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e168 VOL. 130, NO. 4, OCTOBER 2017 OBSTETRICS & GYNECOLOGY
Postpartum Hemorrhage
Maternal hemorrhage , defined as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accom-
panied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of
maternal mortality worldwide (1). Additional important secondary sequelae from hemorrhage exist and include adult
respiratory distress syndrome, shock, disseminated intravascular coagulation, acute renal failure, loss of fertility, and
pituitary necrosis (Sheehan syndrome).
Hemorrhage that leads to blood transfusion is the leading cause of severe maternal morbidity in the United States
closely followed by disseminated intravascular coagulation (2). In the United States, the rate of postpartum hemor-
rhage increased 26% between 1994 and 2006 primarily because of increased rates of atony (3). In contrast, maternal
mortality from postpartum obstetric hemorrhage has decreased since the late 1980s and accounted for slightly more
than 10% of maternal mortalities (approximately 1.7 deaths per 100,000 live births) in 2009 (2, 4). This observed
decrease in mortality is associated with increasing rates of transfusion and peripartum hysterectomy (2–4).
The purpose of this Practice Bulletin is to discuss the risk factors for postpartum hemorrhage as well as its evalu-
ation, prevention, and management. In addition, this document will encourage obstetrician–gynecologists and other
obstetric care providers to play key roles in implementing standardized bundles of care (eg, policies, guidelines, and
algorithms) for the management of postpartum hemorrhage.
Number 183, O ctOber 2017 (Replaces Practice Bulletin Number 76, October 2006)
ACOG P RACTICE BULLET IN
Clinical Management Guidelines for Obstetrician–Gynecologists
Background
The American College of Obstetricians and Gynecolo-
gists’ (ACOG) reVITALize program defines postpartum
hemorrhage as cumulative blood loss greater than or
equal to 1,000 mL or blood loss accompanied by signs
or symptoms of hypovolemia within 24 hours after the
birth process (includes intrapartum loss) regardless of
route of delivery (5). This is in contrast to the more
traditional definitions of postpartum hemorrhage as an
estimated blood loss in excess of 500 mL after a vaginal
birth or a loss of greater than 1,000 mL after a cesarean
birth (6). This new classification is likely to reduce the
number of individuals labeled with postpartum hemor-
rhage. However, despite this new characterization, a
blood loss greater than 500 mL in a vaginal delivery
should be considered abnormal and should serve as an
indication for the health care provider to investigate the
increased blood deficit. Although visually estimated
blood loss is considered inaccurate, use of an educa-
tional process, with limited instruction on estimating
blood loss, has been shown to improve the accuracy of
such estimates (7). Historically, a decrease in hematocrit
of 10% had been proposed as an alternative marker to
define postpartum hemorrhage; however, determinations
of hemoglobin or hematocrit concentrations are often
delayed, may not reflect current hematologic status, and
are not clinically useful in the setting of acute postpartum
hemorrhage (8).
In postpartum women, it is important to recognize
that the signs or symptoms of considerable blood loss
(eg, tachycardia and hypotension) often do not present or
do not present until blood loss is substantial (9). There-
fore, in a patient with tachycardia and hypotension, the
obstetrician–gynecologist or other obstetric care provider
should be concerned that considerable blood loss, usually
Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the American College of Obstetricians and Gynecologists’
Committee on Practice Bulletins–Obstetrics in collaboration with Laurence E. Shields, MD; Dena Goffman, MD; and Aaron B. Caughey, MD, PhD.
VOL. 130, NO. 4, OCTOBER 2017 Practice Bulletin Postpartum Hemorrhage e
uterine massage, bimanual compression, and uterotonic
drugs (15). Maternal trauma is indicated by lacerations,
expanding hematomas, or uterine rupture. Retention of
placental tissue can be readily diagnosed with manual
examination or bedside ultrasonography of the uterine
cavity and is addressed with manual removal or uter-
ine curettage. Thrombin is a reminder to evaluate the
patient’s coagulation status and if abnormal to correct
with replacement of clotting factors, fibrinogen, or other
factor replacement sources (see sections on Transfusion
Therapy and Massive Transfusion). It is important to
identify the most likely diagnosis or diagnoses to ini-
tiate appropriate interventions. These diagnoses are
outlined individually in the Clinical Considerations and
Recommendations section.
Risk Factors
Because obstetric hemorrhage is unpredictable, relatively
common, and leads to severe morbidity and mortality, all
obstetric unit members, including the physicians, mid-
wives, and nurses who provide obstetric care, should be
prepared to manage women who experience it. A number
of well-established risk factors such as prolonged labor
or chorioamnionitis are associated with postpartum hem-
orrhage (Table 1). However, many women without these
risk factors can experience a postpartum hemorrhage
(16). State and national organizations have suggested
that a maternal risk assessment should be conducted
antenatally and at the time of admission and continuously
modified as other risk factors develop during labor or the
postpartum period (17).
Risk assessment tools are readily available (18, 19)
and have been shown to identify 60–85% of patients
who will experience a significant obstetric hemorrhage
(17, 20, 21). An example of this type of assessment
tool is outlined in Table 2. However, a validation study
of this tool among a retrospective cohort of more than
10,000 women showed that although the tool correctly
identified more than 80% of patients with severe post-
partum hemorrhage, more than 40% of women who did
not experience hemorrhage were placed into the high-
risk group giving the tool a specificity of just below
60% (20). Additionally, approximately 1% of women
in the low-risk group experienced a severe postpartum
hemorrhage, which indicates that the clinical value for
identifying patients through risk assessment is low.
