Obstetric Hemorrhage Management

Obstetric Anesthesia · 8 min read

Postpartum hemorrhage is a leading cause of maternal death globally. Recognition + stepwise pharmacologic + surgical response within minutes determines outcome. Anesthesia owns the pharmacology + transfusion.

Definition + recognition

PPH definitions are evolving. CLASSICAL: blood loss >500 mL after vaginal delivery or >1000 mL after C-section. ACOG (2017): cumulative blood loss ≥1000 mL OR signs of hypovolemia (tachycardia, hypotension) within 24 h of delivery. EARLY recognition is the priority — visual blood loss is consistently UNDERESTIMATED 50%. Use quantitative assessment when possible (drape volumes, sponge weights). RISK FACTORS: prior PPH, prolonged labor, polyhydramnios, multifetal pregnancy, fibroids, placenta accreta/previa, chorioamnionitis, magnesium sulfate (uterine atony).

The 4 Ts cause framework

TONE — uterine atony — most common (~70%). TRAUMA — laceration, episiotomy, hematoma, uterine inversion (~20%). TISSUE — retained placenta, retained products (~10%). THROMBIN — coagulopathy (DIC, dilutional, AFE) (~1%). Identify the cause AS YOU TREAT — uterotonics for atony, suturing for trauma, exam for retained products, transfusion + factor support for coagulopathy.

Uterotonic stepwise pharmacology

STEP 1 — OXYTOCIN: 10-40 U/L IV continuous + bolus (avoid >5 U bolus — hypotension). Standard postpartum infusion. STEP 2 — METHYLERGONOVINE (Methergine) 0.2 mg IM q2-4h max. CONTRAINDICATED in HTN + preeclampsia (vasoconstrictor). STEP 3 — CARBOPROST (Hemabate, 15-methyl PGF2α) 250 mcg IM (or directly into uterine wall) q15min × max 8 doses (2 mg total). CONTRAINDICATED in asthma (bronchospasm). STEP 4 — MISOPROSTOL (Cytotec, PGE1) 800-1000 mcg per rectum or sublingual. Useful when carboprost contraindicated. ADJUNCT — TXA 1 g IV over 10 min within 3 h of diagnosis (WOMAN trial reduces death from bleeding).

Oxytocin drug entry →

Concurrent resuscitation

AS TREATING UTERUS: BIG IV ACCESS — 16g + 16g antecubital or 14g + central. RESTORE volume — initial 1-2 L crystalloid bolus. ACTIVATE MASSIVE TRANSFUSION PROTOCOL early — 1:1:1 PRBC:FFP:platelets per PROPPR (uterine bleeding behaves like trauma physiologically). LABS: CBC, fibrinogen (target >200 mg/dL — give cryo if low), TEG/ROTEM if available. WARMING — Bair Hugger + warm fluids (hypothermia worsens coagulopathy). CALCIUM CHLORIDE 1 g IV per 4 units PRBC (citrate toxicity). ART LINE early. Communicate FIRMLY with OB team on blood loss + trajectory — they may underestimate.

Mechanical + surgical interventions (when pharmacology fails)

BIMANUAL MASSAGE — first response. INTRAUTERINE BALLOON (Bakri, ebb) — fills + tamponades uterine cavity. UTERINE COMPRESSION SUTURES — B-Lynch suture, Cho square sutures. UTERINE ARTERY EMBOLIZATION — IR-guided, requires hemodynamic stability for transport. INTERNAL ILIAC ARTERY LIGATION — surgical option. HYSTERECTOMY — definitive, last resort. ANESTHESIA implications: prolonged surgery = prolonged anesthesia = prolonged bleeding window. Plan for likely escalation; don't over-stay regional in cases that may need GA + transfer.

When AFE is suspected

Amniotic fluid embolism (AFE) — rare (~1:20,000 deliveries), mortality ~25%. Triphasic: pulmonary HTN + RV failure → LV failure → DIC. Often presents as sudden cardiovascular collapse + respiratory failure DURING delivery or just after. Treatment: AIRWAY (intubate, 100% O2), SHOCK (norepinephrine + vasopressin), INOTROPY for RV (epinephrine, milrinone, iNO), DIC (massive transfusion 1:1:1 + cryoprecipitate), PERIMORTEM CESAREAN if maternal arrest >4 min. "A-OK" protocol (atropine, ondansetron, ketorolac) anecdotal benefit. ECMO consultation. AFE is a clinical diagnosis — don't wait for confirmatory labs to treat.

Pearl — escalation ladder

Have a written escalation ladder for your institution: at 500 mL EBL → notify; at 1000 mL → second IV + activate MTP + uterotonic stepwise; at 1500 mL → invasive monitoring + IR consult; at 2000 mL → escalate to OR + hysterectomy considered. Practiced teams move through this ladder fast. Practice with simulation. The single most important factor in PPH outcomes is RECOGNITION SPEED + EARLY ESCALATION, not heroics at the end.

References

· ACOG Practice Bulletin 183 — Postpartum Hemorrhage
· Chestnut Obstetric Anesthesia 6e Ch 38
· WOMAN trial Lancet 2017
· SOAP Consensus Statement on PPH