Postpartum hemorrhage is the leading cause of maternal death worldwide and a major preventable cause in the United States. Most deaths result from delayed recognition and delayed escalation.
Definitions
- ACOG (US): cumulative blood loss of 1,000 mL or more, or blood loss accompanied by signs or symptoms of hypovolemia, within 24 hours after birth, regardless of route of birth (vaginal or cesarean). Blood loss above 500 mL after a vaginal birth is abnormal and warrants closer assessment
- WHO/FIGO/ICM consolidated guidelines (2025): PPH treatment is triggered when measured blood loss reaches 500 mL, or 300 mL together with abnormal vital signs (e.g., tachycardia, hypotension), using objective measurement such as calibrated drapes
- Primary PPH: within 24 hours; secondary (late) PPH: after 24 hours up to 12 weeks (often from subinvolution, retained tissue, or infection)
Causes — the 4 Ts
| Cause | Share | Examples |
|---|
| Tone (uterine atony) | Most common (about 70%) | Overdistension (macrosomia, twins, polyhydramnios), prolonged or precipitous labor, oxytocin exposure, magnesium sulfate, chorioamnionitis, grand multiparity, full bladder |
| Trauma | About 20% | Lacerations of cervix, vagina, perineum; hematoma; uterine rupture; uterine inversion |
| Tissue | About 10% | Retained placenta or fragments, placenta accreta spectrum |
| Thrombin | Under 1% | Coagulopathy: DIC (abruption, AFE, sepsis, preeclampsia/HELLP), von Willebrand disease, anticoagulants |
Pregnancy-related blood volume expansion (about 40–50%) allows substantial loss before blood pressure falls — tachycardia comes first; hypotension is a late sign.
- Boggy, soft, enlarged uterus above the umbilicus → atony (also with retained tissue)
- Firm, well-contracted uterus with steady bright red bleeding → laceration
- Severe perineal, vaginal, or rectal pain or pressure with a firm uterus and signs of shock out of proportion to visible bleeding → hematoma
- Uterine inversion: sudden hemorrhage, shock, fundus not palpable or a dimple at the fundus, a mass in the vagina
- Hypovolemia progression: tachycardia (earliest), anxiety, pallor, cool clammy skin, delayed capillary refill, tachypnea, decreased urine output, falling BP, altered mental status
- Shock index (heart rate ÷ systolic BP): above 0.9–1.0 suggests significant blood loss; 1.4 or higher often signals the need for transfusion and escalation
- Quantitative blood loss (QBL): calibrated under-buttock drapes, suction canisters (subtract amniotic fluid), and weighing pads and sponges (1 g ≈ 1 mL) — far more accurate than visual estimates, which underestimate large losses. Counting pads is imprecise
- Hemoglobin/hematocrit (may not fall until equilibration), platelet count, fibrinogen (low levels predict severe PPH), PT/INR, aPTT, type and crossmatch
- Bedside ultrasound for retained tissue
- Viscoelastic testing where available
Prevention: risk assessment on admission and before birth; active management of the third stage with a uterotonic after birth (oxytocin preferred; heat-stable carbetocin where available — carbetocin is for prevention only, not treatment, and is given only after birth of the infant); QBL for every birth.
WHO "MOTIVE" first-response bundle (start together, as soon as PPH is diagnosed)
- Massage of the uterus
- Oxytocic drugs
- Tranexamic acid
- Intravenous fluids
- Vaginal and genital tract examination
- Escalation of care if bleeding continues
Uterotonic drugs — know doses and contraindications
| Drug | Dose (typical) | Key contraindications and safety |
|---|
| Oxytocin | 10 units IM, or 10–40 units in 500–1,000 mL IV infusion | First line. Never give as an undiluted rapid IV push (hypotension, dysrhythmia); water intoxication with large volumes |
| Methylergonovine | 0.2 mg IM every 2–4 hours | Contraindicated with hypertension, preeclampsia, and cardiovascular disease; check BP before giving. Can cause severe hypertension, stroke, coronary spasm. Avoid with strong CYP3A4 inhibitors (e.g., HIV protease inhibitors, some macrolides). Not given IV routinely |
| Carboprost (15-methyl PGF2α) | 250 mcg IM (or intramyometrial) every 15–90 minutes, maximum 8 doses (2 mg) | Contraindicated with asthma (bronchospasm); caution with hepatic, renal, cardiac disease. Diarrhea, vomiting, fever, flushing. Refrigerate |
| Misoprostol (PGE1) | 600–1,000 mcg sublingual, buccal, oral, or rectal | WHO treatment dose 800 mcg sublingual when oxytocin is unavailable. Slower onset; fever, shivering, diarrhea; useful where injectables or refrigeration are unavailable |
| Tranexamic acid (TXA) | 1 g IV over 10 minutes, within 3 hours of birth; a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours | Antifibrinolytic — benefit is greatest the earlier it is given; not started after 3 hours. Give slowly (rapid injection → hypotension). Caution with active thromboembolic disease; seizures with high doses |
Escalation
- Bimanual uterine compression; repair lacerations; manual removal of the placenta or curettage for retained tissue
- Intrauterine tamponade balloon or vacuum-induced hemorrhage-control device (ACOG 2025 update on nonsurgical devices)
- Blood transfusion; massive transfusion protocol with balanced red cells, plasma, and platelets; cryoprecipitate or fibrinogen concentrate for low fibrinogen; calcium replacement
- Uterine artery embolization; laparotomy with compression sutures (B-Lynch), vessel ligation; hysterectomy as definitive treatment
- Uterine inversion: stop uterotonics, do not remove an attached placenta, manually replace the uterus immediately; uterine relaxants (terbutaline, nitroglycerin, or general anesthesia) may be needed; give uterotonics only after replacement
- Hematoma: evacuation if large or expanding
Listed in priority order.
