Postpartum Hemorrhage (PPH) Toolkit

Format: Policy-style monochrome packet for hospital use.

Author: Focus Information Technology, Mark Curran, M.D., FACOG

Intended Use: Clinical personnel trained in obstetrics and maternal–fetal medicine.

Revision Date: 2025

PPH Management Algorithm
Uterotonics & TXA Dosing
PPH Risk Factor Checklist
Antenatal Planning for Placenta Accreta Spectrum
Massive Transfusion Protocol Summary
References & Disclaimer

1. PPH Management Algorithm

Recognition & Activation

Blood loss ≥500 mL (vaginal) or ≥1000 mL (cesarean), OR any hemodynamic instability.
Activate hemorrhage team, anesthesia, blood bank, OR, and critical care as indicated.
Begin quantitative blood loss measurement (weigh pads, measure suction).

Initial Response

Two large-bore IVs, rapid crystalloid infusion.
Oxygen, continuous vital signs, ECG monitoring.
Foley catheter and urine output monitoring.
Labs: CBC, PT/INR, aPTT, fibrinogen, type & screen/cross, electrolytes, ABG/lactate as indicated.

Assess Etiology (Four Ts)

Tone: uterine atony (boggy uterus).
Trauma: lacerations, hematomas, uterine rupture, inversion.
Tissue: retained placenta or membranes, placenta accreta spectrum.
Thrombin: coagulopathy, DIC, thrombocytopenia, anticoagulant use.

Therapeutic Steps (Overview)

Uterine massage and bimanual compression.
Uterotonics per protocol (see dosing section).
Repair trauma and evacuate hematomas.
Remove retained tissue; evaluate for accreta when placenta does not separate easily.
Administer tranexamic acid (TXA) and blood products as indicated.
Escalate to balloon tamponade, compression sutures, arterial ligation, IR embolization, and hysterectomy for refractory hemorrhage.

2. Uterotonics & TXA Dosing

Note: Doses reflect commonly used obstetric practice and should be adapted to institutional formulary and pharmacy policy.

Medication	Dose & Route	Key Notes / Contraindications
Oxytocin	10 IU slow IV bolus (or IM if no IV). Infusion: 10–40 IU in 1 L crystalloid, titrated per protocol.	Avoid rapid IV push due to risk of hypotension and tachycardia.
Methylergonovine	0.2 mg IM every 2–4 hours as needed.	Contraindicated in hypertension, preeclampsia, or significant cardiovascular disease.
Carboprost (15-methyl PGF2α)	250 mcg IM every 15–90 minutes; maximum total dose approximately 2 mg.	Use with caution or avoid in patients with asthma or severe pulmonary disease.
Misoprostol	600–1000 mcg PR / SL / PO, depending on protocol.	Common side effects include fever, shivering, and gastrointestinal symptoms.
Tranexamic Acid (TXA)	1 g IV over 10 minutes as soon as PPH is diagnosed. A second 1 g dose may be given if bleeding continues within 24 hours.	Most effective if given within 3 hours of birth; avoid with active thromboembolic disease.
Cryoprecipitate / Fibrinogen Concentrate	Dose to maintain fibrinogen > 200 mg/dL, or per viscoelastic testing if available.	Consider early in severe PPH or DIC patterns.
Packed Red Blood Cells	Typically raises hemoglobin by approximately 1 g/dL per unit.	Transfuse based on hemodynamics, bleeding, and hemoglobin level; integrate into MTP if rapid loss.
Platelets	Maintain platelet count > 50,000/µL during active bleeding or major surgery.	Higher targets may be used according to local policy.
Fresh Frozen Plasma	Typically 10–15 mL/kg; dosing per MTP ratios and coagulation studies.	Used to correct coagulopathy (prolonged PT/INR/aPTT).

3. PPH Risk Factor Checklist

Antepartum Risk Factors

Placenta previa or low-lying placenta.
Suspected or confirmed placenta accreta spectrum.
Multiple gestation.
Polyhydramnios.
Fetal macrosomia.
Previous cesarean delivery or uterine surgery.
History of prior PPH.
Anemia (e.g., hemoglobin < 10 g/dL).
Coagulopathy or thrombocytopenia; anticoagulant therapy.
High parity (e.g., ≥4 births).

Intrapartum / Immediate Risk Factors

Induction or augmentation with high-dose oxytocin.
Prolonged labor or precipitous labor.
Chorioamnionitis or intrapartum fever.
Operative vaginal delivery.
Cesarean delivery, especially emergent.
Uterine overdistension (multiple gestation, polyhydramnios, macrosomia).
Magnesium sulfate use (uterine relaxation).
Retained placenta or membranes; manual removal of placenta.
Uterine atony after delivery.

4. Antenatal Planning for Placenta Accreta Spectrum (PAS)

Identification & Diagnosis

Screen patients with previa and prior cesarean, prior uterine surgery, IVF, or multiple cesareans.
Perform targeted ultrasound and, where indicated, MRI to characterize placental invasion.
Document level of suspicion (low / moderate / high) and communicate with the care team.

Referral & Delivery Site

Refer suspected PAS cases to a center with MFM, experienced surgeons, 24/7 blood bank, and ICU.
Plan delivery in an operating room with full access to surgical and anesthetic support.
Ensure blood products are available (or crossmatched and immediately accessible) before incision.

Delivery Planning

Plan delivery before onset of labor or significant bleeding, often in the 34–36+ week range per guideline and patient factors.
Cesarean delivery is usually indicated; consider cesarean hysterectomy without attempting placental separation for confirmed accreta.
Hold a multidisciplinary planning meeting and document roles, MTP plan, and postoperative disposition.

5. Massive Transfusion Protocol (MTP) Summary for PPH

Activation (Examples)

Estimated blood loss > 1500–2000 mL with ongoing hemorrhage.
Expected transfusion > 4 units RBC in 1–2 hours.
Hemodynamic instability despite initial resuscitation.
High risk scenario such as PAS, uterine rupture, or uncontrollable atony.

Transfusion Strategy

Use balanced ratios of RBC, FFP, and platelets per institutional protocol.
Consider early cryoprecipitate or fibrinogen concentrate to maintain fibrinogen > 200 mg/dL.
Monitor labs periodically (CBC, PT/INR, aPTT, fibrinogen, platelets) and adjust therapy accordingly.
Use viscoelastic testing (ROTEM/TEG) if available to guide targeted transfusion.

Supportive Measures

Prevent hypothermia (forced-air warming, warmed fluids/blood).
Monitor and correct acidosis and ionized calcium levels.
Assign a team leader to coordinate communication with blood bank and document MTP progression.

6. References & Disclaimer

Selected References

American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin on Postpartum Hemorrhage.
World Health Organization (WHO). Guidance on the prevention and treatment of postpartum hemorrhage.
Royal College of Obstetricians and Gynaecologists (RCOG). Green-top Guideline No. 52: Postpartum Haemorrhage.
FIGO Guidelines on the Management of Postpartum Hemorrhage.

Disclaimer

This toolkit is intended for use by qualified healthcare professionals. It supplements but does not replace institutional policies, national guidelines, regulatory requirements, or individual clinical judgment. Local protocols, formulary restrictions, and resources may necessitate modification of the steps and dosing described.