Management of Bleeding After Cesarean Section

Initial Management

Uterine atony is the most common cause of postpartum hemorrhage (PPH) after cesarean section, occurring in >75% of cases, according to the American College of Radiology 1

Ergometrine may cause bronchospasm, particularly with general anesthetics, and should be avoided in women with asthma, as recommended by the European Respiratory Society 2

Tranexamic acid 1 g IV (over 10 minutes) within 3 hours of bleeding onset is recommended, as suggested by the Anaesthesia journal 3, 4
If bleeding continues after 30 minutes or restarts within 24 hours, a second dose of 1 g IV can be given, according to the Anaesthesia journal 4

Uterine compression sutures (during cesarean section) can be used if pharmacological management fails, as recommended by the American College of Radiology 1
Uterine or ovarian artery ligation (during cesarean section) can be used if pharmacological management fails, according to the American College of Radiology 1
Arterial embolization (if patient is stable enough for transfer to interventional radiology) can be used if pharmacological management fails, as suggested by the American College of Radiology 1

For severe bleeding, red blood cells, fibrinogen, and fresh frozen plasma may be administered without awaiting laboratory results, and point-of-care testing is recommended in this setting, as suggested by the Anaesthesia journal 5

Hypofibrinogenemia (fibrinogen <2 g/L) with ongoing bleeding is associated with progression to massive obstetric hemorrhage, according to the Anaesthesia journal 4
Cell salvage can be used during cesarean section with excessive bleeding (use a leukocyte filter for autotransfusion), as recommended by the Anaesthesia journal 4
Consider thromboprophylaxis after bleeding is controlled, especially in women with additional risk factors for VTE, as suggested by the American College of Obstetricians and Gynecologists and the American College of Chest Physicians 6, 7

A calibrated blood-collection drape and volumetric and gravimetric measurement tools should be used for accurate measurement of blood loss, as visual estimation is often inaccurate 8
Point-of-care testing devices for hemostatic assessment should be available for use if possible 9
Blood sampling tubes for coagulation studies, complete blood count, and fibrinogen levels should be included in the PPH tray 10
Blood filters and cell salvage equipment with leukocyte filter should be available for use in emergency situations 8
A blood loss recording chart should be used to document blood loss accurately 8

Early recognition of bleeding with accurate measurement is crucial, as visual estimation of blood loss is often inaccurate 8
Hypofibrinogenemia (fibrinogen <2 g/L) should be monitored closely, as it is the most common factor deficiency in PPH 9
A FIBTEM A5 value <12 mm on viscoelastic testing can predict progression to severe hemorrhage 11
Platelet transfusion is rarely required unless PPH exceeds 5000 ml or platelet count is <75 × 10^9/L 9

Underestimating blood loss due to visual assessment should be avoided, and calibrated measurement tools should be used instead 8
Waiting for laboratory results before initiating blood component therapy in severe bleeding should be avoided 10