These findings reinforce the need for diligent surveil-
lance in all patients, including those initially thought to
be at low risk.
Prevention
Many organizations have recommended active manage-
ment of the third stage of labor as a method to reduce
representing 25% of the woman’s total blood volume
(or approximately 1,500 mL or more), has occurred (10).
Thus, earlier recognition of postpartum hemorrhage (eg,
before deterioration in vital signs) should be the goal in
order to improve outcomes.
Differential Diagnosis
The initial management of any patient with obstetric
hemorrhage requires that the obstetrician–gynecologist
or other obstetric care provider first identify the source
of bleeding (uterine, cervical, vaginal, periurethral, peri-
clitoral, perineal, perianal, or rectal). This can be quickly
done with a careful physical examination. After the
anatomic site is identified, it is important to identify the
cause because treatment may vary. The most common
etiologies (see Box 1) are broken into primary or sec-
ondary causes. Primary postpartum hemorrhage occurs
within the first 24 hours of birth, whereas secondary
postpartum hemorrhage is defined as excessive bleeding
that occurs more than 24 hours after delivery and up to
12 weeks postpartum (11, 12).
When evaluating a patient who is bleeding, it may be
helpful to consider “the 4 Ts” mnemonic device—tone,
trauma, tissue, and thrombin (13). Abnormal uterine
tone (uterine atony) is estimated to cause 70–80% of
postpartum hemorrhage and usually should be suspected
first as the etiology of postpartum hemorrhage (14).
Recommended interventions for uterine atony include
Box 1. Etiology of Postpartum Hemorrhage ^
Primary:
- Uterine atony
- Lacerations
- Retained placenta
- Abnormally adherent placenta (accreta)
- Defects of coagulation (eg, disseminated intravascular
coagulation)*
Secondary:
- Subinvolution of the placental site
- Retained products of conception
- Infection
- Inherited coagulation defects (eg, factor deficiency
such as von Willebrand)
*These include inherited coagulation defects as well as acute coagulopathies that may develop from events such as amniotic fluid embolism, placental abruption, or severe preeclampsia.
VOL. 130, NO. 4, OCTOBER 2017 Practice Bulletin Postpartum Hemorrhage e
aimed at treating cases early and consistently to reduce
severe maternal morbidity and mortality as well as to
identify the need for more aggressive interventions (such
as hysterectomy or other surgeries) and intensive care
unit admissions. Although it does appear that hemor-
rhage is treated earlier with such approaches, evidence
regarding maternal outcomes, such as severe maternal
morbidity or intensive care unit admission, is inconsis-
tent (12).
Facilities With Limited Resources
Many hospitals that provide maternal services are
located in rural or small communities. In the United
States, obstetric services are provided in 50% of criti-
cal access hospitals and 92% of rural hospitals (37).
Because these centers typically do not have the same
resources as most urban centers, developing a compre-
hensive plan for dealing with obstetric emergencies such
as postpartum hemorrhage is important. In particular,
these small centers should consider establishing guide-
lines regarding appropriate case selection to triage or
transfer patients to higher-level centers. Additionally,
assessing available resources and developing a com-
prehensive plan for evaluating and managing obstetric
hemorrhage are important for reducing morbidity. For
more information see Obstetric Care Consensus No. 2,
Levels of Maternal Care (38).
Clinical Considerations and
Recommendations
What should be considered in the initial evaluation and management of a patient with excessive bleeding in the immediate postpartum period?
When postpartum bleeding exceeds expected volumes
(500 mL in a vaginal delivery or 1,000 mL in a cesarean
delivery), a careful and thorough evaluation should be
undertaken. A rapid physical examination of the uterus,
cervix, vagina, vulva, and perineum can often identify
the etiology (sometimes multiple sources) of the postpar-
tum hemorrhage. Obstetrician–gynecologists and other
obstetric care providers should be familiar with algo-
rithms for the diagnosis and management of postpartum
hemorrhage (18, 39) and, ideally, these should be posted
on labor and delivery units (see For More Information).
The most common etiologies include uterine atony, gen-
ital tract lacerations, retained placental tissue and, less
commonly, placental abruption, coagulopathy (acquired
or inherited), amniotic fluid embolism, placenta accreta,
or uterine inversion.
or with placental delivery—has not been adequately
studied or found to be associated with a difference in
the risk of hemorrhage (28). Specifically, delaying
oxytocin until after delayed umbilical cord clamping
has not been found to increase the risk of hemorrhage
(29). The World Health Organization, ACOG, American
Academy of Family Physicians, and Association of
Women’s Health, Obstetric and Neonatal Nurses recom-
mend administering uterotonics (usually oxytocin) after
all births for the prevention of postpartum hemorrhage
(13, 22, 24). Therefore, all obstetric care facilities should
have guidelines for the routine administration of utero-
tonics in the immediate postpartum period.
