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Massive Transfusion Protocol — Summary for Postpartum Hemorrhage

Generic framework only. Replace with your institution’s activation criteria, component “box” contents, and ordering workflow.

Important MTPs are local. The safest approach is to follow your hospital policy and blood bank guidance while using this as a bedside checklist.
1

Activation criteria (examples)

  • Estimated blood loss > 1500–2000 mL with ongoing bleeding, or rapid trajectory toward major hemorrhage.
  • Transfusion anticipated to exceed 4 units RBC in ~1–2 hours (or ongoing need for repeated units with instability).
  • Hemodynamic instability despite initial resuscitation (tachycardia, hypotension, altered mentation, oliguria).
  • High-risk mechanism with rapid progression potential (e.g., suspected/confirmed PAS, uterine rupture, severe abruption).

Add: local blood bank phone/pager, MTP order name in the EHR, and who is authorized to activate.

2

Initial component package / ratios (customize locally)

  • Many MTPs start with a balanced approach (example only): RBC : plasma : platelets in an approximately 1:1:1 strategy (often implemented as a “cooler/box” such as 4 RBC + 4 plasma + 1 apheresis platelet, or local equivalent).
  • Use standardized MTP boxes/coolers with clear labeling and a runner to/from blood bank.
  • Switch from “ratio-based” resuscitation to goal-directed replacement as soon as labs/TEG/ROTEM are available.
Early fibrinogen replacement (practical reminders)
  • In obstetric hemorrhage, fibrinogen can fall early. Many protocols treat when fibrinogen is low or falling rapidly (commonly targeting > 200 mg/dL, per local policy).
  • Replace with cryoprecipitate or fibrinogen concentrate depending on local availability and policy.
  • If you embed a cryoprecipitate calculator elsewhere, link it here (e.g., “Cryo dosing tool”).
3

Ongoing monitoring & targets

  • Repeat labs frequently during active hemorrhage (often q30–60 min): CBC, PT/INR, aPTT, fibrinogen, platelets; consider CMP and ABG/lactate.
  • Use point-of-care coagulation testing (e.g., TEG/ROTEM) if available to guide targeted product replacement.
  • Monitor and replace ionized calcium to prevent citrate-related hypocalcemia (especially with rapid plasma/RBC infusion).
  • Maintain normothermia (forced-air warming, warmed fluids/blood) and treat acidosis to support coagulation.
  • Track urine output (Foley) and consider invasive monitoring per severity and anesthesia plan.
Common “don’t-miss” contributors to coagulopathy Hypothermia • Acidosis • Hypocalcemia • Ongoing tissue source of bleeding (Tone/Trauma/Tissue) • Delayed fibrinogen replacement
4

Communication & logistics

  • Assign a clear MTP leader responsible for communication with blood bank and for tracking products given.
  • Use a standardized checklist/documentation tool (times, units, labs, warming, calcium, TXA, procedures).
  • Notify OR/IR/ICU/neonatology as appropriate; plan transport with ongoing transfusion capability.
  • When bleeding stabilizes, make an explicit MTP deactivation call to the blood bank to stop additional coolers.
5

Post-event review

  • Immediate team debrief: what worked, delays, communication gaps, equipment issues.
  • Complete institutional hemorrhage/MTP review form and report for quality improvement.
  • Track metrics (time to activation, time to first cooler, total products, complications, ICU admission, outcomes).

UPDATED: 2025 • Attach/link your hospital’s full MTP policy (ordering workflow, product contents, and transfusion thresholds).

Disclaimer For use by medical professionals. This summary supports, but does not replace, institutional protocols or clinical judgment.