Postpartum hemorrhage

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 1)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 1)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Multidisciplinaire richtlijn Postpartumzorg in de eerste lijn (deel 2)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2024Guideline multidisciplinaire des soins postnatals dans la première ligne de soins (partie 2)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2024

The aims of treatment for PPH are to:[2]

Minimize blood loss by identifying and treating the cause of bleeding
Maintain hemodynamic stability and prevent progression to hemorrhagic shock by restoring circulating blood volume
Prevent the development of complications including hypoperfusion- and transfusion-related complications, treatment-related infection, and loss of future fertility.

Prompt identification of women with PPH relies on accurate assessment of blood loss and vital signs. See Diagnosis approach.

Ongoing assessment of cumulative blood loss and frequent monitoring of hemodynamic signs are critical steps in the management of PPH.[21][101]

The initial approach to managing PPH involves timely recognition and stabilization of the patient.[21] Appropriate interventions will be dictated by the underlying cause of bleeding, the severity of PPH, and the available treatment options.[2]

First-line treatment of primary PPH involves the following interventions, all of which must ideally be initiated within 15 minutes of a PPH diagnosis:[72]
- The administration of intravenous fluid[2]
- The administration of uterotonics and uterine massage. Both these interventions are indicated for uterine atony and form part of routine PPH management since atony is the most common underlying cause[2]
- Consideration of the need for tranexamic acid and blood product resuscitation.[2]
In cases of severe refractory PPH, the STASIS algorithm provides a systematic surgical approach for further evaluation and treatment.[77]
Optimal management of placenta accreta spectrum involves a standardized surgical approach with a comprehensive multidisciplinary care team to decrease maternal morbidity and mortality.
Treatment of secondary PPH typically involves the use of uterotonics, antibiotics to treat endometritis, and uterine curettage if necessary for retained placental tissue.

Less invasive methods are used initially but in the scenario of severe, refractory PPH, more aggressive life-saving interventions may be needed.[2]

Primary PPH: overview of initial interventions

Ensure immediate resuscitation measures, including the administration of intravenous fluids, as well as blood product transfusion if necessary. Monitor vital signs closely.[6][21]

Immediate resuscitation is vital to prevent the development of hemorrhagic shock, metabolic acidosis, and coagulopathy.
Establish intravenous access using two large bore cannulas, typically 16-18 gauge, and promptly collect blood samples for type and crossmatch, complete blood count (CBC), and coagulation studies, including fibrinogen levels.
Initiate fluid resuscitation with isotonic crystalloids, while simultaneously placing a Foley catheter to decompress the bladder and monitor hourly fluid intake and urine output.
Consider a patient warming system (e.g., Bair Hugger™) to counteract hypothermia which may develop in the setting of maternal hypoperfusion.

Assess and treat any signs of shock using ABCDE principles and standard protocols.

Additional initial management steps depend on which of the four Ts (Tone, Trauma, Tissue, Thrombin) has been identified as the cause of PPH. For more detail on underlying causes, see Diagnosis approach.

Be aware that there may be more than one of the 4Ts contributing to an individual woman's PPH.
Suspect and treat atony first as the most likely underlying etiology.[2][12] Uterine atony is the most common cause of PPH, accounting for 70% to 80% of cases, and steps to address it typically form a routine part of the initial management in every patient with PPH.[2][20][21][49]

Management of uterine atony

Follow the steps included in the World Health Organization's (WHO) First Response PPH Bundle for the management of PPH due to uterine atony:[12][101]

Perform a uterine massage (after ensuring the bladder is empty) to promote uterine contraction and control bleeding.[2]
Administer a uterotonic as soon as PPH is diagnosed. Additional uterotonics may be used if needed; it is common for multiple agents to be needed.[2]
Initiate intravenous fluids concurrently with the administration of uterotonics. Isotonic crystalloid is the fluid of choice.
Consider administration of tranexamic acid, an antifibrinolytic agent, as soon as possible after clinical diagnosis of PPH. Tranexamic acid helps to stabilize blood clots and reduce bleeding.

Ideally, all the steps listed above must be initiated within 15 minutes of a PPH diagnosis being made.[72]

Note that guidelines vary on the indications for tranexamic acid in management of PPH.

Whereas the WHO recommends routine use of tranexamic acid within 3 hours of birth for all women with primary PPH, the American College of Obstetricians and Gynecologists (ACOG) recommends only to consider tranexamic acid if bleeding persists after initial medical therapy.[2][102] For more detail, see Tranexamic acid.

Management of other causes of PPH

If visible lacerations are identified as the cause of bleeding, ensure they are repaired promptly.[2][21]

If bleeding is ongoing and uncontrolled after implementation of the treatments for uterine atony, do not delay the decision to move the patient to the operating room for better visualization or administration of anesthesia as a less easily visible traumatic cause may be present.
Obstetric trauma is the second most common cause of PPH, accounting for 20% to 30% of cases.[20]

In cases where PPH occurs in the context of placental retention, the first step is to attempt prompt manual extraction of the placenta.[2] This can help to control bleeding and prevent further complications.

Additionally, administer a single dose of antibiotics to reduce the risk of infection following manual extraction of the placenta.[5]

If the patient is diagnosed with coagulopathy, replacement of clotting factors, fibrinogen, or other factors is indicated.[2]

Note that all the interventions described above are part of the initial management of PPH and must be performed as soon as possible in a coordinated manner.

Further interventions and treatments may be required based on the severity and persistence of the hemorrhage.
Close monitoring of the patient's condition, vital signs, and ongoing assessment are essential throughout the management process.[21][101]

Primary PPH: resuscitation with intravenous fluid ± blood products

Intravenous fluid

Use a balanced crystalloid.[5][49]

Balanced crystalloids (e.g., Ringer lactate) are preferred over saline because of the potential risks associated with saline-containing solutions, including hyperchloremic acidosis and compromised kidney function.[103]
By opting for balanced crystalloids, the aim is to optimize patient outcomes while minimizing the likelihood of complications arising from fluid resuscitation.

