Notes · Obstetrics & Gynaecology · 5 November 2026

Postpartum hemorrhage

Definition

• Post‑partum hemorrhage (PPH) is defined as cumulative blood loss of ≥500 mL after a vaginal delivery or ≥1000 mL after a cesarean section, or any amount of bleeding that is associated with signs of hypovolemia within the first 24 hours postpartum (primary PPH).
• Bleeding occurring after 24 hours up to 12 weeks postpartum is termed secondary PPH.

Epidemiology

• Globally, PPH accounts for ≈25 % of maternal deaths; it is the leading cause of maternal mortality in low‑ and middle‑income countries.
• Incidence in high‑resource settings is about 2–5 % of all deliveries; in low‑resource settings it can rise to 10–12 %.
• The risk of PPH increases with multiple gestation, cesarean delivery, and maternal anemia.

Aetiology (The “4 Ts”)

• Tone (uterine atony): Failure of the uterus to contract effectively after delivery; responsible for ≈70 % of primary PPH.
• Tissue (retained placenta or placental fragments): Incomplete placental separation prevents uterine contraction.
• Trauma (genital tract injury): Lacerations of the cervix, vagina, perineum, or uterine rupture.
• Thrombin (coagulopathy): Pre‑existing or pregnancy‑induced clotting disorders (e.g., DIC, severe pre‑eclampsia, liver disease).

Pathophysiology

• Uterine atony: After delivery, the myometrium should contract, compressing spiral arteries and reducing blood flow. In atony, the myometrial fibers remain relaxed, leaving the spiral arteries open and leading to massive bleeding.
• Retained tissue: Placental villi or membranes act as a mechanical barrier, preventing the myometrium from achieving full tone.
• Trauma: Direct disruption of vascular integrity leads to rapid blood loss; the larger the laceration, the greater the hemorrhage.
• Coagulopathy: Impaired clot formation or excessive fibrinolysis prevents hemostasis, causing ongoing bleeding even if uterine tone is adequate.

Clinical Features

• Visible bleeding: Bright red blood soaking pads; may be concealed (e.g., retro‑peritoneal bleed).
• Signs of hypovolemia: Tachycardia, hypotension, pallor, cold clammy skin, decreased urine output (<30 mL/h).
• Uterine assessment: Soft, boggy uterus that fails to contract after fundal massage suggests atony; a firm uterus points toward trauma or retained tissue.
• Pain: Cramping pain is common with uterine atony; severe abdominal pain may indicate uterine rupture.
• Laboratory clues: Falling hemoglobin/hematocrit, elevated lactate, prolonged PT/INR, low fibrinogen (<2 g/L) suggest coagulopathy.

Investigations

• Quantification of blood loss: Gravimetric method (weighing soaked pads) or calibrated drape; aim for accurate estimation >500 mL.
• Complete blood count (CBC): Hemoglobin, hematocrit, platelet count.
• Coagulation profile: PT, INR, aPTT, fibrinogen, D‑dimer; low fibrinogen is an early marker of severe PPH.
• Blood typing and cross‑match: Immediate “O‑negative” or “low‑titer O‑positive” for transfusion.
• Ultrasound (if retained tissue suspected): End‑ovarian or intra‑uterine echogenic material.
• Renal and liver function tests: Baseline before massive transfusion.

Management (Current Guidelines – WHO 2022, RCOG 2023, ACOG 2023)

1. Immediate Steps (First 10 minutes)

• Call for help: Activate obstetric emergency team and blood bank.
• Fundal uterine massage: Apply firm, continuous pressure to stimulate contraction.
• Position: Left lateral tilt to improve venous return.
• Oxygen: 10 L/min via face mask.
• IV access: Two large‑bore cannulas; begin rapid crystalloid infusion (e.g., 1 L normal saline or Ringer’s lactate).

2. Pharmacologic Uterotonics (Administer in order unless contraindicated)

• Tranexamic acid (TXA): 1 g IV over 10 min, followed by 1 g over 8 h; give within 3 hours of birth (WHO 2022). Reduces mortality by ~20 % when given early.

