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Postpartum Hemorrhage (PPH) — Management Algorithm

Thresholds refer to ≥500 mL blood loss after vaginal birth or ≥1000 mL after cesarean, or any blood loss causing hemodynamic instability.

Clinical note This algorithm supports but does not replace clinical judgment. Adapt thresholds and specific drug doses to your local protocol, formulary, and institutional PPH bundle.
Algorithm overview

Stepwise PPH Management — Flow

Step 1Recognize hemorrhage & activate team
  • Blood loss ≥500 mL (vaginal) or ≥1000 mL (cesarean), OR any hemodynamic instability.
  • Call hemorrhage team; notify anesthesia, nursing, blood bank, OR, critical care as needed.
  • Begin quantitative blood loss measurement.
Act early — do not wait for exact volume if instability is present.
Step 2Initial resuscitation & monitoring
  • Two large-bore IVs (16–18g), oxygen, continuous vitals, ECG.
  • Rapid crystalloid infusion while preparing blood products.
  • Foley catheter to monitor urine output.
  • Labs: CBC, PT/INR, aPTT, fibrinogen, type & screen/cross, lactate, ABG (per protocol).
Consider early activation of massive transfusion protocol (MTP) if blood loss is escalating or shock is developing.
Step 3Rapid cause assessment — Four Ts
  • Tone: Boggy uterus → atony.
  • Trauma: Lacerations, rupture, inversion, hematomas.
  • Tissue: Retained placenta/fragments, accreta spectrum.
  • Thrombin: Coagulopathy (DIC, low fibrinogen, anticoagulants).
Step 4AFirst-line therapy for uterine atony
  • Bimanual uterine compression + uterine massage.
  • Oxytocin bolus + infusion.
  • Add second-line uterotonics (per contraindications):
    • Methylergonovine 0.2 mg IM q2–4h (avoid in HTN/preeclampsia).
    • Carboprost 250 mcg IM q15–90 min (max 2 mg; caution asthma).
    • Misoprostol 600–1000 mcg PR/SL/PO.
  • Empty bladder to improve tone.
Step 4BFirst-line therapy for Trauma, Tissue, Thrombin
  • Trauma: Repair lacerations; evacuate hematomas.
  • Inversion: Replace uterus immediately; then uterotonics.
  • Tissue: Manual removal; ultrasound-guided curettage if needed.
  • Thrombin: Transfuse blood products based on labs/MTP.
Step 5Adjunct pharmacologic & transfusion therapy
  • TXA 1 g IV over 10 min ASAP; repeat 1 g if bleeding continues (timing per protocol; best ≤3 hrs).
  • Maintain:
    • Fibrinogen > 200 mg/dL
    • Platelets > 50,000/µL
    • Correct INR/PT/aPTT
    • Correct ionized Ca, acidosis, hypothermia
Step 6Mechanical / minimally invasive
  • Uterine balloon tamponade (e.g., Bakri).
  • Packing (if balloon not available).
  • Compression sutures (e.g., B-Lynch).
  • Uterine or internal iliac artery ligation.
  • IR → uterine artery embolization if available and stable enough.
Escalate based on stability: Balloon → sutures → IR → laparotomy.
Step 7Refractory hemorrhage — definitive surgery
  • Laparotomy for uncontrolled bleeding or rupture.
  • Cesarean hysterectomy for accreta spectrum or refractory atony.
  • Multidisciplinary team required.
Do not delay hysterectomy if bleeding remains life-threatening.
Step 8Post-control monitoring & follow-up
  • Vital signs, lochia, uterine tone, urine output.
  • Serial labs for H/H, fibrinogen, platelets.
  • Treat anemia; support lactation.
  • Team debrief + QI reporting.
  • Patient counseling on future risk.
Medications

Uterotonics & Adjuncts — Quick Reference Dosing

Doses reflect common U.S. obstetric use; always follow institutional formulary and pharmacy policy.

Medication Dose & route Notes / contraindications
Oxytocin IV bolus 10 IU slow (or IM 10 IU).
Infusion: 10–40 IU in 1 L NS/LR.		 Avoid rapid IV push (hypotension/tachycardia).
Methylergonovine 0.2 mg IM q2–4h. Avoid in hypertension/preeclampsia.
Carboprost (Hemabate) 250 mcg IM q15–90 min; max 2 mg. Caution in asthma.
Misoprostol 600–1000 mcg PR/SL/PO. Higher fever/GI effects at higher doses.
Tranexamic acid (TXA) 1 g IV over 10 min; repeat 1 g if persists (timing per protocol). Best if given within 3 hrs of birth when indicated.
Cryoprecipitate / fibrinogen concentrate Maintain fibrinogen > 200 mg/dL. Consider early in severe PPH/coagulopathy per protocol.
Packed RBCs ~1 g/dL Hgb increase per unit (adult, not actively bleeding). Use with MTP if rapid loss/instability.
Platelets Maintain platelets > 50,000/µL. Higher target may be used for major surgery.
Fresh frozen plasma (FFP) 10–15 mL/kg. Correct coagulopathy.
Expanded details

Key Clinical Considerations

PPH thresholds & early activation

PPH is commonly defined as ≥500 mL after vaginal birth or ≥1000 mL after cesarean, or any blood loss with signs of hypovolemia/hemodynamic instability.

Laboratory & transfusion strategy

Maintain fibrinogen > 200 mg/dL, platelets > 50k, and correct PT/INR/aPTT. Use targeted therapy guided by labs/viscoelastic testing (if available) and clinical response.

TXA details

Give early when indicated; repeat dosing may be used if bleeding persists per protocol. Use clinical judgment for patients with active thrombosis.

Accreta spectrum & high-risk delivery

Planned delivery at an appropriate center with multidisciplinary preparation is recommended; hysterectomy is often required for PAS with uncontrolled bleeding.

References

Selected Guideline Sources

  1. World Health Organization. Postpartum hemorrhage guidance / recommendations.
  2. RCOG. Green-top Guideline No. 52 (Prevention and Management of PPH).
  3. ACOG Practice Bulletin / guidance on postpartum hemorrhage.
  4. FIGO recommendations/consensus on PPH management.
  5. Key reviews on structured PPH algorithms and bundles.
Disclaimer: For use by medical professionals. This page supports clinical decision-making and does not replace institutional protocols or clinical judgment.
UPDATED: 2025