Consider the benefits of hypotensive fluid resuscitation alongside early administration of blood products. Follow your local protocol for PPH resuscitation.

The traditional approach to fluid resuscitation in cases of significant blood loss due to PPH has centered around aggressive volume replacement. The prevailing notion has been to administer large volumes of crystalloid fluid (4-5 liters for every liter of blood lost), aiming to swiftly restore circulating blood volume and normalize blood pressure.[49][104] However, contemporary data have presented an alternative perspective, introducing the concept of hypotensive fluid resuscitation (or permissive hypotension) during the initial stages of hemorrhagic shock.[105][106]
The hypotensive fluid resuscitation approach advocates early and assertive administration of blood products instead of relying heavily on extensive crystalloid replacement. The primary objective is to prioritize the prompt delivery of blood products while mitigating the risks associated with aggressive crystalloid infusion, e.g., dilutional coagulopathy; the disruption of pre-existing blood clots due to heightened intravascular pressures; and the development of hypothermia.[2]
By employing small-volume (500 mL) boluses of fluid, the restrictive approach to intravenous fluid resuscitation aims to minimize the incidence of third spacing and fluid extravasation. This strategy, in turn, helps to preserve hemodynamic stability, sustain cardiac function, and maintain renal perfusion by averting the adverse effects of increased intra-abdominal pressure.[107][108]
Prior studies have shown that patients with PPH who received more than 4 L of fluid to address acute blood loss experienced increased subsequent bleeding and adverse maternal outcomes. Consequently, the evidence now leans towards permissive hypotension, with the objective of maintaining a mean arterial pressure between 50-60 mmHg or systolic blood pressure between 80-90 mmHg until hemorrhage control measures have proven effective.[103][109]

Ensure serial assessments to determine the effectiveness of resuscitation. These evaluations aim to ensure the restoration of normal mental status, and to achieve and maintain the targeted mean arterial pressure, adequate urine output, and normal serum pH and bicarbonate levels.[110] Monitor:

Lactate: serial measurements of serum lactate are a valuable tool for guiding ongoing resuscitation efforts. Persistently elevated lactate levels indicate tissue hypoperfusion and the need for continued resuscitation.[111] One key advantage of using serial measurements is the relatively short half-life of lactic acid (approximately 20 minutes), meaning changes in lactate levels can be detected quickly, allowing for timely adjustments in ongoing resuscitation.[111]
Arterial blood gas (ABG) or venous blood gas (VBG): assessments of serum pH and bicarbonate can be useful adjunctive markers to determine successful resuscitation.[110] Significant metabolic acidosis may indicate under-resuscitation in severe PPH.
Electrolytes: assessment for electrolyte derangements (including hyperkalemia, hypocalcemia, and hypomagnesemia) is paramount during massive transfusion and large volume resuscitation. It facilitates early correction to avoid cardiac arrhythmias.[112]

Blood transfusion

Effective resuscitation prioritizes early replacement of blood products.[107]

Thresholds for administering blood products vary between guidelines and PPH care bundles.[21]
ACOG recommends initiating immediate preparations for blood transfusion as soon as an estimated blood loss (EBL) ≥1500 mL is reached with ongoing bleeding, or when hemodynamic changes such as tachycardia and hypotension become apparent (regardless of degree of EBL).[2]
Because such extensive blood loss includes depletion of coagulation factors, it is common for such patients to develop disseminated intravascular coagulation (DIC), requiring the administration of platelets and coagulation factors in addition to red blood cells (RBCs). Use of multicomponent therapy with fixed ratios is recommended.[2]

Note that in an emergency where immediate transfusion is required and there is not time to wait for a crossmatch and/or for supplies of group-specific blood, use group O, Rh-negative emergency blood.[2][113]

Switch to a group-specific blood as soon as feasible.[113]

The components of transfusion are:[21]

RBCs: consider administering for hemoglobin (Hb) <7 or <8 g/dL, depending on your institution-specific protocol and your assessment of maternal status and coexisting conditions.[21] A typical dose of 1 unit RBC is expected to increase the maternal Hb level by 1 g/dL.
Fresh frozen plasma (FFP): contains plasma proteins, clotting factors such as antithrombin III, factor V, factor VIII, fibrinogen, and proteins C and S. Consider administering after every 1, 4, or 6 units of RBCs or if prothrombin time (PT) is prolonged (international normalized ratio [INR] or activiated partial thromboplastin time [aPTT] >1.5 times the normal value). A FFP dose of 10-20 mL/kg will increase clotting factors by approximately 10% to 20%.
Platelets: consider administering if platelet count is <50,000 per microliter or <75,000 per microliter with active bleeding, or after every 1, 4, or 6 units of RBCs administered. One apheresis unit, or 6 units of pooled platelets, will typically increase the platelet count by 25,000-35,000 per microliter.[21][68]
Cryoprecipitate: contains fibrinogen, clotting factors such as factor VIII, XIII, and von Willebrand factor. Consider administering at a dose of 1 unit per 5-10 kg if fibrinogen level is <100 or <200 mg/dL depending on your local protocol.[21]

Massive transfusion protocol (MTP)

Massive blood transfusion may become necessary.[21]

Massive transfusion is characterized by the transfusion of ≥10 units of RBCs within 24 hours, transfusion of 4 units of RBCs within 1 hour with ongoing need for more blood, or replacement of a complete blood volume.[2][21]

Ensure prompt activation of the MTP in the presence of clinically significant and rapid bleeding. This is a crucial step to minimize maternal morbidity and mortality.[114][115][116] MTPs should be part of a comprehensive PPH management protocol in settings with adequate blood banking.[2]

Specific initiation thresholds for MTP and transfusion-specific treatment goals vary between institutions so check your local protocol.
One guideline, from the British Committee for Standards in Haematology, has proposed a treatment goal of maintaining the Hb level >8 g/dL, fibrinogen >200 mg/dL, platelet count >50,000 per microliter, and aPTT and PT levels at <1.5 times the normal values.[68]
The use of MTPs has demonstrated a reduction in hemorrhage-related mortality by effectively addressing coagulopathy.[117][118]

MTPs entail the automatic release of RBCs, FFP, platelets, and cryoprecipitate in predefined ratios.

