Postpartum hemorrhage - NYSORA

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Postpartum hemorrhage

Learning objectives

  • Understand the common causes of postpartum hemorrhage (PPH)
  • Management of PPH

Definition and mechanisms

  • Abnormal blood loss within 24 hours after birth 
    • Vaginal delivery: estimated blood loss (EBL) > 500 ml 
    • Post-C-section: EBL > 1000 ml
  • PPH is the leading cause of maternal mortality in low-income countries and the primary cause of nearly one-quarter of all maternal deaths globally

Signs and symptoms 

  • EBL > 500
  • Tachycardia 
  • Hypotension
  • Delayed capillary refill 
  • Decreased urine output 
  • Pallor 
  • Lightheadedness 
  • Palpitations 
  • Confusion
  • Syncope 
  • Fatigue 
  • Air hunger 
  • Diaphoresis 

Risk factors

Medical or surgical historyPrevious postpartum hemorrhage
Previous Caesarean delivery or other uterine instrumentation
Fetal issuesMultifetal gestation
Large-for-gestational-age fetus
Fetal macrosomia
Maternal issues Hypertensive disorders of pregnancy
Perioperative anemia
Inherited coagulopathy such as Von Willebrand’s Disease (VWD)
Acquired coagulopathy such as HELLP syndrome
Trial of labor after Caesarean delivery
Prolonged labor
Induction and augmentation of labor
The arrest of progress during the second stage of labor
The prolonged third stage of labor
Instrumentation during delivery
Placental/uterine issues Placental abruption
Placenta praevia
Retained placenta
Acute Uterine inversion
Subinvolution of the uterus

However, 20% of postpartum hemorrhage occurs in women with no risk factors


The four T’s mnemonic of postpartum hemorrhage:

TonusAtonic uterus70%
TissueRetained placenta, invasive placenta10%
TraumaLaceration, hematoma, Uterine inversion, rupture 20%

Anesthetic management

Postpartum hemorrhage, oxytocin, cord traction, uterine massage, placenta, estimated blood loss, vaginal delivery, uterus, uterotonica, lacerations, hematoma, currettage, blood transfusion, methotrexate, FFP, platelets, cryoprecipitate, factor VIIa, uterine packing, ligation, tamponade procedure, airway, breathing, circulation, RSI, ETT

Suggested reading 

  • Watkins EJ, Stem K. Postpartum hemorrhage. JAAPA. 2020;33(4):29-33.
  • Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician. 2017; 95(7): 442-449. 
  • 2017. Prevention and Management of Postpartum Haemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology 124, e106–e149.
  • E. Mavrides, S. Allard, E. Chandraharan, P. Collins, L. Green, BJ. Hunt, S. Riris. AJ. Thomason on behalf of the Royal college of obstetricians and gynaecologists. Prevention and management of postpartum haemorrhage. BJOG 2016; 124:e 106-e149
  • Anderson JM, Etches D. Prevention and management of postpartum hemorrhage. Am Fam Physician. 2007;75(6):875-882.
  • WHO recommendations for the prevention and treatment of postpartum haemorrhage.

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