3. Mechanical Measures

• Uterine balloon tamponade: Insert a Foley catheter or purpose‑made Bakri balloon, inflate with 300–500 mL saline; maintain pressure for 12–24 h. Effective in 70–90 % of refractory atony.
• Compression sutures (B‑Lynch): Vertical sutures that compress the uterus; used when tamponade fails.
• Arterial ligation: Bilateral uterine artery or internal iliac artery ligation; preserves fertility but requires surgical expertise.
• Hysterectomy: Performed as a life‑saving measure when all conservative methods fail.

4. Blood Product Replacement (Massive Transfusion Protocol)

• Ratio‑guided transfusion: 1 unit PRBC : 1 unit plasma : 1 unit platelets (1 : 1 : 1) or 4 : 4 : 1 as per ACOG 2023.
• Fibrinogen concentrate or cryoprecipitate: Give 2–4 g fibrinogen if level <2 g/L.
• Calcium replacement: 1 g calcium gluconate IV for every 4 units PRBC to prevent hypocalcemia.
• Monitoring: Repeat CBC, coagulation profile every 30 min during active bleeding.

5. Post‑stabilisation Care

• Continue uterotonics for 24 h (oxytocin infusion 10 IU/L).
• Monitor vitals, urine output, and labs for delayed coagulopathy.
• Counsel regarding future pregnancies and need for delivery in a tertiary centre.

Complications

• Hypovolemic shock: Can progress to multi‑organ failure if not corrected promptly.
• Disseminated intravascular coagulation (DIC): Consumptive coagulopathy leading to further bleeding.
• Acute renal injury: Due to hypoperfusion; monitor creatinine.
• Pulmonary edema: From aggressive fluid resuscitation; balance fluids with diuretics if needed.
• Infection: From retained tissue or invasive procedures.
• Future fertility issues: Particularly after uterine artery ligation or hysterectomy.

High‑Yield Exam Points

• 4 Ts are the cornerstone for remembering PPH causes.
• Primary vs. secondary PPH: Primary occurs ≤24 h; secondary 24 h–12 weeks.
• First‑line uterotonic: Oxytocin; give as a bolus followed by infusion.
• Tranexamic acid: Give 1 g IV within 3 h of birth; improves survival.
• Uterine balloon tamponade is the recommended second‑line mechanical method before surgical steps.
• Massive transfusion protocol uses a 1 : 1 : 1 ratio of PRBC, plasma, platelets; start early when estimated blood loss >1500 mL.
• Fibrinogen level <2 g/L predicts severe PPH; treat aggressively with cryoprecipitate or fibrinogen concentrate.
• RCOG 2023 recommends early use of TXA and uterine tamponade; WHO 2022 emphasizes active management of the third stage (AMTSL) for all births.
• Signs of uterine atony: Soft, enlarged uterus that does not firm up after massage.
• Surgical hierarchy: Balloon tamponade → compression sutures → arterial ligation → hysterectomy.

Practice questions

1. A 28‑year‑old woman delivers a 3.5 kg baby vaginally. Within 15 minutes she has soaked three large pads, her pulse is 120/min, BP 90/55 mmHg, and the uterus feels soft and boggy. Which of the following is the most appropriate immediate intervention?

• A) Immediate laparotomy and hysterectomy
• B) Intravenous oxytocin bolus followed by infusion and fundal massage
• C) Intravenous carboprost 250 µg
• D) Uterine artery ligation

Answer: B — oxytocin bolus with infusion and uterine massage are first‑line for uterine atony.

2. According to the WHO 2022 guidelines, tranexamic acid should be administered:

• A) Only if blood loss exceeds 1500 mL
• B) Within 3 hours of birth, regardless of blood loss amount
• C) After the first unit of packed red cells is given
• D) Only in women with known coagulopathy

Answer: B — TXA given within 3 hours of birth reduces mortality, independent of volume lost.

3. A patient with postpartum hemorrhage is not responding to uterotonics and uterine massage. The next step, according to RCOG 2023, is:

• A) Immediate hysterectomy
• B) Administration of misoprostol 800 µg sublingually
• C) Insertion of a uterine balloon tamponade
• D) Start of high‑dose steroids

Answer: C — balloon tamponade is the recommended second‑line mechanical measure before surgical options.

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