The standard ratio typically follows a 1:1:1 distribution designed to mimic whole blood, consisting of 1 unit of RBCs, 1 unit of FFP, and 1 unit of pooled platelets (equivalent to 6 packs).[2][21] Cryoprecipitate, which is rich in fibrinogen, assumes a vital role within the MTP, especially for patients with DIC or fibrinogen levels <200-300 mg/dL.[2]
In the US, activation of the MTP can be initiated by a physician or nurse, with the release of blood products continuously provided by the blood bank until the MTP is deactivated.[104][119][120][121]

Point-of-care tests such as thromboelastography (TEG) or rotational thromboelastometry (ROTEM®) are now increasingly used in obstetric intensive care units where they play a pivotal role in guiding transfusion needs and uncovering the underlying factors contributing to coagulopathy in patients experiencing refractory PPH.[88][89] See Diagnosis - Investigations.

Interventions for uterine atony

Suspect and treat atony first as the most likely underlying cause of PPH.[2][12]

Uterine atony is the most common cause of PPH, accounting for 70% to 80% of cases.[20]
Steps to address it therefore typically form a routine part of the initial management in every patient with PPH.[2][21][49]

Uterine massage

Perform a uterine massage as an initial intervention for uterine atony.[2][21][49][101]

It is important to concomitantly administer uterotonics, initiate fluid resuscitation, and address any other underlying cause of PPH.
Ensure the patient’s bladder is emptied to facilitate uterine contraction, perform a bimanual pelvic exam to assess for retained placental tissue and to remove any remaining clots from within the uterus, and perform uterine massage.[2]

To perform effective uterine massage:[2][21]

Place your hand over the uterine fundus.
Apply gentle but firm circular or kneading motions directly over the uterine fundus with continuous pressure to stimulate uterine contractions.
Start uterine massage at the fundus of the uterus and gradually move downward towards the cervix. This helps expel any clots or retained products and encourages effective contractions through the stimulation of endogenous prostaglandins.
The uterus should become more firm and decrease in size as uterine atony improves. Assess ongoing bleeding and monitor vital signs to determine the effectiveness of the massage.

In the scenario of lower uterine segment atony, the fundus is typically firm and well contracted, while the lower uterine segment remains dilated and atonic.[2]

Perform a bimanual pelvic exam to remove any remaining clots from the lower uterine segment.
Employ bimanual uterine compression with the concomitant administration of uterotonics.

Uterotonics

Uterotonics are the first-line drug for the treatment of uterine atony.[2][21][49] The most common uterotonics (i.e., oxytocin, methylergonovine, carboprost, misoprostol) all have similar efficacy and the choice between them is often determined by local protocols, together with the availability of intravenous access and the uterotonic that was used as prophylaxis in the third stage of labor.[2][122]

Multiple uterotonics may be used concomitantly or in rapid succession in the setting of ongoing PPH.
Consider escalation to non-medical interventions (such as tamponade or surgical techniques) when multiple uterotonics fail to successfully treat PPH secondary to uterine atony.[2]

Uterotonics: oxytocin

Administer oxytocin as the first-line therapy for the medical management of PPH.[5][21][49]

Oxytocin is typically administered concomitantly with uterine massage.
It works immediately by stimulating oxytocin receptors in the uterus to induce uterine contractions, as the half-life of oxytocin is 1 to 6 minutes.[21]
Intravenous administration is preferred.[5][49] Oxytocin can also be administered intramuscularly if intravenous access is not available.
Take care to avoid rapid intravenous bolus administration of high-dose oxytocin, as this may induce hyponatremia, hypotension, tachycardia, and arrhythmias.
Oxytocin is rarely contraindicated, but should not be used in patients with significant hypotension or syndrome of inappropriate antidiuretic hormone secretion (SIADH).

A second uterotonic is required in addition to oxytocin in 3% to 25% of cases of PPH.[2]

In the case of inadequate response and ongoing bleeding, ensure rapid administration of an additional agent.

Uterotonics: methylergonovine

Methylergonovine (an ergot alkaloid) is the most commonly selected add-on option for the treatment of uterine atony after oxytocin.[21]

Methylergonovine stimulates uterine smooth muscle and uterine vascular alpha-1-adrenergic receptors, resulting in sustained vasoconstriction and bleeding resolution.[21]
Intramuscular methylergonovine is preferred over the oral formulation in the acute treatment of PPH. Methylergonovine can also be given orally for 2-7 days as an adjunct to intramuscular methylergonovine to prevent recurrent PPH in some patients.
Methylergonovine is contraindicated in patients with hypertension and cardiovascular disease, including stroke and Raynaud disease.

Uterotonics: carboprost

Carboprost (a prostaglandin F2-alpha analog) is an alternative add-on option for the treatment of uterine atony.[2][21]

Carboprost acts as a prostaglandin F2-alpha agonist in the uterine myometrium, stimulating uterine contractions.
It is contraindicated in patients with asthma, and is relatively contraindicated in patients with hypertension or active cardiac, hepatic, or pulmonary disease.

Uterotonics: misoprostol

Misoprostol (a prostaglandin E1 analog) is another add-on option used for the treatment of uterine atony.[2][21]

Misoprostol acts as a prostaglandin E1 agonist in the uterine myometrium.
It can be administered sublingually, orally, or rectally. Repeat doses are not recommended.
There are few if any absolute contraindications.