Although the number of well-conducted studies is
limited, one small study found that the use of uterine
massage was associated with reduced postpartum blood
loss and reduced need for additional uterotonic agents
(30); however, a Cochrane review found no statistical
differences and found the evidence inconclusive (31).
Furthermore, neither early umbilical cord clamping nor
umbilical cord traction have been shown to have a sig-
nificant effect on the incidence or volume of postpartum
hemorrhage (32). Additionally, in a Cochrane review,
two trials examining nipple stimulation or breastfeeding
did not demonstrate a difference in postpartum hemor-
rhage (33, 34).
Techniques for Management
Management may vary greatly among patients and
depends on the etiology and available treatment options.
In general, management of postpartum hemorrhage
should use a multidisciplinary and multifaceted approach
that involves maintaining hemodynamic stability while
simultaneously identifying and treating the cause of
blood loss. Treatment options for postpartum hemor-
rhage because of uterine atony include administration of
uterotonics or pharmacologic agents, tamponade of the
uterus (eg, intrauterine balloons), surgical techniques to
control the bleeding (eg, the B-Lynch procedure), embo-
lization of pelvic arteries or, ultimately, hysterectomy.
Generally, less invasive methods should be tried initially
if possible; however, if unsuccessful, more invasive
measures may be required. More specific guidance for
these management approaches is delineated later in the
document.
Systematic approaches to postpartum hemorrhage
based on algorithms have been created, and these
approaches have been used more widely at individual
hospitals and in health systems (19, 35, 36). These
approaches employ a multidisciplinary (eg, obstet-
rics, nursing, anesthesia, transfusion medicine), multi-
faceted, stepwise approach to the detection and manage-
ment of postpartum hemorrhage. The approaches are
e172 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
precipitous uncontrolled delivery or an operative vaginal
delivery. Labial, rectal, pelvic pressure or pain, or vital
sign deterioration may be the only symptoms of genital
tract hematomas and may not be recognized until hours
after delivery. Once identified, most genital tract hema-
tomas can be managed conservatively. However, rapid
progressive enlargement of the hematoma, particularly
in the setting of abnormal vital signs, indicates a need
for incision and drainage. One reason that opening a
hematoma is reserved for only the most severe cases
is that often a single bleeding source is not identified
when a hematoma is incised. Exploration with sutur-
ing or packing may be needed to achieve hemostasis.
Arterial embolization is another option for management
of a hematoma and should be considered as a possibility
before opening the hematoma.
Deterioration of maternal vital signs without obvi-
ous bleeding should alert the obstetric team that there
may be intraperitoneal or retroperitoneal bleeding. In
this setting, resuscitative measures, diagnostic imaging,
and surgical intervention or an interventional radiology
procedure should not be delayed.
Retained Placenta
Detailed visual inspection of the placenta for complete-
ness should be conducted after all deliveries. Even when
the placenta appears intact, there may be additional
remaining products of conception (eg, succenturiate
lobe) within the uterine cavity. Manual removal of the
placenta, prior uterine surgery, or other risk factors
for morbidly adherent placenta should raise suspi-
cion for retained placental tissue or placenta accreta.
Ultrasonography or intrauterine manual examination
is usually used to diagnose retained placental tissue.
Retained placental tissue is unlikely when ultrasonog-
raphy reveals a normal endometrial stripe. However,
although ultrasonographic images of retained placental
tissue can be inconsistent, detection of an echogenic
mass within the uterus is highly suspicious. When a
retained placenta is identified, the first step is to attempt
manual removal of the tissue. If a woman has adequate
regional analgesia, assessment of the uterine cavity may
be performed. If manual extraction fails, either a “banjo”
curette or large oval forceps (Sopher or Bierer) can be
used for removal. Because of the concern for uterine
perforation in the postpartum uterus and to ensure
removal of all tissue, ultrasound guidance may be used.
If the placental tissue is adherent to the uterine wall,
there should be increased suspicion for placenta accreta,
particularly in the presence of risk factors for placenta
accreta. Management of placenta accreta is discussed
later in the document.
Uterine Atony
Because uterine atony causes 70–80% of cases of post-
partum hemorrhage, it remains the single most common
cause, and its incidence appears to be increasing (14,
21, 40). At the time of delivery, risk factors include, but
are not limited to, prolonged labor, induction of labor,
prolonged use of oxytocin, chorioamnionitis, multiple
gestation, polyhydramnios, and uterine leiomyomas (see
Table 1 and Table 2).
In the setting of postpartum hemorrhage, identifica-
tion of a soft, poorly contracted (boggy) uterus suggests
atony as a causative factor. When atony is suspected,
the bladder should be emptied and a bimanual pelvic
examination conducted, any intrauterine clots should
be removed, and uterine massage should be performed.
In addition to oxytocin, a second uterotonic agent is
required in 3–25% of cases of postpartum hemorrhage
(15). Supplemental uterotonics that are most com-
monly administered include methylergonovine, 15-
methyl prostaglandin F 2 a, or misoprostol. As discussed
in a 2015 systematic review, there is a lack of evidence
that suggests which specific additional uterotonics are
the most effective (12). Treatment of refractory atony
may require the use of secondary methods such as uter-
ine tamponade with an intrauterine tamponade balloon
or compression sutures (41, 42).
