Log In
Sign Up
Obstetrics & GynecologyPostpartum Hemorrhage

Postpartum Hemorrhage

Must-Not-Miss / Red Flags

  • Massive PPH: bleeding >2,000 mL or requiring ≥4 units of blood products – immediate massive transfusion protocol
  • Disseminated intravascular coagulation (DIC): oozing from puncture sites, generalized bleeding
  • Uterine inversion: severe pain, shock, palpable mass at cervix – obstetric emergency
Patient Explanation
“You’re bleeding more than expected after delivery because your uterus is not contracting well. We’ll give you medicine and massage your belly to help it tighten and stop the bleeding.”
Board Fact
“The ‘4 Ts’ mnemonic for PPH causes: Tone (uterine atony), Trauma (lacerations), Tissue (retained placenta), Thrombin (coagulopathy).”
ICD-10
O72.1

Definition & Core Concept

Postpartum hemorrhage (PPH) is excessive bleeding (≥1,000 mL or accompanied by signs of hypovolemia) within 24 hours of delivery. The most common cause is uterine atony, accounting for 70‑80% of cases.

Epidemiology & Risk Factors

  • PPH occurs in 1‑5% of deliveries
  • Leading cause of maternal mortality worldwide (25% of maternal deaths)
  • Risk factors: prolonged labor, uterine overdistension (multiple gestation, polyhydramnios), chorioamnionitis, prior PPH

Clinical Vignette

A 30‑year‑old G2P1 delivers a 4,200‑g infant vaginally after a prolonged second stage. Immediately after delivery, she has heavy vaginal bleeding; the uterus is boggy on palpation. Estimated blood loss reaches 1,500 mL. BP drops to 85/50, HR 120. She receives oxytocin, methylergonovine, and TXA, with a Bakri balloon placed.

Pearls & Pitfalls

  • Early recognition and aggressive management are critical – do not wait for hypotension to develop; by then, 30‑40% of blood volume may already be lost.
  • Uterine atony is the most common cause – always start with uterine massage and oxytocin while assessing other causes.

Discharge & Follow-Up

Monitor for delayed PPH (up to 6 weeks postpartum). Iron supplementation for anemia. Contraception counseling. Debrief with patient about the event.

Literature & Guidelines

ACOG 2024 Practice Bulletin #189: Postpartum Hemorrhage. PMID: 38683401.

Personal Clinical Notes