Postpartum haemorrhage
Blood loss after delivery (4 Ts)
Overview
Blood loss ≥500 mL after vaginal birth (≥1000 mL after caesarean), or any loss causing compromise. Primary PPH (<24h) is most often uterine ATONY (the commonest cause); the four causes are the "4 Ts" — Tone, Trauma, Tissue, Thrombin.
Recognise
- Heavy bleeding after delivery; signs of hypovolaemia
- Atony: soft "boggy" non-contracted uterus (commonest)
- Trauma: tears/episiotomy; Tissue: retained placenta; Thrombin: coagulopathy
Red flags
- Massive haemorrhage, shock, DIC — obstetric emergency
Differentials & how to tell them apart
Investigations
Identify cause (palpate uterine tone, inspect for tears, check placenta complete, coagulation). Bloods, crossmatch, monitor.
Management
Resuscitate + uterotonics for atony (oxytocin first) + tranexamic acid
- 1ABC resuscitation, large-bore access, crossmatch, tranexamic acid. Atony: uterine massage + uterotonics — oxytocin first, then ergometrine, carboprost, misoprostol.Gate: Ergometrine is contraindicated in hypertension/pre-eclampsia; carboprost is contraindicated in asthma → choose the uterotonic by comorbidity
- 2Mechanical/surgical if medical fails: bimanual compression, intrauterine balloon tamponade, B-Lynch suture, uterine artery ligation, hysterectomy. Repair trauma; remove retained tissue; correct coagulopathy.
Key points
Atony is the commonest cause (4 Ts: Tone, Trauma, Tissue, Thrombin). Drug contraindications are high-yield: NO ergometrine in hypertension; NO carboprost in asthma. Active management of the third stage prevents PPH.
Monitor & prognosis
Blood loss, vitals, uterine tone, coagulation.
Good with prompt escalation; a leading cause of maternal death worldwide.
Source: RCOG Green-top 52