Occasionally, the fundus is firm and contracted
down, but the lower uterine segment is dilated and
atonic. In this setting, the usual approach is to manually
remove any clots and to use bimanual compression to
reduce the blood loss while waiting for the uterotonic
agents to work. Treatment with the intrauterine tampon-
ade balloon can be considered if there is persistent lower
uterine segment atony.
Obstetric Trauma
Genital tract lacerations are the most common complica-
tions of obstetric trauma. Although such lacerations are
predominantly venous bleeding, they can be the primary
source of a postpartum hemorrhage. Rapid identification
and repair of cervical lacerations, lacerations compli-
cated by arterial bleeding, and high vaginal lacerations
should be performed. Similarly, distal vaginal, vulvar,
periclitoral, and perineal lacerations should be repaired
if contributing significantly to blood loss. If a uterine
artery laceration is suspected, interventional radiology
or surgical exploration and ligation should be consid-
ered. Repair may require assistance from anesthesia and
transfer to a well-equipped operating room.
Genital tract hematomas (labial, vaginal, broad
ligament, or retroperitoneal) also can lead to significant
blood loss and should be suspected in the setting of a
e174 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
ending with extension of the gauze through the cervi-
cal os. To avoid leaving gauze in the uterus at time of
removal, it can be carefully counted and tied together.
Similarly, multiple large Foley catheters (which were
common before the development of commercial intra-
uterine tamponade devices) can still be used, but the
challenge is placing multiple devices and keeping
Tamponade Techniques
When uterotonics and bimanual uterine massage fail to
sustain uterine contractions and satisfactorily control
hemorrhage, the use of compression (including manual
compression), intrauterine tamponade or packing can be
effective in decreasing hemorrhage secondary to uterine
atony (Table 4). Although the evidence that compares
these approaches is poor or absent, it is important for
institutions to adopt an approach and train personnel
in this approach. For example, the California Maternal
Quality Care Collaborative recommends the use of an
intrauterine balloon for tamponade after uterotonics
have failed.
Evidence for the benefits of use of intrauterine bal-
loon tamponade is limited; however, in one study, 86%
of women who had balloon tamponade did not require
further procedures or surgeries (12, 51). Similarly, a
summary of studies showed that 75% of patients did
not need further treatment after intrauterine balloon
tamponade (12). In some refractory cases, intrauterine
tamponade and uterine compression sutures (described
later) may be used together (52).
If a balloon tamponade system is not available, the
uterus may be packed with gauze. This requires careful
layering of the material back and forth from one uterine
cornu to the other repeatedly using a sponge stick, and
Table 3. Acute Medical Management of Postpartum Hemorrhage ^
Drug Dose and Route Frequency Contraindications Adverse Effects*
Oxytocin IV: 10–40 units per 500–1,000 mL Continuous Rare, hypersensitivity to Usually none. as continuous infusion medication Nausea, vomiting, or hyponatremia with IM: 10 units prolonged dosing. Hypotension can result from IV push, which is not recommended.
Methylergonovine IM: 0.2 mg Every 2–4 h Hypertension, preeclampsia, Nausea, vomiting, severe cardiovascular disease, hypertension particularly hypersensitivity to drug when given IV, which is not recommended
15-methyl PGF 2 a IM: 0.25 mg Every 15–90 min, Asthma. Relative Nausea, vomiting, Intramyometrial: 0.25 mg eight doses contraindication for diarrhea, fever (transient), maximum hypertension, active hepatic, headache, chills, pulmonary, or cardiac disease shivering hypertension, bronchospasm
Misoprostol 600–1,000 micrograms oral, One time Rare, hypersensitivity to Nausea, vomiting, diarrhea sublingual, or rectal medication or to prostaglandins shivering, fever (transient), headache
Abbreviations: IV, intravenously; IM, intramuscularly; PG, prostaglandin. *All agents can cause nausea and vomiting. Modified from Lyndon A, Lagrew D, Shields L, Main E, Cape V, editors. Improving health care response to obstetric hemorrhage version 2.0. A California quality improve- ment toolkit. Stamford (CA): California Maternal Quality Care Collaborative; Sacramento (CA): California Department of Public Health; 2015.
Table 4. Tamponade Techniques for Postpartum Hemorrhage
^
Technique Comment
Commercially available intrauterine balloon tamponade devices
- Bakri Balloon
- ebb uterine tamponade system
Foley catheter Insert one or more 60 mL bulbs and fill with 60 mL of saline. Uterine packing 4-inch gauze, can be soaked with 5,000 units of thrombin in 5 mL of saline then insert from one cornua to the other with ring forceps.
Inserted transcervically or through cesarean incision; has an exit port for blood drainage Inflated with 300–500 mL of saline Double Balloon: maximum rec- ommended fill volumes are 750 mL for the uterine balloon and 300 mL for the vaginal balloon.
VOL. 130, NO. 4, OCTOBER 2017 Practice Bulletin Postpartum Hemorrhage e
to postpartum hemorrhage, the median success of vascu-
lar ligation is 92% (12).
However, because these less invasive vascular tech-
niques appear to be effective, it appears that internal iliac
(hypogastric) artery ligation is performed less frequently
than in the past. The procedure has been found to be con-
siderably less successful than originally thought (57) and
because practitioners have become less familiar with this
technique (which requires a retroperitoneal approach) it
is rarely used today.
