Postpartum Hemorrhage (PPH) — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] 4 T's cause + resuscitation
   PPH (≥1000 mL or with signs of hypovolemia) — which T is the main cause? (PPH = cumulative blood loss ≥1000 mL within 24 h of birth, or with signs of hypovolemia (any mode of delivery). The 4 T's: Tone (uterine atony, ~80%), Trauma (genital tract), Tissue (retained placenta), Thrombin (coagulopathy). Start resuscitation in parallel (IV access, fluids/transfusion, call for help, monitoring).)
   • Uterine atony (Tone) → Uterine atony
   • Trauma / Tissue / Thrombin → Trauma / Tissue / Thrombin
2. [End] Uterine atony
   Bimanual uterine massage/compression + uterotonics: oxytocin first-line (IV infusion 10–40 IU/500–1000 mL, or 10 IU IM; do not give IV push — causes hypotension) → second-line ergometrine 0.2 mg IM (avoid in hypertension/pre-eclampsia), carboprost 250 µg IM (avoid in asthma), misoprostol 600–1000 µg. Add tranexamic acid 1 g IV (over 10 min, within 3 h of birth). Refractory → intrauterine balloon tamponade, uterine artery embolization, compression sutures (B-Lynch), surgery/hysterectomy.
3. [End] Trauma / Tissue / Thrombin
   Trauma: explore and repair genital tract lacerations/evacuate hematoma. Tissue: manual or instrumental removal of retained placenta. Thrombin: correct coagulopathy (transfuse FFP/platelets/cryoprecipitate/fibrinogen). All: add tranexamic acid 1 g IV (within 3 h), continue resuscitation and transfusion, monitor; escalate to interventional/surgical for refractory bleeding.

Source guidelines & references

• ACOG Practice Bulletin on postpartum hemorrhage; WHO PPH recommendations
• WOMAN trial (tranexamic acid reduces bleeding death). Lancet 2017

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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