Postpartum Hemorrhage Management Part 2: Meds, Devices, and Surgical Management:
Welcome back. This is Part 2 of our series on postpartum hemorrhage (PPH). If you haven’t already, be sure to go back and read (or listen to) Part 1, where we covered the definition, risk factors, causes, and initial interventions for PPH.
Before we dive in, I want to let you know about a free live training I’m hosting for fourth-year medical students who just matched into OB/GYN:
The Intern’s Guide to Managing Labor: Induction and Augmentation
In the training, you’ll learn:
Indications and contraindications to induction of labor
How to counsel patients confidently about the risks, benefits, and process of labor induction
How to calculate and implement the Bishop score to determine your plan of care
When, how and why we use Misoprostol, Dinoprostone, Oxytocin, and mechanical methods to induce and augment labor
You can download it at https://subscribepage.io/interntraining
Now, let’s pick up where we left off. You’ve identified a postpartum hemorrhage after a vaginal delivery. You’ve already:
Performed a bimanual exam and massage
Drained the bladder
Repaired any obstetric lacerations
Completed a uterine sweep to check for retained products
But bleeding is still ongoing. Now what?
Step 1: Pharmacologic Interventions
If uterine atony is the issue, your next step is uterotonics. These medications stimulate uterine contraction and are essential when tone is the problem. If atony is not the cause, these medications will not be effective.
The three main uterotonics are:
1. Methylergonovine (Methergine)
Onset: 2 to 5 minutes
Avoid in patients with hypertension
2. 15-Methyl Prostaglandin F2α (Hemabate)
Onset: 15 to 60 minutes (for peak concentration)
Avoid in patients with asthma
3. Misoprostol (Cytotec)
Onset: Approximately 30 minutes
Commonly given rectally
In terms of which to use first, there’s no evidence that any one option is superior. I usually start with Methergine for its faster onset. If bleeding continues, I’ll place Cytotec rectally so it has time to work while assessing next steps.
For detailed information on dosing, frequency, contraindications, and side effects, refer to Table 3 in ACOG Practice Bulletin 183.
Tranexamic Acid (TXA)
TXA is an antifibrinolytic—not a uterotonic—but can be life-saving in the context of PPH. According to the 2017 WOMAN trial, IV administration of 1g of TXA within 3 hours of delivery reduced mortality from obstetric hemorrhage.
ACOG recommends considering TXA when initial medical therapy fails. Importantly, the sooner it’s given, the more effective it likely is.
Step 2: Mechanical Interventions
If medications are not sufficient, the next step is mechanical tamponade.
Intrauterine Balloon (e.g., Bakri Balloon)
Inserted through the cervix and filled with up to 500 mL of saline
Typically left in place for several hours, but no longer than 24 hours
Intrauterine Vacuum (e.g., Jada System)
Inserted through the cervix and placed on low-level suction
Mimics uterine contraction by suction
Usually left in place for 1 to 3 hours, but no longer than 24 hours
Less Preferred Options
Uterine Foley balloons: Typically too small to be effective (60–80 mL capacity)
Uterine packing: Can be done with gauze or gauze soaked in thrombin but is less effective than other options
Step 3: Last-Resort Interventions
If bleeding continues and the patient remains hemodynamically unstable or has failed all of the above steps, surgical intervention is required.
Uterine Artery Embolization
Performed by interventional radiology (only if the patient is stable). This procedure occludes the blood supply to the uterus and may control bleeding without surgery.
Surgical Management
In unstable patients or when IR is not available or unsuccessful, an exploratory laparotomy is indicated. Be sure to activate the massive transfusion protocol and notify gynecologic oncology and/or trauma surgery as appropriate for back-up.
Intraoperative options include:
Uterine artery ligation (O’Leary stitch)
Utero-ovarian ligament ligation
Internal iliac artery ligation (requires retroperitoneal dissection which involves more time and experience)
Uterine Compression Sutures
These include the B-Lynch, Cho, or Hayman techniques. They work by compressing the uterus to tamponade bleeding vessels.
Hysterectomy
If all other methods fail, hysterectomy becomes the definitive treatment. Again, this should be coordinated with Gyn/Onc or Trauma and done in the context of active transfusion and appropriate support.
Quick Recap: Postpartum Hemorrhage Management
Definition
Blood loss ≥1000 mL or any loss associated with hypovolemia within 24 hours of birth
Primary = within 24 hours
Secondary = after 24 hours
Causes
Uterine atony (most common)
Lacerations
Retained products
Abnormally adherent placenta
Coagulopathy
Uterine inversion
Initial Management
Bimanual massage
Bladder drainage
Repair lacerations
Manual sweep
Medications
Methergine, Hemabate, Cytotec
Consider early administration of TXA
Mechanical Interventions
Bakri balloon
Jada system
Advanced Interventions
Uterine artery embolization
Vessel ligation
Compression sutures
Hysterectomy
That wraps up Part 2 of the postpartum hemorrhage series. I hope this gives you a clear framework for managing escalating bleeding and understanding when and how to step up interventions.
All references mentioned are linked below, and don’t forget to get your copy of the free OB/GYN Residency Starter Pack.
See you next Saturday.
