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Postpartum hemorrhage

Key sources
The following summarized guidelines for the evaluation and management of postpartum hemorrhage are prepared by our editorial team based on guidelines from the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022; 2018), the International Federation of Gynecology and Obstetrics (FIGO 2022), the British Society for Haematology (BSH 2022; 2018), the European Society of Intensive Care Medicine (ESICM 2021), the American College of Obstetricians and Gynecologists (ACOG 2020; 2017), the World Health Organization (WHO 2018), the Royal College of Obstetricians and Gynaecologists (RCOG 2017), and the American Academy of Family Physicians (AAFP 2017).


1.Classification and risk stratification

Risk assessment: obtain an individualized risk assessment for PPH, including calculation of the maximum allowable blood loss,
documented in a checklist upon arrival to a labor unit and updated throughout labor and delivery.
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2.Diagnostic investigations

Physical examination: as per FIGO 2022 guidelines, obtain postpartum abdominal uterine tonus assessment for early identification of uterine atony in all patients.

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  • Blood loss estimation

  • Viscoelastic testing

3.Medical management

Multidisciplinary care: as per SOGC 2022 guidelines, use a multidisciplinary team approach consisting of obstetrics, anesthesia, nursing, and transfusion medicine for the management of severe obstetrical hemorrhage.

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  • General principles

  • Initial resuscitation

  • Uterotonics

  • Tranexamic acid

  • Recombinant activated factor VII

  • Management of secondary PPH

4.Inpatient care

Hemodynamic monitoring: obtain the following monitoring and investigations in major PPH (blood loss > 1,000 mL) and ongoing hemorrhage or clinical shock:
perform immediate venipuncture (20 mL) for cross-match (4 units minimum), CBC, coagulation screen including fibrinogen, renal and liver function for baseline
monitor temperature every 15 minutes
record pulse, BP and respiratory rate continuously (using oximeter, ECG and automated BP recording)
place a Foley catheter to monitor urine output
place 2 peripheral cannulae (14-gauge)
consider monitoring arterial line (once appropriately experienced staff available for insertion)
consider transfer to ICU once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate
record parameters on a MEOWS chart
act and escalate promptly when abnormal scores from a MEOWS chart are observed
document fluid balance, blood/blood products and procedures

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  • Coagulation monitoring

5.Nonpharmacologic interventions

Uterine massage/compression
As per FIGO 2022 guidelines:
Perform uterine massage for the management of PPH.
Perform bimanual uterine compression or external aortic compression for the management of PPH due to uterine atony after vaginal birth as a temporizing measure until appropriate care is available.

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  • Non-pneumatic anti-shock garment

6.Therapeutic procedures

Blood product transfusion
As per SOGC 2022 guidelines:
Administer 4 units of RBCs before other blood products in patients with active bleeding approaching the maximum allowable blood loss, unless the patient has a coagulation defect.
Consider using a massive hemorrhage protocol with ratios of RBCs-to-FFP-to-platelets of 1:1:1: or 2:1:1, in the absence of timely laboratory results.

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  • Uterine packing

  • Uterine balloon tamponade

  • Uterine artery embolization

7.Surgical interventions

Indications for surgery: as per FIGO 2022 guidelines, perform surgical interventions, including compression suture techniques, uterine and hypogastric artery ligation, or hysterectomy, if bleeding does not stop despite treatment with uterotonics and other available conservative interventions (such as uterine massage, balloon tamponade).

8.Patient education

Communication with the patient
Ensure communication with the patient and her birthing partner and provide clear information of what is happening.
Offer an opportunity to discuss the events surrounding the obstetric hemorrhage to the woman (possibly with her birthing partner) at a mutually convenient time.

9.Preventative measures

Management of risk factors: as per SOGC 2022 guidelines, identify both antenatal and postnatal anemia and treat it aggressively.

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  • Active management of labor

  • Prophylactic uterotonics

  • Prophylactic tranexamic acid

  • Avoidance of episiotomy

  • Umbilical cord clamping

  • Placental cord drainage

  • Delivery of placenta

  • Uterine massage

10.Quality improvement

Hospital requirements and protocols
As per SOGC 2022 guidelines:
Implement an obstetrical massive hemorrhage protocol, including defined roles and responsibilities of each team member.
Conduct simulation training with all multidisciplinary team members regularly, ideally by a trained facilitator.