Uterine Compression Sutures
Although there are no good-quality studies that pro-
vide evidence for the success of uterine compression
sutures, the B-Lynch technique probably is the most
common uterine compression technique for atony (42);
however, other techniques, such as Cho and Hayman,
have been described (42, 58–61). The effectiveness of
uterine compression sutures as a secondary treatment
for uterine atony unresponsive to medical management
appears to be approximately 60–75%, with none of the
techniques shown to be superior to another (12, 62, 63).
B-lynch sutures are placed from the cervix to fundus
and provide physical compression of the uterus. A large
suture (eg, a number 1 chromic suture) should be used
to prevent breaking and the suture should be rapidly
absorbed to prevent risk of bowel herniation through
a persistent loop of suture after uterine involution.
Physicians should be familiar with the technique and it
could be helpful to have diagrams available on labor and
delivery for quick reference such as those available in
the Alliance for Innovation on Maternal Health Obstetric
Hemorrhage Bundle (64) (see For More Information).
Direct comparisons between compression sutures and
uterine balloons have been described in small case series
and suggest they have similar effectiveness (65). Uterine
necrosis after placement of compression sutures has
been reported; however, the exact incidence is not clear
because of the small number of patients in case reports
and series.
Hysterectomy
When more conservative therapies have failed, hys-
terectomy is considered the definitive treatment and is
not only associated with permanent sterility but also
potential surgical complications. For example, six small
studies have shown that bladder injuries range from 6%
to 12% and ureteral injuries range from 0.4% to 41%
(12). There are inadequate studies that compared hyster-
ectomy to other management approaches. Additionally,
there is inadequate evidence examining different surgi-
cal approaches to hysterectomy (eg, total hysterectomy
versus supracervical hysterectomy). Therefore, in the
careful count of them. In cases where compression, or
intrauterine tamponade, or both, fail to adequately con-
trol hemorrhage, they may be used to temporize while
planning to move to uterine artery embolization (UAE)
or hysterectomy.
Uterine Artery Embolization
Candidates for UAE typically are hemodynamically
stable, appear to have persistent slow bleeding and have
failed less invasive therapy (uterotonic agents, uterine
massage, uterine compression, and manual removal of
any clots) (12). When successful, UAE also has the
benefit of a woman retaining her uterus and, potentially,
future fertility. Fluoroscopic identification of bleeding
vessels allows embolization with absorbable gelatin
sponges, coils, or microparticles. Studies (n=15) have
shown that UAE for postpartum hemorrhage has a
median success rate of 89%, ranging from 58% to 98%
(12). Moreover, one of the largest series (114 UAE pro-
cedures) reported a success rate greater than 80%, with
15% requiring subsequent hysterectomy (53). The risk
of significant harm (uterine necrosis, deep vein throm-
bosis, or peripheral neuropathy) appears to be low (less
than 5%) based on reports from small case series (12).
After UAE, infertility has been reported in up to 43% of
women (12). Other studies have reported that in women
who have had a UAE, subsequent pregnancy complica-
tions such as preterm birth (5–15%) and fetal growth
restriction (7%) appear to be similar to the general
obstetric population (12, 54).
Surgical Management
Vascular Ligation
When less invasive approaches such as uterotonic agents
(with or without tamponade measures) or UAE fail to
control bleeding in the setting of postpartum hemor-
rhage, exploratory laparotomy is indicated. In the setting
of a vaginal delivery, it is common to use a midline verti-
cal abdominal incision to optimize exposure and reduce
risk of surgical bleeding. In the setting of cesarean birth,
the existing surgical incision may be used. Several tech-
niques are available to control bleeding with limited evi-
dence for each (12). The general aim of vascular ligation
in the setting of atony is to diminish the pulse pressure of
blood flowing to the uterus. A common first approach is
bilateral uterine artery ligation (O’Leary sutures), which
commonly accomplishes this goal of reducing blood
flow to the uterus, and is quickly and easily performed
(55, 56). Similarly, to further diminish blood flow to
the uterus, sutures also can be placed across the vessels
within the utero–ovarian ligaments. Reports from case
series indicate that, when used as a second-line approach
VOL. 130, NO. 4, OCTOBER 2017 Practice Bulletin Postpartum Hemorrhage e
tributes to secondary hemorrhage. Ultrasound evalua-
tion can help identify intrauterine tissue. Endometritis
should be strongly suspected in the presence of uterine
tenderness and a low grade fever. Secondary postpartum
hemorrhage also may be the first indication of bleeding
disorders such as von Willebrand disease.
Treatment should be focused on the etiology of
the hemorrhage and may include uterotonic agents and
antibiotics, but if these fail to resolve the problem or if
retained products of conception are suspected, uterine
curettage may be necessary. If treating endometritis,
broad antibiotic coverage with clindamycin and genta-
micin is a common choice, although other combinations
also are used (86). Often the volume of tissue removed
by curettage is relatively small, yet bleeding usually
subsides promptly. Concurrent ultrasound assessment
at the time of curettage can help prevent uterine per-
foration. Patients should be counseled about the pos-
sibility of hysterectomy before initiating any operative
procedure.
What is best practice for blood product replacement during and after a postpartum hemorrhage?
