🔴 POSTPARTUM HAEMORRHAGE (PPH)

COMPREHENSIVE CLINICAL PROTOCOL FOR INDIAN HEALTHCARE SETTINGS

For Healthcare Professionals Only | Aligned with WHO 2023, FIGO 2022, FOGSI, LaQshya Guidelines

SECTION 1: FUNDAMENTALS

1.1 DEFINITIONS

Term	Definition	Clinical Significance
PPH (Traditional - Vaginal)	Blood loss ≥500 mL after vaginal delivery	Threshold for documentation; often underestimates true loss
PPH (Traditional - CS)	Blood loss ≥1000 mL after caesarean section	Higher baseline expected loss in CS
Severe PPH	Blood loss ≥1000 mL regardless of mode	Requires aggressive intervention
Clinical PPH (Preferred)	Blood loss causing haemodynamic instability OR requiring intervention	Most practical definition; treat the patient, not the number
Primary PPH	Within 24 hours of delivery	Most common, most dangerous
Secondary PPH	24 hours to 12 weeks postpartum	Usually infection or retained products

🚨 Clinical Pearl: Visual estimation underestimates blood loss by 30-50%. A soaked maternity pad holds ~100 mL; a soaked under-buttock drape holds ~500-1000 mL. When in doubt, treat as PPH.

1.2 EPIDEMIOLOGY (INDIA-SPECIFIC)

Parameter	Data
Incidence	2-4% of all deliveries; up to 6% in some settings
Maternal mortality contribution	38% of direct maternal deaths (leading cause)
Case fatality rate	1% (higher in rural/resource-limited settings)
Time to death	Can occur within 2 hours if untreated

Why Indian Women Are More Vulnerable:

High prevalence of anaemia (Hb <11 g/dL in >50% of pregnant women)
Malnutrition
High fertility rates
Home deliveries without skilled attendants
Delayed recognition and referral
Limited blood bank access

1.3 AETIOLOGY: THE 4 Ts (In Order of Frequency)

TONE (70-80%) – Uterine Atony

Risk Factors	Mechanism
Overdistended uterus	Multiple pregnancy, polyhydramnios, macrosomia (>4 kg)
Uterine muscle fatigue	Prolonged labour, rapid labour (precipitate), prolonged oxytocin use
Uterine muscle impairment	Grand multiparity (≥5), previous PPH, fibroids, chorioamnionitis
Drug-induced relaxation	MgSO₄, tocolytics (terbutaline, nifedipine), halogenated anaesthetics
Other	Full bladder (prevents contraction), uterine inversion

TRAUMA (10-20%) – Genital Tract Injury

Type	Causes	Clinical Features
Perineal tears	Precipitate delivery, large baby, instrumental delivery	Visible bleeding from perineum
Vaginal tears	Instrumental delivery, malpresentation	Bleeding with contracted uterus
Cervical tears	Rapid dilatation, pushing before full dilatation	Bleeding despite contracted uterus; need speculum exam
Uterine rupture	Previous CS, obstructed labour, oxytocin excess	Sudden pain, shock, loss of contractions
Uterine inversion	Cord traction before separation, fundal pressure	Mass at/outside introitus, shock out of proportion
Broad ligament haematoma	Extension of uterine incision (CS), instrumental	Expanding pelvic mass, shock

TISSUE (5-10%) – Retained Products

Type	Causes	Clinical Features
Retained placenta	Placenta accreta spectrum, manual removal failure	Placenta not delivered within 30 min
Retained cotyledon/membrane	Incomplete placental examination	Uterus doesn’t contract fully; check placenta
Retained blood clots	Atony, coagulopathy	Soft uterus despite uterotonics; clots on massage
Succenturiate lobe	Abnormal placentation	Vessels running to edge of membranes