- Call for help and massage the fundus — the first action for a boggy uterus: support the lower segment with one hand and firmly massage the fundus with the other until firm; express clots
- Airway, breathing, circulation
- Oxygen for hypoxemia or shock; two large-bore IV lines; warmed crystalloid and blood as ordered
- Legs elevated (modified Trendelenburg) or supine with lateral tilt if still pregnant-sized uterus
- Give uterotonics and TXA as ordered — check BP before methylergonovine and ask about asthma before carboprost; record the time of birth for the TXA window
- Empty the bladder — a distended bladder prevents contraction; indwelling catheter to also track urine output (≥ 30 mL/h)
- Quantify blood loss continuously and report cumulative totals; monitor vital signs and SpO2 every 5–15 minutes; calculate shock index
- Prepare for escalation — labs, blood products, OR; keep the client warm (hypothermia worsens coagulopathy)
- Support client and family — explain events; after stabilization, debrief
Prevention during the fourth stage: fundus and lochia checks every 15 minutes for the first hour; do not leave the client to rest unobserved during this high-risk hour; encourage voiding and early breastfeeding.
- Before discharge: soaking more than one pad in an hour or passing clots the size of an egg or larger needs urgent care; so do dizziness, fainting, racing heart
- Late bleeding can occur up to 12 weeks after birth (retained tissue, infection)
- After PPH: iron-rich diet and iron supplements (constipation, dark stools), rise slowly (orthostatic hypotension), rest; fatigue and low milk supply may occur
- Report failure to lactate, extreme fatigue, or absent menses later — possible Sheehan syndrome (pituitary necrosis after severe hemorrhage)
- Future pregnancies: inform providers of previous PPH (recurrence risk)
| Complication | Signs |
|---|
| Hypovolemic shock | Tachycardia, hypotension, oliguria, confusion |
| DIC | Oozing from IV sites and incisions, petechiae, low fibrinogen and platelets |
| Transfusion reactions, TACO/TRALI | Fever, dyspnea, hypoxia |
| Sheehan syndrome | Lactation failure, amenorrhea, hypothyroid and adrenal symptoms |
| Hysterectomy | Loss of fertility — psychological support |
| Anemia | Fatigue, poor wound healing |
- ACOG PPH: ≥ 1,000 mL cumulative or blood loss with hypovolemia within 24 hours, any route of birth
- WHO 2025: act at 500 mL, or 300 mL with abnormal vital signs
- Atony (tone) is the most common cause → fundal massage first
- Firm uterus + bleeding = laceration; severe pain/pressure + firm uterus = hematoma
- Tachycardia before hypotension; use shock index
- QBL by weighing (1 g = 1 mL) beats visual estimates
- Methylergonovine: no hypertension/preeclampsia; carboprost: no asthma
- TXA 1 g IV over 10 minutes within 3 hours; may repeat once
- Oxytocin is never an undiluted IV push
- Full bladder → atony → empty it
- Uterine inversion: replace first, uterotonics after
Country Notes
United States
- The Alliance for Innovation on Maternal Health (AIM) Obstetric Hemorrhage bundle promotes risk assessment, QBL, hemorrhage carts, and staged protocols. The Joint Commission requires hospitals to have hemorrhage procedures and drills.
Philippines
- PPH is a leading cause of maternal death. Under the DOH Essential Intrapartum and Newborn Care protocol, every birth gets active management of the third stage with oxytocin 10 IU IM, the first-line uterotonic in DOH facilities. Misoprostol is not registered with the Philippine FDA, so it is not part of routine DOH PPH care. Blood availability is a major barrier outside hospitals — early referral is key.