PPH Identified
Blood loss ≥1000mL OR signs of hypovolemia regardless of blood loss
All Pathways
Obstetrics & GynecologyEmergency
Postpartum Hemorrhage Management (ACOG 2017/2024)
Postpartum Hemorrhage Management (ACOG 2017/2024): PPH Identified → Stage 0: Active Management 3rd Stage → Blood loss ≥1000mL or hemodynamically unstabl...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action 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
03Decision Blood loss ≥1000mL or hemodynamically unstable?
Assess quantified blood loss and vital signs
04Action 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
05Decision 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)
06Action 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
07Decision Bleeding controlled?
Reassess blood loss and hemodynamic status
08Outcome 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
09Action 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
10Decision Bleeding controlled after Stage 2?
Reassess response to interventions
- Path rejoins step 08Shared downstream outcome
11Warning 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
12Outcome 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
13Action 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
- Path rejoins step 07Shared downstream outcome
14Action 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
- Path rejoins step 07Shared downstream outcome
15Action 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
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
Guideline Source
ACOG Practice Bulletin No. 183: Postpartum Hemorrhage
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not replace clinical judgment in complex cases
- Institutional protocols may vary for blood product availability
- Requires adaptation for resource-limited settings
- Does not address antepartum hemorrhage
Applicable Regions
USEUGlobal
US: Based on ACOG Practice Bulletin with 2025 update on hemorrhage-control devices
Global: WHO also has PPH guidelines - adapt to local resources
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Postpartum Hemorrhage Management (ACOG 2017/2024)?
The Postpartum Hemorrhage Management (ACOG 2017/2024) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Practice Bulletin No. 183: Postpartum Hemorrhage.
What guideline is the Postpartum Hemorrhage Management (ACOG 2017/2024) based on?
This algorithm is based on ACOG Practice Bulletin No. 183: Postpartum Hemorrhage (DOI: 10.1097/AOG.0000000000002351).
What are the limitations of the Postpartum Hemorrhage Management (ACOG 2017/2024)?
Known limitations include: Does not replace clinical judgment in complex cases; Institutional protocols may vary for blood product availability; Requires adaptation for resource-limited settings; Does not address antepartum hemorrhage. Individual patient factors may require deviation from these recommendations.
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