The Timing of Transfusion Therapy ^
Initiation of transfusion therapy generally is based
on estimated blood deficit and ongoing blood loss.
However, in the setting of postpartum hemorrhage,
acute changes in hemoglobin or hematocrit will not
accurately reflect blood loss. As noted previously,
maternal vital signs typically do not change drasti-
cally until significant blood loss has occurred (10).
Inadequate early resuscitation and hypoperfusion
may lead to lactic acidosis, systemic inflammatory
response syndrome with accompanying multiorgan
dysfunction, and coagulopathy (87). In women with
ongoing bleeding that equates to the blood loss of
1,500 mL or more or in women with abnormal vital signs
(tachycardia and hypotension), immediate preparation
for transfusion should be made (18, 19, 39). Because
such a large blood loss includes depletion of coagula-
tion factors, it is common for such patients to develop
a consumptive coagulopathy, commonly labeled as
disseminated intravascular coagulation, and the patients
will require platelets and coagulation factors in addition
to packed red blood cells.
Transfusion and Massive Obstetric Hemorrhage ^
Massive transfusion usually is defined as a transfusion
of 10 or more units of packed red blood cells within
at cesarean delivery (74, 75). Uterine inversion in a prior
pregnancy leads to an increased risk in a subsequent preg-
nancy (1 per 26 subsequent deliveries) although it is still
relatively uncommon (74). Upon bimanual examination,
the finding of a firm mass at or below the cervix, coupled
with the absence of identification of the uterine corpus
on abdominal examination, suggests inversion. If the
inversion occurs before placental separation, detachment
or removal of the placenta is generally not undertaken
before replacement of the uterus because, presumably,
this could lead to additional hemorrhage (76).
Manual replacement of the uterine corpus involves
placing the palm of the hand or a closed fist against the
fundus (now inverted and lowermost at or through the
cervix), as if holding a tennis ball, with the fingertips
exerting upward pressure circumferentially (77). To
restore normal anatomy, relaxation of the uterus may be
necessary. Terbutaline, magnesium sulfate, halogenated
general anesthetics, and nitroglycerin have all been used
for uterine relaxation without clear evidence supporting
any one approach as superior to the others (78). Manual
replacement with or without uterine relaxants usually
is successful with the large majority being successfully
replaced in one small series (76). In the unusual circum-
stance in which it is not, laparotomy is required. Two
procedures have been reported to return the uterine cor-
pus to the abdominal cavity. The Huntington procedure
involves progressive upward traction on the inverted
corpus using Babcock or Allis forceps (79). The Haultain
procedure involves incising the cervix posteriorly, which
allows for digital repositioning of the inverted corpus,
with subsequent repair of the incision (80).
Supportive measures and treatment of the associated
hemorrhage should be employed while the inversion is
corrected. In the setting of recurrent uterine inversion,
the use of intrauterine tamponade balloons has been
reported to prevent recurrent uterine inversion as well
as the accompanying hemorrhage in a number of case
reports (81–84). The use of uterine compression sutures
for prevention of acute recurrence also has been success-
ful in a limited number of case reports (59, 85).
What is the management approach for secondary or delayed postpartum hemorrhage?
Secondary postpartum hemorrhage , defined as excessive
bleeding that occurs more than 24 hours after delivery
and up to 12 weeks postpartum, occurs in approximately
1% of pregnancies (11). In the event of secondary
hemorrhage, a number of specific etiologies should be
considered. Uterine atony (perhaps secondary to retained
products of conception) with or without infection con-
e178 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
It is also important to establish approaches to
address situations in which patients decline various treat-
ment approaches. For example, refusal of blood products
is common in patients who are Jehovah’s Witnesses.
This subset of patients has between a 44-fold to 130-
fold higher risk of maternal mortality from obstetric
hemorrhage because of refusal of blood products (94,
95). Because this population may accept some blood
products, a predelivery directive that can be used in the
event of a severe postpartum hemorrhage can be dis-
cussed with the patient during the prenatal period (18,
96). Greater detail on this issue is outlined in Committee
Opinion No. 664, Refusal of Medically Recommended
Treatment During Pregnancy.
Although transfusion is often lifesaving in obstet-
rics, usage of blood products, particularly in the setting
of massive transfusion, is not without risk. Massive
transfusion is associated with hyperkalemia from packed
red blood cells and citrate (used as a preservative in
stored blood products) toxicity that will typically worsen
hypocalcemia. The combination of acidosis, hypocalce-
mia, and hypothermia all contribute to worsening coagu-
lopathy and increased morbidity (87, 97). Overzealous
resuscitation with crystalloid also can be associated with
dilution-related coagulopathy and can contribute to pul-
monary edema (98). Other complications include transfu-
sion febrile nonhemolytic reactions (0.8 per 1,000 units
transfused), acute hemolytic transfusion reaction (0.
per 1,000 units transfused), and acute transfusion reac-
tions related lung injury (TRALI, 0.1 per 1,000 units
transfused) (99). Transfusion-associated infections (eg,
hepatitis, human immunodeficiency virus, West Nile
virus, Chagas disease, malaria, and Lyme disease) are
relatively rare (less than 1/100,000–1,000,000) (100).
Other Related Therapies
Cell Salvage
Intraoperative cell salvage—also known as autologous
blood transfusion—has been shown to be effective
and safe in obstetric patients. Limitations are primarily
related to availability of appropriate staff and equipment.