THROMBIN (1-2%) – Coagulopathy

Type	Causes	Clinical Features
Pre-existing	Von Willebrand disease, haemophilia carriers, ITP, anticoagulant use	Known history; bleeding from multiple sites
Acquired - Pregnancy	Severe preeclampsia/HELLP, placental abruption, amniotic fluid embolism, IUFD (especially >4 weeks)	Oozing from IV sites, wound, no clot formation
Acquired - Dilutional	Massive crystalloid resuscitation, massive transfusion without FFP	After large volume replacement
DIC	Abruption, sepsis, AFE, IUFD	Consumptive; low fibrinogen, prolonged PT/aPTT

1.4 RISK STRATIFICATION

Antenatal Risk Assessment

Risk Level	Factors	Action
HIGH RISK	Previous PPH, placenta praevia, suspected accreta, multiple pregnancy, polyhydramnios, large fibroids, bleeding disorder, severe anaemia (Hb <7), anticoagulant use	Deliver at CEmONC facility with blood bank; Group & Save/Crossmatch; senior obstetrician; anaesthesia standby
MODERATE RISK	Grand multiparity (≥5), previous CS, overdistended uterus, Hb 7-9, obesity	Deliver at facility with blood transfusion capability; Group & Save; IV access before delivery
LOW RISK	No risk factors identified	Routine AMTSL; be prepared (PPH can occur without risk factors)

⚠️ 40% of PPH occurs in women with NO identifiable risk factors. Always be prepared.

Intrapartum Risk Assessment (Reassess Continuously)

New Risk Factor	Action
Prolonged first stage (>12h nullipara, >10h multipara)	Prepare blood, senior involvement
Prolonged second stage	Consider instrumental vs CS; have uterotonics ready
Chorioamnionitis	IV antibiotics; anticipate atony
Instrumental delivery	Check for trauma; have sutures ready
Emergency CS	Anticipate higher blood loss
MgSO₄ use	Atony risk increased

SECTION 2: PREVENTION

2.1 ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR (AMTSL)

Reduces PPH by 60-70% – Should be offered to ALL women

Components

Component	Technique	Timing
1. Prophylactic Uterotonic	Oxytocin 10 IU IM (preferred) OR IV over 1-2 min	Within 1 minute of delivery of baby
2. Controlled Cord Traction (CCT)	Apply steady traction on cord while providing counter-traction above pubic symphysis	Only when uterus contracted and cord lengthening
3. Uterine Massage	Gentle fundal massage after placental delivery	Until uterus well-contracted

Preferred Uterotonic for Prophylaxis

Drug	Dose	Route	Notes
Oxytocin	10 IU	IM (preferred) or slow IV	First choice; safest profile
Carbetocin	100 mcg	Single IM/IV dose	Longer acting; useful where cold chain limited
Oxytocin + Ergometrine (Syntometrine)	5 IU + 0.5 mg	IM	More effective but more side effects; avoid in HTN
Misoprostol	600 mcg	Oral	Where oxytocin unavailable; more side effects

Controlled Cord Traction Technique

TECHNIQUE:

1. Wait for signs of placental separation:

- Uterus becomes globular and firm

- Gush of blood

- Cord lengthens

- Uterus rises in abdomen

2. Clamp cord close to perineum; hold with one hand

3. Place other hand suprapubically, palm facing toward

umbilicus (counter-traction hand)

4. Apply steady, gentle downward traction on cord while

pushing uterus upward/backward with counter-traction hand

5. If placenta doesn't descend with 30-40 sec of traction:

- Stop pulling

- Wait for next contraction

- Try again

6. Once placenta visible at introitus, use both hands to

gently rotate and ease out membranes

7. NEVER use excessive force – risk of uterine inversion

Examination of Placenta

CHECKLIST:

□ Maternal surface: All cotyledons present? Missing piece?

□ Fetal surface: Vessels run to edge? (succenturiate lobe if yes)

□ Membranes: Complete? Hole suggesting missing lobe?

