Postpartum Hemorrhage Management: Clinical Protocols

Postpartum Hemorrhage Management

Clinical Protocols, Recognition, and Emergency Response

Defining PPH: ACOG vs. WHO

Cumulative blood loss ≥ 1,000 mL OR blood loss accompanied by signs/symptoms of hypovolemia within 24 hours after the birth process.

Traditional definition: ≥ 500 mL (vaginal) or ≥ 1,000 mL (cesarean). New emphasis on clinical instability.

Etiology: The 4 T's Frequency

Uterine Atony (Tone) accounts for 70-80% of all PPH cases.

Recognition: Quantitative Blood Loss (QBL)

Visual estimation underestimates loss by 30-50%.

Protocol: Weigh all blood-soaked materials (1g = 1mL).

Keep a running total displayed on the whiteboard.

The Shock Index (SI) as Early Warning

SI = Heart Rate ÷ Systolic BP. Normal range is 0.5-0.7 for non-pregnant, 0.7-0.9 for pregnant.

First-Line Medical Management: Uterotonics

OXYTOCIN

First Line. 10-40 units IV infusion (or IM). No contraindications.

METHYLERGONOVINE

0.2 mg IM q2-4hr. AVOID in Hypertension/Preeclampsia.

CARBOPROST (Hemabate)

250 mcg IM q15-90min. AVOID in Asthma.

MISOPROSTOL

800-1000 mcg Rectal. Safe in HTN/Asthma. Slow onset.

Tranexamic Acid (TXA)

TIMING IS CRITICAL: Administer within 3 hours of birth.

Dose: 1 gram IV over 10 minutes.

Mechanism: Antifibrinolytic (Prevents clot breakdown).

Intrauterine Balloon Tamponade (UBT)

When Uterotonics Fail

1. Inflate with 300-500mL sterile saline.<br>2. Can be combined with compression sutures (sandwich).<br>3. Monitor drainage output continuously.

Massive Transfusion Protocol (MTP)

Orchestrated Release ratio 1:1:1

TRIGGER: >1500mL QBL, VS instability, or ongoing bleeding.

Surgical Escalation Ladder

1. Uterine Conservation

D&C, Compression Sutures (B-Lynch).

2. Vascular Ligation

Uterine Artery, Ovarian Artery, Internal Iliac (Hypogastric).

3. Hysterectomy

Definitive management when all else fails.

Summary: PPH Algorithm

STAGE 1: Activate > Fundal Massage > Oxytocin > Empty Bladder > TXA > 2nd Line Meds

STAGE 2: Move to OR > Balloon Tamponade (UBT) > Consider MTP

STAGE 3: Surgical Intervention > MTP > Hysterectomy