In certain settings where significant blood loss is antici-
pated, such as placenta previa and placenta accreta, hav-
ing this tool available may reduce the need for or volume
of allogeneic blood transfusion. Early concerns related
to amniotic fluid contamination have been dispelled
with higher quality filtering techniques (101). There is
some concern for anti-D isoimmunization, and appropri-
ate testing and treatment with anti-D immunoglobulin is
necessary (102, 103). However, because the large major-
ity of postpartum hemorrhage events are unpredictable,
cell salvage is rarely available or used.
24 hours, transfusion of 4 units of packed red blood
cells within 1 hour when ongoing need for more blood is
anticipated, or replacement of a complete blood volume
(87). Despite the low quality of evidence regarding the
benefit of massive transfusion for early postpartum hem-
orrhage (12), massive transfusion protocols should be
part of a comprehensive management plan for treatment
of postpartum hemorrhage in settings with adequate
blood banking.
Recommendations for optimal blood product
replacement therapy and timing of transfusion in obstet-
ric patients have been primarily limited to consensus
opinion (18), protocols adapted from trauma literature
(88, 89), and a few clinical reports (19, 39, 90–92). All
recommend the use of multicomponent therapy with
fixed ratios of packed red blood cells, fresh or thawed
plasma, platelets, and cryoprecipitate. When a massive
transfusion protocol is needed, fixed ratios of packed
red blood cells, fresh frozen plasma, and platelets should
be used. The recommended initial transfusion ratio for
packed red blood cells:fresh frozen plasma:platelets
has been in the range of 1:1:1 and is designed to mimic
replacement of whole blood. In a recent survey, more
than 80% of institutions reported using the 1:1 red blood
cell:plasma ratio (93). These recommendations are dif-
ferent from protocols that have previously suggested
ratios such as 4:4:1 or 6:4:1 and are related to how a
unit of platelets is defined (18). What is more important
than the actual ratio is that there is a specific protocol
for multicomponent therapy in place at each institution.
In women with suspected disseminated intravascular
coagulation (ie, consumptive coagulopathy, or low
fibrinogen, or both) administration of cryoprecipitate
also should be considered. Findings of critically low
fibrinogen should be particularly anticipated in the set-
ting of placental abruption or amniotic fluid embolism,
and early use of cryoprecipitate is commonly included as
part of the resuscitation.
Although smaller hospitals may not have all blood
products, every obstetric unit should have a compre-
hensive maternal hemorrhage emergency management
plan that includes protocols for accessing packed red
blood cells. In emergency situations, type specific or
type O Rh-negative blood also should be readily avail-
able. Physicians should be familiar with their hospitals’
protocol and recommendations for use of combination
blood component therapy. No specific hemorrhage pro-
tocol has been proved to be more effective than another;
therefore, each hospital will need to address its specific
resources and make modifications specific to its unique
setting. For examples of algorithms, see For More
Information.
e180 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
for escalation of care, and a functioning massive trans-
fusion protocol.
Every obstetric unit should have an organized, sys-
tematic obstetric hemorrhage response that coordinates
care among all critical personnel. Hospitals should
consider adopting a system to implement key elements
in four categories: 1) readiness to respond to a maternal
hemorrhage, 2) recognition and prevention measures in
place for all patients, 3) a multidisciplinary response
to excessive maternal bleeding, and 4) a systems-based
quality improvement process to improve responsiveness
through reporting and system learning. The Council on
Patient Safety in Women’s Healthcare has endorsed a
system and further details can be found on the For More
Information web page. Education, drills, and review of
team protocol compliance are needed to ensure everyone
remains proficient with the treatment algorithm and tools
at each facility.
Multidisciplinary simulation-based team training,
including postpartum hemorrhage scenarios, have been
associated with improved safety culture and outcomes in
obstetrics (113–115). Hemorrhage drills have been used
for multiple purposes, including the following: identify
management pitfalls (116), improve confidence and com-
petence in skills (117), pilot and modify checklists (118),
identify and correct systems issues (119, 120), famil-
iarize staff with management algorithms, and ensure
timely management of hemorrhage (19). Although one
standardized approach for drills, simulation, and team
training has not been established, there are several rec-
ommended tools and techniques that can be incorporated
into unit-based improvement strategies (121, 122).
Summary of
Recommendations and
Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
All obstetric care facilities should have guidelines
for the routine administration of uterotonics in the
immediate postpartum period.
Uterotonic agents should be the first-line treatment
for postpartum hemorrhage caused by uterine atony.
The specific agent selected, outside of recognized
contraindications, is at the health care provider’s dis-
cretion because none has been shown to have greater
efficacy than others for the treatment of uterine
atony.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
When uterotonics fail to adequately control post-
partum hemorrhage, prompt escalation to other
interventions (such as tamponade or surgical tech-
niques) and escalation of intensity of care and sup-
port personnel are indicated.
Given the mortality reduction findings, tranexamic
acid should be considered in the setting of obstetric
hemorrhage when initial medical therapy fails.
