Postpartum hemorrhage

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Clinical Features

  • Loss of >500 mL blood after vaginal delivery
  • Usually within 24 hours of delivery
  • If occurs more than 24 hours after delivery, consider: retained POC, coagulopathy, etc

Differential Diagnosis

Postpartum Emergencies



  • CBC
  • Coags
  • Type and cross


  • Clinical diagnosis


  • Fluid resuscitation
  • Consider Blood Products for Hemodynamic Instability
  • Consider tranexamic acid (TXA) to reduce blood loss and hysterectomy[1]
    • For refractory atonic or traumatic bleed[2]
    • WOMAN trial underway - 1 g IV of TXA, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose[3]
    • Weigh risks and benefits, as pregnant females are hypercoagulable
  • Evaluate placenta for retained products
  • Examine for tears under good lighting and suction
  • Treat underlying cause - 4T's: Tone, Trauma, Tissue, Thrombosis


Uterine atony (boggy uterus)

  • Bimanual Massage
  • Oxytocin (Pitocin)
    • 1st line and most important drug - Oxytocin 80 units in 500 cc NS bag, run it wide open[4]
    • OR 20 MILLIunits/min IV after placenta delivery (rapid administration may cause hypotension)
    • OR 10 units IM if no IV
  • Misoprostol (Cytotec) 600mcg SL or 1000 mcg rectally
  • Methylergonovine (Methergine) 0.2mg IM q2-4 hrs (relative contraindication in patients with hypertension or Preeclampsia - may consider in severely unstable BP)
  • Carboprost (Hemabate) 250mcg IM q15 min (avoid in patients with asthma)
  • Bakri balloon placement, fill with warm 500ml NS (or large/multiple Foleys or pack) - use US to place to top of fundus and ensure no retained placenta


  • Genital tract tear
    • Suture lacerations - figure of eight with 3-0 or 2-0 absorbable
    • Deep lacerations such as those by the cervix may require OR
    • Drain hematomas >3 cm
  • Uterine inversion
    • Manually replace placenta OR do not remove placenta until uterus has been replaced:
    • Place hand inside the vagina and push the fundus cephalad along long axis of vagina
    • Prompt replacement important since cervix contracts over time creating a constriction ring
    • Discontinue uterotonic meds (oxytocin) if uterus not reduced, and consider uterine relaxant options:[5]:
    • After replacement:
      • Fundal massage ± bimanual massage/compression
      • Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr


Retained placental tissue

  • Pelvic exam may be normal other than blood
  • Detect with US
  • Manual removal
  • Curettage


Reverse any coagulopathies

  • Labs - platelets, coags, fibrinogen, d-dimer
  • Replace appropriate blood components


  • Admit

See Also


  1. Ducloy-Bouthors AS et al. High-dose tranexamic acid reduces blood loss in postpartum haemorrhage. Crit Care. 2011;15(2):R117.
  2. WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012.
  3. Shakur H et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11:40.
  4. Tita AT et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2012 Feb;119(2 Patient 1):293-300.
  5. Rosen's Emergency Medicine - Concepts and Clinical Practice. 8th ed. 2013. Chapter 181: Labor and Delivery and their Complications. 2349.