Manage Postpartum Hemorrhage Like a Pro (Part 1): Prevention and Initial Management
Postpartum hemorrhage (PPH) remains one of the most critical obstetric emergencies, and it's something every OB/GYN provider needs to manage quickly and confidently. In this episode, we’re breaking down the basics: how to define postpartum hemorrhage, the key risk factors, primary causes, and—most importantly—what to do in those crucial early minutes when you recognize a patient is bleeding more than expected.
The Current Definition of Postpartum Hemorrhage
The American College of Obstetricians and Gynecologists (ACOG) currently defines postpartum hemorrhage as:
A cumulative blood loss of ≥1000 mL, or
Any blood loss associated with signs or symptoms of hypovolemia
Within 24 hours of delivery, regardless of delivery mode
This is a shift from older definitions that used different thresholds for vaginal versus cesarean births. Approximately 3–5% of all deliveries are complicated by PPH, making it the leading cause of maternal mortality worldwide.
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What’s Normal Blood Loss?
Vaginal delivery: ~500 mL
Cesarean section: ~1000 mL
But here’s the key—due to physiologic changes of pregnancy, patients can lose 25% of their blood volume before showing clinical signs like tachycardia or hypotension. So, we want to recognize hemorrhage early—before vital signs deteriorate.
Risk Factors to Know
While PPH can occur in anyone, certain risk factors increase the likelihood:
Uterine overdistension (macrosomia, polyhydramnios, twins, fibroids)
Prolonged oxytocin use
Intra-amniotic infection
General anesthesia
Grand multiparity
Precipitous labor and delivery
A full list is available in ACOG Practice Bulletin #183.
Two Types of PPH
Primary (Early) Hemorrhage: Occurs within 24 hours of delivery
Secondary (Late) Hemorrhage: Occurs from 24 hours up to 12 weeks postpartum
This episode focuses on primary postpartum hemorrhage.
Most Common Cause: Uterine Atony
At term, uterine blood flow is 500–700 mL/min. When the placenta separates, those spiral arteries are left open, and the uterus must contract to clamp them shut. If the uterus fails to contract, that’s uterine atony—the most common cause of primary PPH.
Other causes include:
Vaginal or cervical lacerations
Retained placental tissue
Placenta accreta spectrum disorders
Coagulopathy (e.g., DIC)
Uterine inversion
Preventing Postpartum Hemorrhage
We prevent hemorrhage through active management of the third stage of labor:
Administer oxytocin (Pitocin) immediately after delivery
Perform uterine massage
Apply gentle cord traction to assist placental delivery
First Steps in Management
If bleeding begins despite prevention efforts, here’s what to do:
Step 1: Confirm Pitocin Is Running
It’s easy to forget this step amidst the excitement of delivery—double-check with your bedside nurse that the infusion is running.
Step 2: Perform a Bimanual Exam
Palpate the uterus internally and externally. If soft or boggy, begin bimanual massage.
Use one hand internally (through the vagina to massage the lower uterine segment)
Use the other hand externally (to massage the fundus)
Remove any trapped clots from the cervix and lower uterine segment
Step 3: Empty the Bladder
A full bladder can prevent the uterus from contracting. Insert a straight cath if needed.
Step 4: Look for Lacerations
Inspect the vagina, cervix, and perineum—repair any bleeding tears.
Step 5: Monitor Blood Loss & Activate Hemorrhage Protocol
If bleeding is brisk and approaches 500 mL, activate your institution’s postpartum hemorrhage protocol
Step 6: If No Standardized Hemorrhage Protocol → Take These Immediate Actions
Ensure two large-bore IVs are in place
Begin fluid resuscitation with 500–1000 mL NS or LR
Call for hemorrhage meds to bedside
Keep the patient warm with blankets
Step 7: Uterine Sweep
If the uterus is still soft, insert your hand into the uterine cavity (all the way to the fundus) to remove retained tissue or membranes. This can also be done under ultrasound guidance if needed.
By this point, your hemorrhage kit should be at the bedside.
Keep in mind that the above steps do not necessarily need to be performed in this exact order. Often, many of these interventions happen all at once. For example, while you confirm the Pitocin is running, you’re already doing a bimanual exam and checking for lacerations. And you might perform a manual sweep before you drain the bladder. As long as you know that these are the initial key interventions, you’ll be set up for success!
Quick Recap
Primary PPH = ≥1000 mL blood loss or any blood loss with hypovolemia within 24hr of birth
Most common cause: uterine atony
Other causes: retained tissue, lacerations, accreta, DIC, inversion
Prevent with active third stage management
Initial steps: Confirm oxytocin infusion, massage the uterus, clear out clots, empty the bladder, assess for lacerations, perform a uterine sweep
Next week’s episode will cover pharmacologic, mechanical, and intra-operative interventions for postpartum hemorrhage.
Be sure to check the episode notes for references and to grab your free OB/GYN Residency Starter Pack if you haven’t already.
See you next week!
