Postpartum Hemorrhage (PPH)

Risk-stratify on admission - The California PPH toolkit flags high risk as bleeding on presentation to L&D, prior PPH, hematocrit under 30%, a known bleeding diathesis, morbidly adherent placenta, or hypotension/tachycardia at presentation. Medium-risk features (prior uterine surgery, multiple gestation, grand multiparity, large fibroids, macrosomia, BMI over 40, anemia, chorioamnionitis, prolonged second stage, oxytocin beyond 24 hours, magnesium) get a type and screen; high risk gets a type and cross and a conversation about cell salvage.

Read the uterus, not the canister - A boggy, soft, enlarged uterus on bimanual exam after vaginal delivery, or on direct palpation at cesarean, points to atony. A firm uterus with ongoing bleeding sends you hunting for lacerations, retained placenta, or uterine inversion. Focal atony can hide — a well-contracted fundus with a dilated, atonic lower segment shows up on vaginal exam, not abdominal.

Vital signs lie postpartum - Tachycardia and hypotension are masked in the postpartum patient. Once they appear, assume loss of more than 25% of blood volume and act on that number, not on the one you can see on the drapes.

Labs help but do not gate treatment - Type and screen or crossmatch, serial CBC (values lag the clinical picture), and coagulation studies with fibrinogen when DIC is suspected. Never hold uterotonics or blood products waiting on results.

Oozing at the IV sites means DIC - Widespread bleeding from venipuncture sites alongside the uterine bleeding is consumptive coagulopathy, not just atony, and it changes both the transfusion plan and any thought of neuraxial technique.

Uterotonics in sequence - Oxytocin is standard at delivery; add bimanual massage plus ergot alkaloids and prostaglandins as bleeding continues. Make sure the cavity is empty — retained tissue defeats every drug on the list.

Oxytocin has a ceiling - Inappropriately large doses cause tachycardia, arrhythmias, and myocardial ischemia. Given in large volume or over 24 hours it acts as an antidiuretic and can produce water intoxication with confusion, seizures, and coma; patients taking oral fluids are at higher risk.

Magnesium raises the risk - Magnesium sulfate increases the risk of postpartum hemorrhage, so a parturient running mag for seizure prophylaxis or fetal neuroprotection starts one notch further up the risk ladder.

Uterine inversion needs relaxation first - Steady fist pressure replaces the uterus; a halogenated agent, terbutaline, magnesium sulfate, or nitroglycerin can be used to relax it for repositioning. The moment it is back in place, switch the strategy to oxytocin and other uterotonics.

Escalate surgically without dawdling - When massage and drugs fail: intrauterine balloon tamponade (250 to 500 mL of saline) or uterine packing, then uterine artery embolization in a stable patient, then laparotomy for O'Leary uterine artery sutures, utero-ovarian ligation, a B-Lynch compression suture, or internal iliac ligation. Hysterectomy is the definitive stop. Keep a count of everything placed in the uterus.

Move to the OR early - Anesthesia gets called for a difficult laceration repair, uterine inversion, manual removal of retained products, or exploration. Making that move before the patient decompensates is far easier than making it after.

Get access and activate protocols - Ample large-bore IV access and early activation of the massive transfusion protocol, driven by direct cumulative blood loss assessment rather than a lagging hemoglobin.

Tranexamic acid as an adjunct - TXA is used as an antifibrinolytic adjunct in obstetric hemorrhage; confirm the dose against your institution's PPH protocol.

Look downstream - Hypovolemic shock at 20% loss brings tachycardia, tachypnea, narrowed pulse pressure, and delayed capillary refill, and can leave ischemic injury to liver, brain, heart, and kidney. Sheehan syndrome (postpartum hypopituitarism) is the late complication of a large bleed. A prior PPH carries up to a 15% recurrence risk in a subsequent pregnancy.

Postpartum hemorrhage (PPH) is cumulative blood loss over 1,000 mL with signs or symptoms of hypovolemia within 24 hours of birth, regardless of route — the 2017 ACOG definition. More than 500 mL after a vaginal delivery is still abnormal and worth acting on, since blood loss at delivery is routinely underestimated. Primary PPH falls in the first 24 hours; secondary runs from 24 hours to 12 weeks. It complicates roughly 1% to 6% of deliveries and is the leading cause of death in childbirth. The mechanism is mechanical: the spiral arteries feeding the placental bed have no muscular wall of their own and depend entirely on myometrial contraction to squeeze them into hemostasis. When the uterus does not contract, they keep bleeding — uterine atony accounts for 70% to 80% of cases and complicates about 1 in 40 births.