Tranexamic acid

Guidelines vary on the indications for administering tranexamic acid as part of PPH management. Check your local protocol.

Tranexamic acid functions as an antifibrinolytic agent by impeding the activation of plasmin, thereby inhibiting the degradation of fibrinogen and fibrin. The rationale behind administering tranexamic acid is its potential to mitigate bleeding, as increased fibrinolysis is observed during the early stages of hemorrhage.[116][123]
The WOMAN trial demonstrated significant reductions in maternal mortality (1.2% vs. 1.7%, P = 0.008) and need for surgical intervention in patients with PPH who received tranexamic acid within 3 hours of birth when compared with placebo.[124]
A Cochrane review based on the WOMAN trial and a smaller French trial (20,212 women in total) concluded that intravenous tranexamic acid given within 3 hours of birth reduced the risk of maternal death due to bleeding in women with primary PPH (risk ratio 0.81, 95% CI 0.65 to 1.00). This was without increasing the risk of thromboembolic events and irrespective of vaginal versus cesarean delivery.[125]

ACOG recommends to consider tranexamic acid if initial medical therapy for PPH fails, and highlights that the benefit seen in the WOMAN trial was primarily in women treated within 3 hours of delivery.[2]

The ACOG-endorsed Safe Motherhood Initiative recommends to consider tranexamic acid if EBL >1000 mL despite initial interventions and/or administration of ≥2 uterotonics has failed to control bleeding.[6]

The WHO and the International Federation of Gynecology and Obstetrics (FIGO) both recommend the simultaneous administration of tranexamic acid alongside uterotonics as a standard first-line treatment for all women diagnosed with PPH following vaginal or cesarean delivery.[49][102]

Tranexamic acid is recommended as part of the standard management protocol by WHO and FIGO regardless of the underlying cause of PPH. It must be administered as soon as PPH is clinically diagnosed and within 3 hours of delivery.
Do not give tranexamic acid more than 3 hours after birth as there is no clear evidence of benefit.

A second dose of tranexamic acid may be given if persistent bleeding continues after 30 minutes or if recurrent bleeding occurs within 24 hours of the first dose.[49][102]

While the current obstetric dose of tranexamic acid does not pose a significant risk of thrombosis, caution should still be exercised when administering tranexamic acid to patients at higher risk of thrombotic events.[126] It is important to note that tranexamic acid is contraindicated in patients with renal dysfunction due to its renal clearance.

Initial interventions for other causes of PPH

Management of retained products of conception

It is crucial to evaluate for retained products of conception in any woman with PPH, as approximately 2% to 3% of all births can be complicated by retained products.[2][79] See Diagnosis approach.

If identified, prompt removal of the retained products is necessary to ensure the effectiveness of uterotonics in treating uterine atony.
Attempt manual removal initially, followed by surgical removal if manual removal fails.[2]
To minimize the risk of uterine perforation during surgical removal, suction dilation and curettage (D&C) should be performed under ultrasound guidance. This approach offers the dual advantage of facilitating the precise removal of retained products and confirming the complete evacuation of the uterus.
Following manual placental extraction, administer a single dose of antibiotics to reduce the risk of infection.[5]

Treatment of uterine inversion

Consider the possibility of uterine inversion in any case of PPH where the fundus cannot be palpated.[77]

Once uterine inversion is identified, take immediate measures to reposition the uterus to its normal anatomical position. This involves applying steady, continuous pressure on the inverted uterine fundus transvaginally, using a closed fist.[2]
It is crucial to initiate this maneuver promptly, as delayed attempts may be more challenging due to progressive uterine edema. Concurrent administration of nitroglycerin or terbutaline can aid in uterine relaxation during the repositioning process. If the placenta has not yet separated, leave it in place during the procedure to prevent additional hemorrhage.[2][21]
Ensure appropriate uterine tone after correction of inversion, since recurrence of inversion can occur if there is atony. Standard uterotonics can be used for this purpose.[77]

Refractory primary PPH

In patients with refractory PPH, more aggressive life-saving interventions may be needed.[2]

Continue the resuscitation measures started during initial treatment, with ongoing assessment of the patient's vital signs, including blood pressure, heart rate, and oxygen saturation. Continue transfusion of blood products.

Additional steps to take if initial interventions for PPH fail to control ongoing bleeding are outlined in guidelines from the WHO. These include the Response to Refractory PPH Care Bundle, which aims to reduce maternal morbidity and mortality by promoting a standardized approach to managing severe PPH due to uterine atony, and the WHO guideline on prevention and treatment of PPH.[5][101] The WHO recommends:

Temporary compressive measures (e.g., aortic compression or bimanual uterine compression) or nonpneumatic antishock garments (NASGs) to reduce uterine blood flow.[5][49][101]
Uterine tamponade: consider the use of uterine tamponade techniques, such as balloon tamponade or packing the uterus with sterile gauze.[5][101]
To continue to administer additional doses of uterotonics and a second dose of tranexamic acid while using the above measures.[5][101][102]
Radiological interventions: if available, consider the use of interventional radiology techniques (if available), such as uterine artery embolization (UAE), to control bleeding.[2][5][21] UAE involves blocking the blood vessels that supply the uterus to reduce blood flow.
Surgical interventions: if bleeding persists despite the above measures, prepare for surgical interventions. These may include repair of cervical or high vaginal lacerations, laparotomy to identify and address the source of bleeding, uterine artery ligation, or hysterectomy.[5][21]

Note that the specific interventions and their sequence may vary depending on the available resources, healthcare facility capabilities, and the individual patient's condition.[5]

The WHO bundle and wider recommendations provide a framework for a systematic approach to managing refractory PPH that can be adapted to the local context and resources.
Multidisciplinary team care, involving obstetricians, anesthesiologists, and interventional radiologists, is recommended to ensure the best possible outcome.