Obstetrician–gynecologists and other obstetric care
providers should work with their institutions to
ensure the existence of a designated multidisciplinary
response team, a staged postpartum hemorrhage pro-
tocol that includes guidelines for escalation of care,
and a functioning massive transfusion protocol.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
Management of postpartum hemorrhage should use
a multidisciplinary and multifaceted approach that
involves maintaining hemodynamic stability while
simultaneously identifying and treating the cause of
blood loss.
Generally, in the treatment of postpartum hemor-
rhage, less invasive methods should be used initially
if possible, but if unsuccessful, preservation of life
may require more aggressive interventions including
hysterectomy.
When a massive transfusion protocol is needed,
fixed ratios of packed red blood cells, fresh frozen
plasma, and platelets should be used.
Hospitals should consider adopting a system to
implement key elements in four categories: 1) readi-
ness to respond to a maternal hemorrhage, 2) recog-
nition and prevention measures in place for all
patients, 3) a multidisciplinary response to excessive
maternal bleeding, and 4) a systems-based quality
improvement process to improve responsiveness
through reporting and system learning.
For More Information ^
The American College of Obstetricians and Gynecologists
has identified additional resources on topics related to
this document that may be helpful for ob-gyns, other
health care providers, and patients. You may view
VOL. 130, NO. 4, OCTOBER 2017 Practice Bulletin Postpartum Hemorrhage e
postpartum hemorrhage. Comparative Effectiveness Review No. 151. AHRQ Publication No. 15-EHC013- EF. Rockville (MD): Agency for Healthcare Research and Quality; 2015. (Systematic Review)^
- Anderson JM, Etches D. Prevention and manage- ment of postpartum hemorrhage. Am Fam Physician 2007;75:875–82. (Level III)^
- Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg 2010;110:1368–73. (Level II-3)^
- Bateman BT, Tsen LC, Liu J, Butwick AJ, Huybrechts KF. Patterns of second-line uterotonic use in a large sample of hospitalizations for childbirth in the United States: 2007-2011. Anesth Analg 2014;119:1344–9. (Level II-3)^
- Wetta LA, Szychowski JM, Seals S, Mancuso MS, Biggio JR, Tita AT. Risk factors for uterine atony/post- partum hemorrhage requiring treatment after vaginal delivery. Am J Obstet Gynecol 2013;209:51.e1,51–6. (Level II-2)^
- Main EK, Goffman D, Scavone BM, Low LK, Bingham D, Fontaine PL, et al. National Partnership for Maternal Safety: consensus bundle on obstetric hemor- rhage. National Partnership for Maternal Safety, Council on Patient Safety in Women’s Health Care [published erratum appears in Obstet Gynecol 2015;126:1111]. Obstet Gynecol 2015;126:155–62. (Level III)^
- Lyndon A, Lagrew D, Shields L, Main E, Cape V, editors. Improving health care response to obstetric hemorrhage version 2.0. A California quality improve- ment toolkit. Stamford (CA): California Maternal Quality Care Collaborative; Sacramento (CA): California Department of Public Health; 2015. (Level III)^
- Shields LE, Smalarz K, Reffigee L, Mugg S, Burdumy TJ, Propst M. Comprehensive maternal hem- orrhage protocols improve patient safety and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368.e1–8. (Level II-3)^
- Dilla AJ, Waters JH, Yazer MH. Clinical validation of risk stratification criteria for peripartum hemorrhage. Obstet Gynecol 2013;122:120–6. (Level II-3)^
- Kramer MS, Berg C, Abenhaim H, Dahhou M, Rouleau J, Mehrabadi A, et al. Incidence, risk factors, and temporal trends in severe postpartum hemorrhage. Am J Obstet Gynecol 2013;209:449.e1–7. (Level II-3) ^
- Guidelines for oxytocin administration after birth. AWHONN Practice Brief Number 2. J Obstet Gynecol Neonatal Nurs 2015;44:161–3. (Level III)^
- Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Phys- ician 2017;95:442–9. (Level III)^
- World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemor- rhage. Geneva: WHO; 2012. (Level III)^
- Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database of
these resources at www.acog.org/More–Info/Postpartum
Hemorrhage.
These resources are for information only and are not
meant to be comprehensive. Referral to these resources
does not imply the American College of Obstetricians
and Gynecologists’ endorsement of the organization, the
organization’s website, or the content of the resource.
These resources may change without notice.
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e186 Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY
The MEDLINE database, the Cochrane Library, and ACOG’s own internal resources and documents were used to con duct a lit er a ture search to lo cate rel e vant ar ti cles pub lished between January 2000 and June 2017. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at sympo- sia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. Studies were reviewed and evaluated for quali ty according to the method outlined by the U.S. Pre ven tive Services Task Force: I Evidence obtained from at least one properly designed randomized controlled trial. II-1 Evidence obtained from well-designed controlled trials without randomization. II-2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group. II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncon- trolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A—Recommendations are based on good and con- sis tent sci en tif ic evidence. Level B—Recommendations are based on limited or incon- sistent scientific evidence. Level C—Recommendations are based primarily on con- sen sus and expert opinion.
Copyright October 2017 by the American College of Obstetri- cians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. ISSN 1099- The American College of Obstetricians and Gynecologists 409 12th Street, SW, PO Box 96920, Washington, DC 20090- Postpartum hemorrhage. Practice Bulletin No. 183. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130: e168–86.
This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in
the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publica-
tions may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.
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