trials

›Core guidelines

›ACOG Practice Bulletin Postpartum Hemorrhage

›Definition using 1000 mL or greater or hypoperfusion

›Stepwise uterotonic and escalation framework

›RCOG Green top Guideline No 52 prevention and management of postpartum hemorrhage

›Structured response bundles

›Escalation to tamponade and surgery

›FIGO recommendations on management of postpartum hemorrhage

›TXA early use within 3 hours

›Multimodal bundle approach

›WHO recommendation on tranexamic acid for postpartum hemorrhage treatment

›Strong recommendation within 3 hours

›Fixed dose strategy with repeat dosing criteria

›Landmark evidence

›WOMAN trial

›TXA reduces death due to bleeding when given early

›No benefit when delayed beyond 3 hours

›Observational and registry evidence for balloon tamponade

›High success before advanced shock

›Bridge to embolization or surgery

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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