The STASIS algorithm provides a systematic approach for further evaluation and treatment of severe refractory PPH.[77][104] The steps involve:

S: Shift the patient to the operating room for improved visualization. Notify the appropriate ancillary support teams including anesthesiology, gynecology specialty services, and the blood bank, to prepare for the transition to the operating room. Use temporary compressive measures (e.g., bimanual uterine compression) while transferring the patient to the operating room to decrease ongoing blood loss.
T: Tissue, trauma, tamponade. Once in the operating room, a thorough pelvic exam should be conducted to rule out retained tissue or trauma (e.g., lacerations) and address these if identified. Subsequently, balloon tamponade should be employed.
A: Apply compression. The next step involves applying surgical compression sutures to achieve hemostasis.
S: Systemic devascularization. If deemed appropriate, systemic devascularization techniques such as O'Leary, ovarian, hypogastric, quadruple, or internal iliac sutures should be considered.
I: Interventional radiology. Consultation with interventional radiology for UAE should be considered as an option if the patient's condition allows for transfer to the interventional radiology suite.
S: Subtotal/total hysterectomy. Finally, if the prior interventions prove ineffective in controlling refractory PPH, the surgical team should proceed with subtotal or total hysterectomy.

Temporary compressive measures

Temporary compressive measures are recommended to mitigate blood loss in cases of severe PPH refractory to medical management, especially in low-resource settings.[101]

These measures aim to reduce uterine blood flow until appropriate care or transfer to a tertiary care facility is feasible.

Bimanual uterine compression and aortic compression are examples of temporizing compressive measures for refractory PPH caused by uterine atony.[2][5]

To perform bimanual uterine compression, place one hand in the anterior vaginal fornix and position the other hand behind the uterine fundus, allowing for compression of the uterus between the hands.[21]
External aortic compression entails applying external compression, using a closed fist, at the level of the umbilicus, slightly leftward of the midline.
These measures can help decrease blood loss from the uterus until the underlying source of bleeding can be identified and appropriately addressed.

NASGs have emerged as a potential solution for managing refractory PPH and stabilizing patients experiencing hypovolemic shock, particularly in resource-limited settings.[5][127]

These garments serve as a temporary compression device and offer initial aid by reducing uterine blood loss. Designed with neoprene and Velcro segments, they can be swiftly applied to the ankles, calves, thighs, pelvis, and abdomen, providing circumferential counterpressure to the lower body for a duration of up to 48 hours to decrease pelvic perfusion.
This innovative approach aims to buy crucial time and stabilize patients until definitive interventions can be implemented for refractory PPH.

Uterine tamponade

Mechanical intrauterine tamponade is the initial recommended approach for PPH secondary to uterine atony that remains refractory to medical therapy.[2][5][21][77] This approach is most effective when a high-quality device is used promptly after identifying refractory PPH.[49]

Uterine tamponade with a balloon

Balloon tamponade is recommended as an effective nonsurgical technique in women with PPH due to atony who have not responded to uterotonics, after excluding retained products of conception and uterine rupture as contributory factors.[49]

The Bakri balloon is the most commonly used intrauterine balloon tamponade system. It works by applying inward (positive) pressure on the uterine vasculature to decrease uterine blood flow.
Evidence for the benefits of intrauterine balloon tamponade is limited.[2] Studies have suggested that mechanical tamponade reduces the need for more invasive procedures and successfully controls PPH in 80% to 100% of cases.[128][129][130][131]
The balloon can be inserted manually or with the aid of a speculum and ring forceps, and ultrasound guidance can confirm proper placement at the uterine fundus. It is important to ensure that the entire balloon is within the uterus to provide adequate compression of the lower uterine segment. The Bakri balloon can be inflated with up to 500 mL of saline until bleeding decreases, and is typically left in place for 2 to 24 hours, depending on the amount of drainage.[6][132]
Vaginal packing is commonly used alongside the Bakri balloon to secure its position, and a Foley catheter is inserted to drain the bladder and monitor fluid input and output.
If a Bakri balloon is not available, alternative devices can be used.[2] These include Foley catheters, condom catheters, or Sengstaken-Blakemore tubes.
In cases where a balloon tamponade device is not available, uterine packing can be performed with gauze.[2]
Gauze soaked in saline is layered repeatedly from one uterine cornua to the other with a ring forceps until it extends through the cervical os. As an alternative, multiple Foley catheters can also be filled with 60 mL of saline and inserted inside the uterus for tamponade.[2]

Vacuum-induced hemorrhage control device as an alternative to balloon tamponade

Intrauterine vacuum-induced hemorrhage control devices are innovative devices designed to address refractory PPH caused by uterine atony.[133]

These devices differ from uterine balloon tamponade in applying a low-level intrauterine vacuum, thereby using negative pressure to constrict myometrial blood vessels and achieve hemostasis.[134] The device consists of a loop with vacuum pores and a vacuum connector that connects to a wall suction.
Initial studies on one intrauterine vacuum-induced hemorrhage control device have yielded promising results, indicating its potential efficacy in managing refractory PPH secondary to uterine atony. Notably, the device has demonstrated a high success rate in achieving definitive control of bleeding, often within a short duration of approximately 3 minutes.[133] It is important to note, however, that further research is needed on the applicability of vacuum-induced hemorrhage control devices to a broader population, including those with more severe PPH or those who have undergone cesarean births.[135]

Repair of obstetric lacerations

Rapid identification and repair of cervical lacerations, lacerations complicated by arterial bleeding, and high vaginal lacerations is paramount.[2]

Uterine artery laceration may require interventional radiology or surgical exploration. Consider transfer to the operating room.

