Postpartum hemorrhage

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 5 Oct 2024

Last updated: 18 Apr 2024

Postpartum hemorrhage (PPH) is an obstetric emergency that is a major contributor to maternal morbidity and mortality. Early recognition relies on accurate quantification of blood loss, together with frequent ongoing assessment of patient-specific risk factors, vital signs, and symptoms of hemorrhage.

Meticulous physical examination of the uterus, cervix, vagina, vulva, and perineum can facilitate an accurate diagnosis and prompt treatment of the underlying cause to prevent progression to hemorrhagic shock.

The four Ts mnemonic highlights the most common causes of PPH: tone (uterine atony, by far the most frequent cause); trauma (obstetric lacerations/expanding hematomas/uterine rupture); tissue (retained products of conception or placenta accreta spectrum disorders); and thrombin (acquired or inherited coagulopathy). Steps to address uterine atony form a routine part of the initial management in every patient with PPH.

First-line treatment for PPH comprises immediate resuscitation with intravenous fluids (and blood product transfusion if needed), along with uterine massage, administration of a uterotonic, and consideration of intravenous tranexamic acid. All of these must ideally be initiated within 15 minutes of a diagnosis. Additional management steps are dependent on the underlying cause of bleeding.

In women with refractory PPH, more aggressive interventions may be needed. Options include: temporary compressive measures; uterine tamponade; uterine artery embolization; surgical interventions, with hysterectomy sometimes necessary as a life-saving intervention.

The use of obstetric hemorrhage care bundles has been shown to improve outcomes in patients with PPH.

Active management of the third stage of labor is the single most important intervention to prevent PPH. Identification of high-risk women in the prenatal period is also paramount.

Definition

Primary postpartum hemorrhage (PPH) is characterized by a total blood loss ≥1000 mL (including intrapartum loss) or the presence of signs and symptoms of hypovolemia occurring within 24 hours after childbirth, irrespective of the mode of delivery. This standardized definition of PPH was established in 2014 by the reVITALize program and is endorsed by the American College of Obstetricians and Gynecologists.[1]

Primary PPH occurs within the first 24 hours after delivery. Secondary PPH is defined as excessive blood loss that occurs >24 hours and <12 weeks postpartum.[2]

Prior to publication of the reVITALize definition, PPH was traditionally defined as an estimated blood loss (EBL) >500 mL after a vaginal birth or >1000 mL after a cesarean birth.[2][3] International guidelines still vary in their definition of the EBL required for a diagnosis of PPH.[4][5]

History and exam

Key diagnostic factors

estimated blood loss ≥1000 mL within 24 hours of birth (including intrapartum loss)
uterine atony
obstetric lacerations and/or expanding hematomas
signs of hypovolemia
hypotension
retained tissue (placenta, membranes, or placenta accreta spectrum)
uterine defect on bimanual examination

Full details

Other diagnostic factors

symptoms of hypovolemia
uterine tenderness (secondary PPH)
signs of infection, e.g., fever (secondary PPH)

Full details

Risk factors

placenta previa/low lying placenta
placenta accreta spectrum
platelet count <50,000 per microliter
active antepartum bleeding
inherited coagulopathy
acquired coagulopathy
history of PPH in prior delivery
operative (assisted) vaginal delivery
current use of therapeutic anticoagulation
prior cesarean delivery, uterine surgery, or multiple laparotomies
uterine overdistension (multiple gestation, polyhydramnios, fetal macrosomia with estimated fetal weight >4000 g)
grand multiparity (>4 prior births)
large uterine myomas
class III obesity (BMI >40)
pre-existing maternal anemia
prolonged labor or precipitous delivery
labor induction or augmentation with prolonged use of oxytocin
magnesium sulfate use
cesarean delivery
placental abruption
severe preeclampsia or HELLP syndrome
intrauterine fetal demise (IUFD)
intrapartum infection
SSRI or SNRI use in the month before delivery

Full details

Diagnostic tests

1st tests to order

quantification of blood loss
blood type and crossmatch

Full details

Tests to consider

CBC
uterine ultrasound
coagulation profile (PT, PTT, INR, fibrinogen)
inherited coagulation assays
diagnostic laparotomy
CT abdomen/pelvis

Full details

Emerging tests

thromboelastography (TEG) or rotational thromboelastometry (ROTEM®)
app-based blood loss quantification technology

Treatment algorithm

ACUTE

primary postpartum hemorrhage: initial presentation

primary postpartum hemorrhage: refractory to initial interventions

secondary postpartum hemorrhage

ONGOING

postpartum hemorrhage resolved

Contributors

Authors

Dena Goffman, MD

Vice Chair for Quality and Patient Safety

Department of Obstetrics and Gynecology

Columbia University Irving Medical Center

New York

Disclosures

DG declares ongoing advisory board roles for Cooper Surgical Obstetrical Safety Council and Organon Jada Scientific Advisory Board; prior PPH educational speaker roles for PRIME, Haymarket, and Laborie; principal investigator for Treating Abnormal Postpartum Uterine Bleeding or Postpartum Hemorrhage with the Jada System-A Postmarket Registry 6/2021 (grant money paid to institution); NIH grant money paid to institution for Effectiveness of Pictographs to Prevent Wrong-Patient Errors in the NICU, and MPI Simulation for Attending Obstetricians to Improve Technical Skills for Managing Postpartum Hemorrhage; none of the above included an obligation to speak on or disseminate product information.

Lilly Liu, MD, MPH

Department of Obstetrics and Gynecology

Columbia University Irving Medical Center

New York

Disclosures

LL declares that she has no competing interests.

Lisa Nathan, MD

Chief of Obstetrics

Department of Obstetrics and Gynecology

Columbia University Irving Medical Center

New York

Disclosures

LN has been paid to speak at an Organon symposium on the Jada System for obstetric hemorrhage management.

Peer reviewers

John C. Smulian, MD, MPH

Chair

Department of Obstetrics and Gynecology

University of Florida College of Medicine

Gainesville

Disclosures

JCS declares that he has no competing interests.

Dilly O. C. Anumba, MBBS, MD, FRCOG, FWACS, LLM

Professor of Obstetrics and Gynaecology

University of Sheffield

Consultant in Obstetrics and Fetomaternal Medicine

Sheffield Teaching Hospitals NHS Foundation Trust

Sheffield

Disclosures

DOCA declares that he has no competing interests.

Guidelines
- Practice bulletin no. 183: postpartum hemorrhage
- WHO recommendations for the prevention and treatment of postpartum haemorrhage
More Guidelines
Videos
Female urethral catheterization: animated demonstration
Venepuncture and phlebotomy: animated demonstration
More videos
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Postpartum hemorrhage

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Emerging tests

Treatment algorithm

primary postpartum hemorrhage: initial presentation

primary postpartum hemorrhage: refractory to initial interventions

secondary postpartum hemorrhage

postpartum hemorrhage resolved

Contributors

Authors

Dena Goffman, MD

Disclosures

Lilly Liu, MD, MPH

Disclosures

Lisa Nathan, MD

Disclosures

Peer reviewers

John C. Smulian, MD, MPH

Disclosures

Dilly O. C. Anumba, MBBS, MD, FRCOG, FWACS, LLM

Disclosures

Guidelines

Videos

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice