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