A comprehensive systematic pelvic exam should begin with the identification and repair of deeper lacerations or actively bleeding lacerations to minimize ongoing blood loss.[77]

Optimal visualization of the perineum, vaginal vault, vaginal walls, and cervix can be achieved with the use of vaginal wall retractors.
To reduce the risk of hematoma formation following the repair of significant or deep sidewall lacerations, absorbent or temporary packing (e.g., gel foam or gauze) may be employed.

The cervix should be routinely examined using ring forceps, as deep cervical lacerations have the potential to cause substantial bleeding.[77]

Repairing these lacerations typically involves a running locked technique using synthetic absorbable suture material.
Care should be taken to ensure cervical patency at the conclusion of the repair.

In cases where coagulopathy is present or friable vaginal tissue contributes to persistent small areas of bleeding, it may be prudent to consider placing vaginal packing at the end of the repair.[77]

This approach allows for the correction of coagulopathy, promotes spontaneous wound closure, and provides hemostasis without the additional trauma that may result from suture placement.
Vaginal packing is particularly beneficial for tamponade, preventing the enlargement of vaginal hematomas.

Genital tract hematomas, including labial, vaginal, broad ligament, or retroperitoneal hematomas, can result in significant blood loss, particularly in cases of precipitous delivery or operative vaginal delivery.[2]

These hematomas may present with symptoms of rectal or pelvic pressure, pain, or deterioration of vital signs several hours after delivery.[2]
In most cases, conservative management is recommended.[2]
However, incision and drainage may be indicated in the setting of a rapidly enlarging hematoma or unstable patient. Identifying a single bleeding source within the hematoma can be challenging; thus, exploration with suturing or packing may be necessary to achieve hemostasis. Arterial embolization may be considered as an alternative to incision and drainage.[2]

Have a raised suspicion for an intraperitoneal or retroperitoneal hematoma in the event of significant deterioration of vital signs without an apparent source of external bleeding.[2]

In these cases, pursue immediate maternal resuscitation, diagnostic imaging, and surgical intervention or interventional radiology procedures as appropriate.

Surgical management

Surgical management is indicated if PPH fails to respond to uterotonics and all other conservative interventions outlined above.[5]

Surgical management: devascularization and uterine compression sutures

In cases where hemorrhage persists despite medical measures, the surgical team should proceed with a laparotomy to perform surgical devascularization and uterine compression procedures.[2][21][77]

Surgical devascularization involves interrupting uterine blood flow and is considered safe with no known adverse effects on future fertility or pregnancy outcomes.[136]
While there is no particular order in which particular surgical interventions should occur, surgical devascularization procedures are typically the initial procedures performed. One commonly performed procedure is the O'Leary suture, also known as uterine artery ligation. Bilateral uterine artery ligation involves suture ligation of the uterine vessels at the lateral aspect of the lower uterine segment.[21]
If bilateral uterine artery ligation proves ineffective, an alternative option is to perform suture-ligation of the vessels within the utero-ovarian pedicle, known as bilateral utero-ovarian artery ligation.[2][21]
Hypogastric artery ligation is considered a last-resort method of surgical devascularization due to its lower success rate of around 50% to 60%, and the extensive surgical dissection required.[2][137]

If surgical devascularization fails to control the bleeding, uterine compression sutures can be attempted as an alternative surgical technique.[2][21][77]

The B-lynch suture is the most common compression suture used. It involves placing a series of loops with a large absorbable suture to compress the uterine fundus over the lower uterine segment. During the tying of the suture, manual compression of the uterus by another member of the surgical team is necessary for maximum effect.[138]
Other compression sutures such as the Hayman suture, box sutures, Cho multiple square technique, and vertical and horizontal compression sutures can also be considered.[104]
Systematic reviews have shown a success rate >90% for managing PPH with compression sutures.[21]

Surgical management: uterine artery embolization

If a patient with severe refractory PPH is hemodynamically stable and access to interventional radiology services is available, uterine artery embolization (UAE) can be considered as a fertility-sparing alternative to hysterectomy.[2][5][21][49] UAE has high success rates and a lower morbidity profile compared with hysterectomy. However, careful patient selection is essential. The best candidates for UAE are hemodynamically stable, with persistent slow bleeding and have failed less invasive options such as uterotonics, uterine massage, and uterine compression.[2]

UAE, when performed promptly, has been shown in some studies to have success rates of up to 95% for refractory PPH.[139][140]
UAE is associated with reduced blood loss, shorter operative time, and decreased postoperative length of stay compared with hysterectomy.[139][140]
The procedure is associated with a low complication rate.[139][140]
There has been conflicting evidence on the safety of UAE in relation to future fertility and pregnancy outcomes with some studies finding no association between UAE and adverse outcomes in subsequent pregnancies, but others reporting higher rates of preterm birth, fetal growth restriction, and placenta accreta spectrum in pregnancies following UAE.[2][140][141]

Note that UAE is not recommended for cases of brisk, ongoing bleeding where there is insufficient time for embolization, or for hemodynamically unstable patients who require immediate surgical intervention.[139]

Additionally, if uterine artery ligation has been unsuccessful, UAE may not be possible, and hysterectomy becomes necessary.

Surgical management: hysterectomy

Hysterectomy is required for definitive surgical management of severe PPH refractory to all other medical and surgical interventions.[2][21]

No clear recommendations exist to guide the choice between supracervical and total hysterectomy and the decision is generally made by the surgical team on a case-by-case basis, taking account of factors such as the extent and location of bleeding, placental invasion, and the surgical team's expertise.[77]
The primary goal is to minimize blood loss and operative time. Careful consideration and surgical skill are necessary to minimize complications and ensure optimal outcomes.
Hysterectomy may be appropriate at an earlier stage of management if preservation of future fertility is not desired.[21]

Surgical options for specific subgroups

Uterine rupture

In cases of intraoperative bleeding during cesarean delivery or uterine rupture, a thorough evaluation of potential sources of bleeding is crucial.[77]

This includes assessing bleeding from the placental bed, uterine extensions, hematomas, and inferior epigastric vessels within the rectus muscles.
Repairing deep uterine extensions involves identifying the apex of the extension and repairing it with running, locked sutures from the apex towards the hysterotomy.

