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Maternal–Fetal Medicine Tools & Algorithms
Postpartum Hemorrhage Management Algorithm
Updated 2025
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Postpartum Hemorrhage (PPH) — Management Algorithm

Thresholds refer to ≥500 mL blood loss after vaginal birth or ≥1000 mL after cesarean, or any blood loss causing hemodynamic instability.
Clinical note: This algorithm supports but does not replace clinical judgment. Adapt thresholds and specific drug doses to your local protocol, formulary, and institutional PPH bundle.
Algorithm Overview

Stepwise PPH Management — Flow-Chart

Step 1 Recognize hemorrhage & activate team
  • Blood loss ≥500 mL (vaginal) or ≥1000 mL (cesarean), OR any hemodynamic instability.
  • Call hemorrhage team, anesthesia, nursing, blood bank, OR, critical care.
  • Begin **quantitative blood loss measurement**.
Act early—do not wait for exact volume if instability present.
Step 2 Initial resuscitation & monitoring
  • Two large-bore IVs (16–18g), oxygen, continuous vitals, ECG.
  • Rapid crystalloid infusion while preparing blood products.
  • Foley catheter to monitor urine output.
  • Labs: CBC, PT/INR, aPTT, fibrinogen, type & screen/cross, lactate, ABG.

Consider early activation of MTP if blood loss escalating.

Step 3 Rapid cause assessment — Four Ts
  • Tone: Boggy uterus → atony.
  • Trauma: Lacerations, rupture, inversion, hematomas.
  • Tissue: Retained placenta/fragments, accreta spectrum.
  • Thrombin: Coagulopathy (DIC, low fibrinogen, anticoagulants).
Step 4A First-line therapy for uterine atony
  • Bimanual uterine compression + uterine massage.
  • Oxytocin bolus + infusion.
  • Add second-line uterotonics:
    • Methylergonovine 0.2 mg IM q2–4h (avoid in HTN).
    • Carboprost 250 mcg IM q15–90 min (max 2 mg; caution asthma).
    • Misoprostol 600–1000 mcg PR/SL/PO.
  • Empty bladder to improve tone.
Step 4B First-line therapy for Trauma, Tissue, Thrombin
  • Trauma: Repair lacerations; evacuate hematomas.
  • Inversion: Replace uterus immediately; then uterotonics.
  • Tissue: Manual removal; ultrasound-guided curettage if needed.
  • Thrombin: Transfuse blood products based on labs/MTP.
Step 5 Adjunct pharmacologic & transfusion therapy
  • TXA **1 g IV over 10 min** ASAP; repeat 1 g if continues (best ≤3 hrs).
  • Blood transfusion based on labs/instability.
  • Maintain:
    • Fibrinogen > 200 mg/dL
    • Platelets > 50,000/µL
    • Correct INR/PT/aPTT
    • Correct ionized Ca, acidosis, hypothermia
Step 6 Mechanical / minimally invasive
  • Uterine balloon tamponade (e.g., Bakri).
  • Packing (if balloon not available).
  • Compression sutures (e.g., B-Lynch).
  • Uterine or internal iliac artery ligation.
  • IR → uterine artery embolization if available.

Escalate based on stability: Balloon → sutures → IR → laparotomy.

Step 7 Refractory hemorrhage — definitive surgery
  • Laparotomy for uncontrolled bleeding or rupture.
  • Cesarean hysterectomy for accreta spectrum or refractory atony.
  • Multidisciplinary team required.
Do not delay hysterectomy if bleeding remains life-threatening.
Step 8 Post-control monitoring & follow-up
  • Vital signs, lochia, uterine tone, urine output.
  • Serial labs for H/H, fibrinogen, platelets.
  • Treat anemia; support lactation.
  • Team debrief + QI reporting.
  • Patient counseling on future risk.
Medications

Uterotonics & Adjuncts — Quick Reference Dosing

*Doses reflect common U.S. obstetric use; always follow institutional formulary and pharmacy policy.*

Medication Dose & Route Notes / Contraindications
Oxytocin IV bolus 10 IU slow (or IM 10 IU).
Infusion: 10–40 IU in 1 L NS/LR. 		Avoid rapid IV push (hypotension/tachycardia).
Methylergonovine 0.2 mg IM q2–4h. Avoid in hypertension/preeclampsia.
Carboprost (Hemabate) 250 mcg IM q15–90 min; max 2 mg. Caution in asthma.
Misoprostol 600–1000 mcg PR/SL/PO. Higher fever/GI effects at high doses.
Tranexamic Acid (TXA) 1 g IV over 10 min; repeat 1 g if persists (30 min–24h). Best if given within 3 hrs of birth.
Cryoprecipitate / Fibrinogen concentrate Maintain fibrinogen > 200 mg/dL. Use early in severe PPH.
Packed RBCs ~1 g/dL Hgb increase per unit. Use with MTP if rapid loss.
Platelets Maintain platelets > 50,000/µL. Higher target if major surgery.
Fresh Frozen Plasma (FFP) 10–15 mL/kg. Correct coagulopathy.
Expanded details

Key Clinical Considerations

PPH thresholds & early activation

PPH is defined as ≥500 mL after vaginal birth or ≥1000 mL after cesarean OR blood loss causing instability.

Laboratory & transfusion strategy

Maintain fibrinogen > 200 mg/dL, platelets > 50k, and correct PT/INR/aPTT. Use targeted therapy guided by labs and clinical response.

TXA details

Give early; repeat if persistent bleeding. Avoid in active thromboembolism.

Accreta spectrum & high-risk delivery

Deliver at tertiary center, multidisciplinary planning, hysterectomy common.

References

Selected Guideline Sources

  1. World Health Organization. Consolidated Guidance on Postpartum Hemorrhage.
  2. Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 52.
  3. American College of Obstetricians and Gynecologists. Practice Bulletin: Postpartum Hemorrhage.
  4. FIGO Consensus on PPH Management.
  5. Günaydın C, et al. Review and management algorithms for PPH.
This page supports clinical decision-making by licensed clinicians and does not replace institutional protocols.