Postpartum Hemorrhage Management (ACOG 2017/2024)

Algorithm Steps

1. ▶

   Start

   PPH Identified

   Blood loss ≥1000mL OR signs of hypovolemia regardless of blood loss

   1. ●

      Action

      Stage 0: Active Management 3rd Stage

      Prevention & early recognition

      • Oxytocin 10 units IM after delivery of anterior shoulder
      • OR Oxytocin 10-40 units in 1L crystalloid IV after placental delivery
      • Controlled cord traction for placenta
      • Uterine massage after placenta delivery
      • Quantify blood loss (QBL) - use graduated drapes
      1. ◆

         Decision

         Blood loss ≥1000mL or hemodynamically unstable?

         Assess quantified blood loss and vital signs

         1. ●

            Action

            Stage 1: Initial Medical Management

            First-line uterotonics and resuscitation

            • Call for help - activate hemorrhage protocol
            • Bimanual uterine massage
            • Oxytocin 40 units in 500mL NS (run wide open)
            • If atony persists: Methylergonovine 0.2mg IM (avoid if HTN)
            • OR Carboprost 250mcg IM q15-90min (max 2mg, avoid if asthma)
            • OR Misoprostol 800-1000mcg sublingual/rectal
            • Establish 2 large-bore IVs (16-18G)
            • Type and crossmatch, send coags
            • Foley catheter - empty bladder
            1. ◆

               Decision

               Identify Cause (4 Ts)

               Tone (70%), Trauma (20%), Tissue (10%), Thrombin (<1%)

               • TONE: Uterine atony - boggy uterus
               • TRAUMA: Lacerations, hematomas, uterine rupture/inversion
               • TISSUE: Retained placenta or clots
               • THROMBIN: Coagulopathy (DIC, dilutional, pre-existing)
               1. ●

                  Action

                  Atony (Tone)

                  Continue uterotonics, consider tamponade

                  • Continue bimanual massage
                  • Ensure all uterotonics given
                  • Uterine balloon tamponade (Bakri, BT-Cath)
                  • Fill with 300-500mL saline
                  • Apply traction to tamponade effect
                  1. ◆

                     Decision

                     Bleeding controlled?

                     Reassess blood loss and hemodynamic status

                     1. ✓

                        Outcome

                        Hemorrhage Controlled

                        Continue monitoring, ICU if significant blood loss

                        • Close monitoring in PACU or L&D
                        • ICU admission if >4 units pRBC or hemodynamically unstable
                        • Serial H/H, coagulation studies
                        • Thromboprophylaxis when stable
                        • Debrief with patient and team
                     2. ●

                        Action

                        Stage 2: Escalation

                        Transfusion and procedural interventions

                        • Activate massive transfusion protocol (MTP)
                        • 1:1:1 ratio (pRBC:FFP:Platelets)
                        • Consider TXA 1g IV (if within 3h of delivery)
                        • Intrauterine vacuum-induced hemorrhage control (JADA device)
                        • Uterine compression sutures (B-Lynch, Hayman)
                        • Uterine artery ligation
                        • Internal iliac artery ligation
                        • Interventional radiology - uterine artery embolization
                        1. ◆

                           Decision

                           Bleeding controlled after Stage 2?

                           Reassess response to interventions

                           1. ⚠

                              Warning

                              Stage 3: Hysterectomy

                              Definitive surgical management for uncontrolled hemorrhage

                              • Peripartum hysterectomy
                              • Subtotal (supracervical) preferred if faster
                              • Total if cervical bleeding source
                              • Damage control surgery if coagulopathic
                              • Pack and close if needed, return for completion
                              1. ✓

                                 Outcome

                                 Post-Hysterectomy Care

                                 ICU admission, continued resuscitation

                                 • ICU admission mandatory
                                 • Continued MTP as needed
                                 • Monitor for DIC
                                 • Renal function monitoring
                                 • Counseling and support for patient/family
               2. ●

                  Action

                  Trauma

                  Repair lacerations, evacuate hematomas

                  • Systematic inspection of cervix and vagina
                  • Repair all lacerations
                  • Evacuate and drain hematomas
                  • If uterine rupture: laparotomy, repair or hysterectomy
                  • If uterine inversion: manual replacement under anesthesia
               3. ●

                  Action

                  Tissue

                  Remove retained products

                  • Manual exploration of uterine cavity
                  • Remove retained placental fragments
                  • Ultrasound-guided curettage if needed
                  • Suction or sharp curettage for retained products
               4. ●

                  Action

                  Thrombin (Coagulopathy)

                  Correct coagulation defects

                  • Fibrinogen target >200 mg/dL (cryoprecipitate 10 units)
                  • FFP for factor replacement
                  • Platelets if <50,000/μL
                  • Consider factor VIIa in refractory cases
                  • Avoid hypothermia - use fluid warmers
                  • Correct acidosis