In cases of uterine rupture with a prior hysterotomy scar, laparotomy and surgical repair are necessary.[77]

The surgical approach depends on the site and extent of the uterine rupture, the patient’s clinical status, and desire for future fertility. Uterine rupture along a prior cesarean scar may be revised along the edges of the previous incision with a primary closure, although hysterectomy may be required as a life-saving measure in more complex cases with ongoing bleeding.[2]
The involvement of additional structures such as the bladder, ureter, uterine arteries, and broad ligament also needs to be assessed and repaired if necessary in conjunction with supportive resuscitative measures.[2]

Persistent uterine inversion

If persistent uterine inversion occurs despite initial interventions, surgical procedures via laparotomy become necessary.[2][21]

The Huntington procedure is typically the first choice, involving the use of Allis clamps to grasp the round ligaments and gently apply traction to reposition the fundus above the cervical os. If unsuccessful, the Haultain procedure can be attempted, which involves making a vertical posterior uterine incision to release the constriction ring and restore the fundus to its normal position.
Following these procedures, patients should be counseled for cesarean births in subsequent pregnancies due to the uterine scar resembling a posterior classical hysterotomy.

Ensure administration of uterotonics after correcting uterine inversion to prevent uterine atony and recurrence of inversion.[77]

In cases of recurrent uterine inversion, a uterine tamponade balloon may be considered.[2] If all interventions fail to resolve the inversion, hysterectomy is indicated due to the ongoing risk of severe PPH.

Von Willebrand disease

Desmopressin can be considered as an intervention for refractory PPH in patients with known von Willebrand disease type I. It is a synthetic analog of vasopressin and stimulates secretion of von Willebrand factor from endothelial cells, thereby improving platelet function.[142] See Von Willebrand disease.

Placenta accreta spectrum disorder

Placenta accreta spectrum (PAS) disorders (placenta accreta, increta, and percreta) are associated with high maternal morbidity and mortality.

Management guidelines specific to PAS disorders from ACOG recommend:[62]

All women with suspected PAS should deliver whenever possible at a level III or IV hospital that has experience in PAS management and access to a blood bank with a protocol for massive transfusion.
Planned cesarean delivery between 34 weeks' and 35 weeks 6 days' gestation to optimize the balance between the risk of catastrophic hemorrhage versus the risks of prematurity. The ideal approach is cesarean hysterectomy.
Emergent delivery regardless of gestational age in cases of ongoing hemorrhage, recurrent vaginal bleeding, and preterm labor.
A standardized surgical approach for optimal management, under a comprehensive multidisciplinary care team that includes experts in complex pelvic surgery, anesthesiology, blood bank, urology, and neonatal intensive care.[2]

If PAS has not been diagnosed prenatally and is suspected when a vaginal delivery is complicated by PPH and a placenta that fails to detach easily, transfer the patient immediately to the operating room for further evaluation.[2]

Do not make any additional attempts at manual removal of the placenta in the delivery room.
Should continued PPH occur with the diagnosis of likely PAS in the operating room, hysterectomy should be performed without delay.
Blood products and preparation for massive transfusion should be readily available, with a low threshold to transfuse intraoperatively.

Secondary PPH

Secondary PPH (>24 hours and up to 12 weeks postpartum) accounts for approximately 1% to 2% of cases of PPH and management focuses on identifying and addressing the specific cause of the bleeding.[21]

Tailor management to the individual patient, targeting the suspected cause of the hemorrhage to achieve effective control and prevent further complications.[2] This may involve interventions aimed at:[21]

Removing retained products of conception. Perform ultrasound evaluation to assess for retained placental tissue.
Treating infection or inflammation. Suspect endometritis in patients who present with fundal tenderness and infectious signs/symptoms.[2]
Addressing vascular abnormalities or managing coagulation disorders. Rarely, patients with undiagnosed coagulopathy disorders such as von Willebrand disease may present with delayed PPH.[2]
Resolving subinvolution of the placental site.

Initial treatment of secondary PPH typically centers around the use of uterotonics (preferably oxytocin), together with antibiotics if endometritis is present.[2]

Endometritis requires broad-spectrum antibiotic coverage, with a combination of gentamicin plus clindamycin commonly used.[2][143][144]
Uterine curettage may be indicated for the removal of retained placental tissue, and should be performed under ultrasound guidance to prevent perforation.[2]

Patients with subinvolution of the placental site (SPS - a delay or impairment in the normal process of the uterus returning to its prepregnancy state after childbirth) require prompt diagnosis and management to prevent excessive bleeding and other potential complications. This may involve manual removal of retained placental tissue, administration of antibiotics for infection, or other interventions as deemed necessary by healthcare providers. Close monitoring and follow-up are important to ensure proper involution of the uterus and to prevent further complications.[2]

After delivery, the uterus undergoes involution, which is the process of shrinking and contracting back to its nonpregnant size. This process involves the shedding of the excess uterine lining and the regression of blood vessels that supplied the placenta. In cases of SPS, the uterus fails to contract and shrink as expected, leading to a slower regression of the uterus to its prepregnancy size. This can result in prolonged postpartum bleeding and an increased risk of PPH.

