Postpartum hemorrhage: causes, symptoms and treatment

Postpartum hemorrhage is defined as cumulative blood loss of 1,000 ml or more, or any blood loss with signs of hypovolemia, within the first 24 hours after birth; late postpartum hemorrhage develops after 24 hours and up to 12 weeks. This approach shifts the focus from volume to clinical assessment and helps initiate care earlier. [1]

Globally, postpartum hemorrhage remains the leading cause of maternal mortality; updated international guidelines emphasize the need for universal uterotonic prophylaxis for all births. A key preventative measure is high-quality oxytocin, and if cold chain restrictions exist, heat-stable carbetocin or, if injectable options are unavailable, misoprostol. [2]

The modern paradigm is standardized "packages" of interventions: prophylactic in the third stage of labor and therapeutic if bleeding occurs, with early administration of tranexamic acid and a clear escalation from medications to mechanical, interventional, and surgical methods. This reduces decision delays and improves outcomes. [3]

Table 1. Basic definitions and time windows

Concept	Definition	Why is this necessary?
Primary postpartum hemorrhage	Loss ≥1,000 ml or any blood loss with signs of hypovolemia ≤24 hours	Early trigger for activation of the healing package
Secondary postpartum hemorrhage	24 hours - 12 weeks postpartum	Perspective on tissue retention, infection, coagulopathy
Action "packages"	Standardized sequences	Reduce variability and delays
Sources. [4]

Epidemiology and risk factors: why evaluate everyone, even without clear predictors

A large proportion of severe bleeding occurs in women without obvious warning signs, so prophylaxis with uterotonics is used universally, and risk assessment complements rather than replaces universal measures. Registries and reviews highlight a consistent association with uterine atony, birth canal trauma, tissue retention, and coagulopathy. [5]

Clinically significant risk factors include multiple gestations, polyhydramnios, large fetus, prolonged or rapid labor, induction and intensive stimulation with uterotonics, infection, preeclampsia, anemia, placenta previa, uterine surgery, and placental accreta spectrum disorder. However, the absence of risk factors does not negate prevention. [6]

Organizational factors are no less important: lack of quantitative assessment of blood loss, delays in the administration of uterotonics, insufficient readiness for transfusion, lack of balloon tamponade skills, poor training of “packets” are frequent reasons for worsening outcomes and cause-and-effect analyses. [7]

Table 2. Risk factors that are more often associated with severe disease

Category	Examples	Practical consequence
Tone	Polyhydramnios, large fetus, prolonged stimulation	Prescribe and titrate uterotonics more quickly
Injury	Instrumental delivery, ruptures, cesarean section	Early revision and suturing of the source
Fabrics	Retained placenta, placenta accreta	Transition to manual selection, preparation for the operating room
Thrombin	Fibrinogen deficiency, DIC syndrome	Early correction of coagulation
Sources. [8]

Pathogenesis and classification according to the "4 Ts": what to look for in the first minutes

A taxonomy of causes suggests a "branch-by-branch" approach: Tonus, Trauma, Tissue, Thrombin. In practice, uterine atony is most often encountered, but concurrent trauma to the cervix and vagina often obscures the true contribution of each source, so examination and revision are performed in parallel with medication. [9]

Atony is the loss of myometrial contractility after placental delivery; its risk increases with uterine overstretching and after prolonged oxytocin stimulation. Therapeutic emphasis is on uterotonics, mechanical compression, and tamponade. [10]

Trauma – ruptures of the cervix, vagina, perineum, or uterine rupture. The primary measure is immediate identification and suturing of the source under adequate anesthesia, in parallel with a general package of anti-shock measures. [11]

Tissue - retained placental lobules, placenta accreta. Tactics - manual separation when indicated, prophylactic antibiotic therapy, in complex cases - surgical readiness and a multidisciplinary plan. [12]

Thrombin - hemostasis disorders, including hypofibrinogenemia. A fibrinogen threshold of less than 2 g per liter is associated with a severe course and requires early correction. [13]

