Postpartum Hemorrhage

Learning objectives

After completing this chapter, you should be able to recognize postpartum hemorrhage before profound hypotension develops; organize the differential using tone, trauma, tissue, and thrombin; apply a stage-based response; anticipate transfusion, calcium, warming, and hemorrhage-control devices; distinguish primary from secondary postpartum hemorrhage; and make safe transport and diversion decisions.

Opening transport scenario

A 34-year-old patient is two hours postpartum after a vaginal birth at a rural hospital. Estimated blood loss was initially reported as 650 mL, but saturated pads, blood beneath the patient, and additional suction-canister volume bring the cumulative measured loss above 1,200 mL. She is pale and anxious, heart rate is 126/min, blood pressure is 106/68 mm Hg, and the uterus is enlarged and boggy. Oxytocin is infusing. The closest comprehensive obstetric center is 42 minutes away. The transport team must determine whether bleeding is controlled enough to leave, what resources must accompany the patient, and what will trigger diversion or return to the sending facility.

1. Recognizing postpartum hemorrhage

Modern definitions emphasize cumulative blood loss and clinical evidence of hypovolemia rather than waiting for a single volume threshold. A cumulative loss of 1,000 mL or more, or bleeding accompanied by signs of hypovolemia within 24 hours of birth, meets a widely used definition. Blood loss of 500 mL after vaginal birth is still abnormal enough to prompt evaluation and escalation. Visual estimation frequently underestimates loss; quantitative and cumulative measurement is safer.

2. Determine the cause: the four Ts

3. Stage-based hemorrhage response

Successful hemorrhage care is organized rather than sequential. Resuscitation, medication administration, cause identification, blood-bank activation, procedural preparation, and communication occur in parallel. The transport team should know which stage the sending facility has activated and what remains incomplete.

1. Mobilize the team: obstetrics, anesthesia, nursing, laboratory/blood bank, surgery, neonatal support, transport, and medical direction.
2. Quantify and communicate cumulative loss: reconcile all sources and state the trend aloud.
3. Obtain access and monitoring: large-bore IV access when possible, ECG, frequent BP, SpO₂, temperature, mental status, urine output, and waveform capnography when indicated.
4. Treat the mechanism: massage and uterotonics for atony, repair for trauma, removal for retained tissue, and hemostatic replacement for coagulopathy.
5. Escalate early: TXA, blood products, tamponade devices, interventional radiology, operating room, hysterectomy, or transfer to higher capability.

4. Resuscitation, blood products, calcium, and warming

Crystalloid may be used as a bridge, but excessive crystalloid dilutes coagulation factors, lowers fibrinogen, worsens edema, and contributes to hypothermia. Ongoing major hemorrhage requires early blood-product strategy and source control. Product ratios and fibrinogen thresholds vary by protocol; use the established massive-transfusion pathway rather than improvising.

• Request emergency-release blood when delay would threaten life.
• Track the number and type of products already given, infusion times, reactions, and remaining availability.
• Monitor ionized calcium or clinical/ECG evidence of hypocalcemia during large-volume citrate exposure; replace calcium according to protocol.
• Warm the patient, compartment, fluids, and blood products with approved equipment.
• Trend fibrinogen, platelets, hemoglobin, coagulation studies, lactate, blood gas, and ionized calcium when available.
• Prevent the lethal cycle of hypothermia, acidosis, hypocalcemia, and coagulopathy.

5. Tamponade and vacuum-induced hemorrhage-control devices

A Bakri balloon provides intrauterine tamponade by applying outward pressure. A JADA system uses low-level intrauterine vacuum to promote uterine collapse and physiologic contraction. Neither device replaces resuscitation, blood products, medication treatment, or surgical escalation when bleeding persists.

6. Secondary postpartum hemorrhage

Secondary postpartum hemorrhage occurs after the first 24 hours and can present days to weeks after birth. Common causes include retained products, endometritis, subinvolution of the placental site, vascular lesions, and coagulation disorders. Patients may describe intermittent heavy bleeding, passage of clots, fever, uterine tenderness, foul discharge, dizziness, syncope, or progressive anemia.

Do not normalize severe bleeding as “just postpartum.” Assess cumulative loss, hemodynamics, infection, pregnancy and delivery history, placental completeness, anticoagulant use, and access to operative and transfusion resources.

7. Transport readiness and destination

• Do not depart while uncontrolled bleeding is occurring if immediate source control is available at the sending facility.
• Confirm hemorrhage stage, suspected cause, cumulative loss, medication doses, blood products, laboratory trends, and device status.
• Carry enough blood, calcium, warming capability, oxygen, pumps, suction, and medication for the mission plus contingency.
• Define explicit triggers for return, diversion, emergency department activation, or direct operating-room reception.
• Provide an en-route update for any new bleeding, product administration, hypotension, mental-status change, device output, or airway deterioration.

8. Evolving case study

Phase 1: Atony identified

The uterus remains boggy despite massage. The bladder is emptied, uterotonics are administered according to contraindications, TXA is given within the treatment window, and emergency-release blood is requested. Cumulative loss reaches 1,600 mL.

Phase 2: Apparent improvement

After medication and device placement, bleeding slows, but heart rate remains 132/min and ionized calcium is low after several products. The team corrects calcium, continues warming, and verifies that the receiving center can provide immediate operative backup.

Phase 3: En-route change

Device output rises abruptly and BP falls. The original destination remains 30 minutes away; a hospital with obstetric surgery and blood bank is 8 minutes away. The team activates the diversion plan rather than continuing toward the originally selected center.

9. High-yield chapter summary

1. Recognize hemorrhage from cumulative loss and physiology—not blood pressure alone.
2. Use tone, trauma, tissue, and thrombin to organize the cause.
3. Resuscitation and source control must occur in parallel.
4. Quantitative, cumulative blood-loss measurement is safer than visual estimation alone.
5. A firm uterus with ongoing bleeding suggests trauma or another non-atony cause.
6. Major hemorrhage requires early blood-product strategy, calcium awareness, and active warming.
7. Bakri and JADA devices require documented placement, output, connection, and failure criteria.
8. Secondary postpartum hemorrhage may reflect retained tissue, infection, subinvolution, or vascular pathology.
9. Do not begin a long transfer while bleeding remains uncontrolled when definitive care is immediately available.
10. Every mission needs a diversion trigger and a receiving source-control plan.

References

1. International Board of Specialty Certification. Maternal Fetal Transport Microcredential Candidate Handbook. Updated April 2026.
2. Alliance for Innovation on Maternal Health. Obstetric Hemorrhage Patient Safety Bundle. Revised 2022.
3. American College of Obstetricians and Gynecologists. Postpartum Hemorrhage. Practice Bulletin No. 183.
4. World Health Organization. Recommendations for the Prevention and Treatment of Postpartum Haemorrhage.
5. Society for Maternal-Fetal Medicine and ACOG resources on levels of maternal care and obstetric transfer.