Management of Postpartum Hemorrhage

Initial Assessment and Intervention

The American College of Obstetricians and Gynecologists recommends administering tranexamic acid 1 g IV over 10 minutes within 3 hours of birth alongside oxytocin 5-10 IU (IV or IM), initiating uterine massage and bimanual compression, and beginning fluid resuscitation with physiologic electrolyte solutions 1
Tranexamic acid must be administered within 3 hours of birth—effectiveness decreases by approximately 10% for every 15 minutes of delay, and administration beyond 3 hours may be harmful 2, 1, 3

The American College of Obstetricians and Gynecologists recommends giving TXA 1 g IV over 10 minutes immediately upon diagnosis of PPH, regardless of the cause (uterine atony, trauma, or retained tissue) 2, 1
A second dose of TXA 1 g IV can be given if bleeding continues after 30 minutes or restarts within 24 hours 2, 1, 3
The number needed to treat is 276 to prevent one bleeding-related death 3
Methylergonovine 0.2 mg IM is contraindicated in hypertensive patients (>10% risk of severe vasoconstriction and hypertensive crisis) 2, 1, 3

The American College of Obstetricians and Gynecologists recommends beginning IV fluid resuscitation with physiologic electrolyte solutions immediately 2, 1
Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 1
Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio—do not delay transfusion waiting for laboratory results in severe bleeding 1
Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 1

Intrauterine balloon tamponade can be implemented before proceeding to surgery or interventional radiology, with a success rate of 90% when properly placed 2, 1
Success rates range from 79.4% to 88.2% in uterine atony cases 2
Pelvic pressure packing is effective for acute uncontrolled hemorrhage stabilization and can remain for 24 hours 1

Maintain normothermia: Warm all infusion solutions and blood products; use active skin warming, as clotting factors function poorly at lower temperatures 1
Administer supplemental oxygen in severe PPH 1
Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 1
Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts that may precipitate heart failure in women with structural heart disease 2, 1

Active management with uterotonics (oxytocin) is critical in anticoagulated patients, as the primary mechanism of placental bed hemostasis is myometrial contraction, not coagulation 2
If emergent delivery is required on therapeutic anticoagulation, consider protamine (partially reverses LMWH) 1
Caesarean delivery is preferred to reduce fetal intracranial hemorrhage risk 1

Monitor for complications: renal failure, liver failure, infection, Sheehan syndrome 1
Consider thromboprophylaxis after bleeding is controlled, especially with additional VTE risk factors 1
Early ambulation with elastic support stockings can reduce thromboembolism risk 1