Table 3. The Four Ts and the First Target Steps

Cause	Primary goal	First steps
Tone	Restore contractility	Uterotonic, massage, tamponade
Injury	Eliminate the source of bleeding	Revision and suturing, hemostasis
Fabrics	Remove residue	Manual selection, preparation for the operating room
Thrombin	Restore coagulation	Transfusion therapy, fibrinogen
Sources. [14]

Diagnostics and monitoring: from visual assessment to quantitative blood loss

Visual assessment is unpredictable and systematically underestimates large volumes of loss. Objective accounting is recommended: calibrated drapes, weighing of impregnated materials, and aspirator summation—this structural change to the process improves accuracy and speeds up treatment package activation. [15]

Quantitative assessment is combined with early measurement of vital signs and laboratory profiles: hemoglobin, platelets, prothrombin time, activated partial thromboplastin time, and fibrinogen. Protocols emphasize early correction of fibrinogen at values below 2 g per liter. [16]

If trauma or tissue retention is suspected, a systematic examination of the birth canal and uterine cavity is performed. Ultrasound imaging helps identify retained fragments, but a clinical decision to remove them should not be delayed if the source is obvious. [17]

Table 4. Tools for objectifying blood loss and control

Step	What are we doing?	Why is this important?
Calibrated drape	Blood collection and measurement	Early threshold for treatment
Weighing materials	Before and after use	Increases accounting accuracy
Laboratory profile	Hemostasis and fibrinogen	Directs transfusion
Search for the source	Revision, ultrasound assessment if necessary	Provides targeted tactics
Sources. [18]

Prevention: active management of the third stage of labor and choice of uterotonics

Primary prophylaxis is a single dose of oxytocin 10 IU intramuscularly or intravenously immediately after birth, with guaranteed drug quality and a functioning cold chain. This remains the first-line drug in most contexts. [19]

In cases of cold chain problems, heat-stable carbetocin 100 mcg has been proven to be an effective alternative to oxytocin; the need is determined based on cost and logistics. If injectable uterotonics are unavailable, misoprostol in prophylactic doses remains a last resort. [20]

Umbilical cord traction and uterine massage are performed according to local protocols; the consistent recommendation is not to rely on palpatory massage as a substitute for uterotonics for prophylaxis. The key to success is the timeliness of the first dose and readiness to take further steps if signs of bleeding occur. [21]

Table 5. Prophylactic uterotonics: choice in real conditions

Scenario	Preferably	Alternative	Comments
There is a cold chain	Oxytocin 10 IU intramuscularly or intravenously	-	First line standard
There is no cold chain	Heat-stable carbetocin 100 mcg	-	Cost estimation is important
No injectables	-	Misoprostol 600 mcg orally	Last option
Sources. [22]

Treatment: Stepwise 'First Response', Tranexamic Acid and Transfusion Strategy

The treatment package begins immediately: team call, airway and breathing assessment, positioning, fundal massage, discontinuation of residual uterotonics in case of hyperstimulation, and first-line uterotonics according to protocol. Early quantitative measurement of the loss and dynamics of shock signs determines subsequent steps. [23]

Tranexamic acid is administered as early as possible, within the first 3 hours of birth: 1 g intravenously over at least 10 minutes, repeating 1 g if bleeding continues after 30 minutes or if it recurs within 24 hours. The effect is a reduction in mortality from blood loss; data from large studies and meta-analyses confirm the clinical significance. [24]

Transfusion strategies take into account the risk of dilutional coagulopathy: early administration of plasma and platelets along with red blood cells, fibrinogen monitoring, and targeted increases. Formal ratios are determined by local protocol, but the emphasis is on rapid correction of coagulation, not just volume restoration. [25]

If bleeding persists despite uterotonics and tranexamic acid, mechanical hemostasis is used. Balloon tamponade of the uterus is recommended as the next step if atony is suspected; this method is both diagnostic and therapeutic. [26]

