Postpartum Hemorrhage: First Response Protocol

The Four T's: Causes of Postpartum Hemorrhage

Tone (80% of PPH cases): Uterine atony — the uterus does not contract after delivery. Without contraction, the large blood vessels supplying the placental bed remain open.

Trauma (10%): Lacerations of the cervix, vagina, or perineum; uterine rupture.

Tissue (9%): Retained placental tissue preventing uterine contraction.

Thrombin (1%): Coagulation disorders (pre-existing, or disseminated intravascular coagulopathy from another cause).

Most field PPH is uterine atony. Your assessment and treatment focus here.

Assessing Uterine Tone

Feel the fundus through the abdominal wall. The uterus should be:

• Contracted: Firm, about the size of a grapefruit, at or just below the level of the navel
• Involuting: Slightly lower than the navel in the hours after delivery, progressively lower over days

Atony feels like: Soft, boggy, larger than expected. May feel like pressing on a partially filled water balloon.

Uterine Massage: The Primary Intervention

1. Bimanually locate the fundus: Feel through the abdomen for the top of the uterus. In the immediate postpartum period it should be firm and palpable below the navel.

2. Stabilize from below: Place one hand with the heel just above the pubic bone, pressing inward and upward slightly. This prevents the uterus from being pushed downward and supports it.

3. Massage the fundus: With the other hand on top of the fundus, massage in a circular motion applying moderate pressure. You should feel the uterus contracting and firming under your hands.

4. Sustained massage: This is not a brief activity. Maintain massage for several minutes until the uterus remains contracted without stimulation, then re-check every 5-10 minutes. The uterus may relax and require repeat massage.

What to expect: Massage may expel clots from the vagina — this is expected and does not indicate the bleeding is worsening. Clot expulsion allows better uterine contraction.

Bimanual Uterine Compression

For severe atony that does not respond to external massage:

1. One gloved hand inside the vagina: Make a fist and place it in the anterior fornix (front of the vagina, against the front wall of the uterus).

2. Other hand on the fundus externally: Press down on the fundus through the abdominal wall.

3. Compress the uterus between both hands: The two-handed compression provides much greater force than external massage alone.

4. Maintain compression and continue for 15-20 minutes or until the uterus remains contracted.

This technique is uncomfortable but effective. Most practitioners describe it as one of the most physically demanding emergency procedures.

Medications for PPH

Oxytocin (Pitocin): The gold-standard uterotonic. Requires IV or IM administration and refrigeration for long-term storage. 10-40 IU IV in 1000ml saline infused over 15-30 minutes, or 10 IU IM. If you have it, use it.

Misoprostol (Cytotec): Does not require refrigeration, highly stable, oral/sublingual/rectal routes available. Dose for PPH: 800-1000mcg sublingually or rectally. WHO recommended for low-resource settings.

Side effects: Fever, shivering, nausea. Expected and manageable. Do not confuse the fever from misoprostol with sepsis.

Ergometrine/methylergometrine (Methergine): Another uterotonic. Contraindicated in hypertension (raises blood pressure significantly). Requires refrigeration.

Retained Placenta

If the placenta has not delivered 30 minutes after birth, it may be retained. A retained placenta prevents the uterus from fully contracting.

Do not attempt manual removal of a retained placenta without training. Attempting to manually peel a retained placenta from the uterine wall risks:

• Uterine perforation
• Massive hemorrhage
• Uterine inversion

If you have oxytocin or misoprostol: administer to encourage uterine contraction, which may separate the placenta.

If the placenta does not deliver and hemorrhage is progressing, evacuation is mandatory.

Shock: Recognizing and Responding

Compensated shock (blood loss 15-30% of volume):

• Heart rate elevated (above 100)
• Blood pressure normal or slightly low
• Pale, cool extremities
• Anxious, restless

Decompensated shock (blood loss 30-40%):

• Rapid, weak pulse (above 120)
• Blood pressure clearly low (systolic below 90)
• Confusion
• Cold, clammy extremities
• Reduced urine output

Treatment:

• Maintain uterine massage and hemostatic measures
• Lay flat with legs elevated
• IV fluids if available: aggressive normal saline 1-2 liters initially
• Oral fluids if IV unavailable and patient conscious
• Keep warm (shock causes hypothermia rapidly)
• Do not leave the patient

A woman in hemorrhagic shock from PPH requires surgical intervention (uterine packing, ligation, or hysterectomy) if conservative measures fail. This is a medical evacuation situation.

Perineal Laceration Assessment

After addressing uterine tone, check for laceration bleeding:

Grade 1: Skin tear only, minor bleeding. May not need suturing. Grade 2: Through skin and muscle (perineal muscles). Requires suturing. Grade 3-4: Involves anal sphincter or rectum. Requires specialist repair.

For significant lacerations causing bleeding: apply firm direct pressure with a clean gauze pad. Holding sustained pressure is often adequate for venous bleeding from lacerations. A running locked suture pattern can be used if suturing skills are available.