Organization of care

Obstetric hemorrhage care bundles

The implementation of obstetric hemorrhage bundles has demonstrated notable benefits in enhancing patient outcomes in PPH, including expedited resolution of PPH, reduced reliance on blood transfusions, and decreased necessity for invasive procedures such as UAE and cesarean hysterectomy, and reduced rates of severe PPH and maternal death.[69][86][145]

All obstetric facilities should have a standardized hospital-wide process in place for management of PPH.[2][5]
In the US, the Safe Motherhood Initiative and the National Partnership for Maternal Safety have both developed comprehensive care bundles that prioritize prompt access to hemorrhage medications and supplies; clear protocols for massive transfusion and blood bank procedures; and assembling of a proficient multidisciplinary hemorrhage response team.[3][6][7][146] Safe Motherhood Initiative: Obstetric Hemorrhage Bundle Opens in new window
The WHO has outlined recommended care bundles for the treatment of primary PPH, categorized into an initial response bundle and a refractory PPH bundle.[101] The early response bundle includes administering intravenous crystalloids, uterotonics, and tranexamic acid with simultaneous uterine massage. In cases of PPH that do not respond to first-line treatment, the management involves additional administration of uterotonics and a second dose of tranexamic acid; implementation of compressive measures such as intrauterine balloon tamponade, aortic compression, or bimanual uterine compression; and the use of NASGs if available. These measures aim to minimize ongoing blood loss while preparing for or proceeding to invasive surgical procedures.
The E-MOTIVE trial, involving 210,132 women in four African nations who had vaginal deliveries, found that use of a combined early detection and treatment bundle for PPH was associated with a 60% reduction in the composite primary outcome of severe PPH (blood loss ≥1000 mL), or laparotomy or maternal death from PPH (risk ratio 0.40, 95% CI 0.32 to 0.50; P <0.001) when compared with usual care.[86] The treatment bundle was initiated for any woman with blood loss ≥500 mL or with blood loss ≥300 mL together with hypotension or tachycardia. The bundle interventions consisted of:[86]
- uterine massage
- administration of uterotonics, intravenous tranexamic acid, and intravenous fluids
- examination to ensure an empty bladder and complete placental delivery, and to evacuate clots and check for lacerations
- escalation if the cause of bleeding could not be identified, or if the bleeding did not stop in response to first-line interventions.
The E-MOTIVE trial results prompted the WHO to issue a new recommendation in favor of standardized use of a care bundle for detection and treatment of PPH in all women who have vaginal delivery.[72] The WHO stated that all the E-MOTIVE treatment bundle interventions must ideally be initiated within 15 minutes of a PPH diagnosis.[72] It noted that while the evidence supporting a PPH treatment bundle is largely from trials of vaginal birth, the individual interventions included in such bundles are also recommended for women undergoing cesarean section.[72]

It is essential that healthcare professionals have a thorough understanding of the four stages of PPH and are well versed in the appropriate management actions outlined by the Safe Motherhood Initiative obstetric hemorrhage checklist, which is endorsed by ACOG.[6] This knowledge serves as a fundamental asset in the early identification and effective treatment of severe PPH.[7] The four stages and appropriate interventions are as follows:[6][7] Safe Motherhood Initiative: Obstetric hemorrhage checklist Opens in new window

STAGE 1: EBL >1000 mL after delivery with normal vital signs and laboratory values; note that vaginal delivery with EBL 500-999 mL should also be treated as stage 1

Initial steps: ensure large bore intravenous access (16G or 18G); administer intravenous fluids (isotonic crystalloids); insert indwelling urinary catheter; fundal massage
Ensure appropriate medications given patient history: increase oxytocin; consider additional uterotonics
Blood bank: confirm active type and screen and consider crossmatch of 2 units of red blood cells (PRBCs)
Determine etiology and treat: 4Ts; prepare operating room, if clinically indicated (optimize visualization/examination).

STAGE 2: continued bleeding (EBL up to 1500 mL OR >2 uterotonics*) with normal vital signs and laboratory values (*two or more uterotonics in addition to routine oxytocin administration, or >2 administrations of the same uterotonic)

Initial steps: mobilize additional help; place second intravenous cannula (16-18G); draw stat labs (CBC, coagulation studies, fibrinogen levels); prepare operating room
Medications: continue stage 1 medications, consider tranexamic acid
Blood bank: obtain 2 units of PRBCs (do not wait for labs, transfuse per clinical signs/symptoms); thaw 2 units fresh frozen plasma (FFP)
Action: for uterine atony, consider uterine balloon or packing, possible surgical interventions (compression suture/B lynch suture, uterine artery ligation, hysterectomy); consider moving patient to operting room; escalate therapy with goal of hemostasis.

STAGE 3: continued bleeding (EBL >1500 mL OR > 2 RBCs given OR at risk for occult bleeding/coagulopathy OR any patient with abnormal vital signs/labs/oliguria)

Initial steps: mobilize additional help; move to operating room; announce clinical status (vital signs, cumulative blood loss, etiology); outline and communicate plan
Medications: continue stage 1 medications, consider tranexamic acid
Blood bank: initiate massive transfusion protocol (if clinical coagulopathy, add cryoprecipitate, consult for additional agents)
Action: achieve hemostasis, intervention based on etiology; escalate interventions.

STAGE 4: cardiovascular collapse (massive hemorrhage, profound hypovolemic shock, or amniotic fluid embolism)

Initial steps: mobilize additional resources
Medications: advanced cardiovascular life support (ACLS)
Blood bank: simultaneous aggressive massive transfusion
Action: immediate surgical intervention to ensure hemostasis (hysterectomy).

Risk assessment

Patients deemed to be at highest risk for PPH based on prenatal risk factors can benefit from proactive management strategies. By recognizing these high-risk individuals during the prenatal period, healthcare providers can ensure appropriate allocation of care resources during labor and delivery, making necessary preparations such as having crossmatched blood readily available and maintaining well equipped hemorrhage kits.[51] Safe Motherhood Initiative: Risk assessment table: prenatal & antepartum Opens in new window Safe Motherhood Initiative: Risk assessment table: labor & delivery admission/intrapartum Opens in new window

For more detail on risk assessment, see Primary prevention.

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