In severe shock, a non-pneumatic anti-shock suit is considered as a temporary measure to stabilize vital organ perfusion before reaching the operating room. It is included in the emergency kit, especially in resource-limited settings. [27]

Table 6. “First response” for postpartum hemorrhage

Step	Action	Target
Team and evaluation	ABC, positioning, vaginal revision	Identify the source, buy time
Uterotonics	Oxytocin, then according to the protocol (ergometrine, carboprost, misoprostol)	Restore tone
Tranexamic acid	1 g intravenously, if necessary, repeat 1 g	Reduce fibrinolysis
Quantitative accounting	Drape, weighing, aspirator	Early escalation trigger
Mechanics	Balloon tamponade, bimanual compression	Preoperative bleeding control
Sources. [28]

Escalation: interventional and surgical methods, new devices

If balloon tamponade and uterotonics are ineffective, interventional and surgical measures are escalated: uterine artery embolization if available, uterine compression sutures, staged vascular ligation, and, in extreme cases, hysterectomy. The choice depends on the source, time, and resources. [29]

New non-surgical devices, such as intrauterine vacuum hemorrhage control, are gaining evidence and are being included in updated practice guidelines as an adjunct to balloon tamponade when performed by a trained team. Registry and observational data demonstrate rapid achievement of hemostasis in some patients. [30]

Several organizations have issued specific updates on "non-surgical devices" for bleeding control to shorten the path to hemostasis between medication and surgery, formalizing indications, limitations, and training requirements. Implementation is accompanied by outcome audits. [31]

Table 7. Escalation in refractory postpartum hemorrhage

Branch	Tool	When
Interventional	Uterine artery embolization	Stable hemodynamics, access to the X-ray operating room
Surgical	Compression sutures, vascular ligation, hysterectomy	Failure of conservative methods, threat to life
New devices	Vacuum control of bleeding	After uterotonics and with atony before radical surgery
Sources. [32]

Post-stabilization observation and secondary prevention

Once bleeding is controlled, a protocol for monitoring vital signs, uterine tone, and volume loss is necessary, as well as laboratory monitoring of hemoglobin and coagulation. Written checklists of actions and documentation of the timing of key steps for subsequent review are recommended. [33]

Anemia management includes intravenous iron for moderate to severe anemia and oral iron for mild anemia, with a plan for follow-up testing. Lactation, pain management, and signs of late bleeding requiring immediate attention are discussed. [34]

In secondary postpartum hemorrhage, the algorithm shifts to searching for retained tissue and infection; ultrasound assessment and, if necessary, vacuum aspiration with antibiotic therapy help eliminate the cause. The presence of coagulopathy requires parallel correction based on laboratory data. [35]

Table 8. Checklist for the first 24 hours after bleeding

Knot	What to check	How often
Vital signs, uterine tone	Pulse, pressure, uterine consistency	According to local protocol, more often when there is a risk
Blood loss	Collection in drape, inspection of gaskets	Regularly until stabilization
Laboratory	Hemoglobin, fibrinogen, platelets	Around the clinic, with checkpoints
Education	Signs of danger at home	Before discharge
Sources. [36]

Brief FAQ

Should the mother be given oxygen if fetal distress is suspected during hemorrhage? Routinely, no; the priority is to address the underlying cause and correct perfusion, with oxygen administered clinically. [37]

When to administer tranexamic acid? As soon as possible and within 3 hours of birth: 1 g intravenously over at least 10 minutes, if bleeding persists, repeat 1 g. [38]

What should be chosen for prophylaxis in the absence of a cold chain? Heat-stable carbetocin; if injectable options are not available, misoprostol as a backup. [39]

When to proceed to balloon tamponade? If bleeding continues despite uterotonics and tranexamic acid, especially if atony is suspected. [40]

Is there a place for new vacuum bleeding control devices? Yes, as an adjunct to conservative measures in trained hands, according to local protocols. [41]