□ Cord: Length, insertion, number of vessels (2 arteries, 1 vein)

□ Abnormalities: Infarcts, calcifications, tumours

DOCUMENT: Placenta complete/incomplete, weight if abnormal,

sent for histopathology if indicated

2.2 DELAYED CORD CLAMPING

Recommendation	Details
Timing	Clamp cord 1-3 minutes after delivery (if baby vigorous)
Benefit	Increased neonatal haemoglobin, iron stores
Exception	If mother bleeding heavily OR baby needs resuscitation → clamp immediately

2.3 PREPARING FOR PPH (HIGH-RISK CASES)

Pre-Delivery Checklist (High-Risk Woman)

□ IV access established (16-18G, preferably 2 lines)

□ Blood group and crossmatch sent (2-4 units PRBC)

□ Hb, platelets, coagulation if indicated

□ Uterotonics at bedside:

- Oxytocin 10 IU ampules × 5

- Misoprostol 200 mcg tablets × 5

- Methylergometrine 0.2 mg × 2 (if no contraindication)

- Carboprost 250 mcg × 2 (if available, no contraindication)

□ Tranexamic acid 1 g × 2 at bedside

□ IV fluid (NS/RL) running or ready

□ Blood warmer and pressure bag available

□ UBT (Uterine Balloon Tamponade) kit available

□ Senior obstetrician informed

□ Anaesthesia informed

□ Blood bank informed of high-risk case

□ Neonatal team standby

□ Emergency OT on standby (for highest risk: accreta)

SECTION 3: RECOGNITION AND INITIAL RESPONSE

3.1 RECOGNITION

Clinical Signs of PPH

Sign	What to Look For
Visible bleeding	Continuous trickle, gush, soaking drapes, pooling
Uterine fundus	Soft, boggy, above umbilicus (atony) vs firm (trauma/tissue)
Vital signs	Tachycardia, hypotension, tachypnoea
Patient symptoms	Weakness, dizziness, thirst, confusion, restlessness
Appearance	Pallor, cold/clammy, air hunger

Obstetric Shock Index (OSI)

Shock Index = Heart Rate ÷ Systolic Blood Pressure

SI Value	Interpretation	Estimated Blood Loss	Required Action
0.7-0.9	Normal	<500 mL	Monitor, continue routine care
0.9-1.1	Mild shock	500-1000 mL	Alert team, prepare interventions
1.1-1.5	Moderate shock	1000-1500 mL	Aggressive intervention
>1.5	Severe shock	>1500 mL	Massive transfusion protocol

🚨 Why Shock Index Matters: Pregnant women maintain BP until 30-40% blood volume lost due to physiological hypervolaemia. By the time BP drops, patient is in severe shock. Tachycardia and rising SI are earlier warning signs.

Quantitative Blood Loss Measurement

Method	Technique
Weighing	Weigh blood-soaked items; 1 g = 1 mL blood (subtract dry weight)
Graduated drapes	Calibrated under-buttock drapes
Estimation aids	Visual guides showing soaked swabs, drapes, etc.

Visual Estimation Guide:

Item	Approximate Blood Volume
Fully soaked maternity pad	100 mL
Fully soaked incontinence pad (large)	250 mL
Blood clot (fist-sized)	500 mL
Fully soaked under-buttock drape	500-1000 mL
Kidney dish (full)	500 mL

3.2 CALL FOR HELP – FIRST ACTION

🚨 PPH DECLARED – IMMEDIATELY:

□ Call: "I need help – PPH in [location]"

□ Designate:

- Team leader (usually senior obstetrician)

- Person for drugs/fluids

- Person for documentation/time-keeping

- Person for communication (blood bank, OT, ICU)

□ Start timer (or note time)

□ Inform:

- Senior obstetrician (if not present)

- Anaesthetist

- Blood bank

- Nursing supervisor (for additional staff)

□ Move PPH trolley/kit to bedside

PPH Trolley Contents:

Category	Items
Uterotonics	Oxytocin 10 IU × 10, Misoprostol 200 mcg × 10, Methylergometrine 0.2 mg × 5, Carboprost 250 mcg × 4 (refrigerated)
Tranexamic acid	1 g ampules × 4
IV supplies	16G & 18G cannulas × 4 each, IV sets × 4, 3-way stopcock × 2
Fluids	NS 1L × 4, RL 1L × 4
Blood administration	Blood giving sets × 4, blood warmer if available
UBT	Bakri balloon OR Condom catheter kit (Foley 22-24F, condom, silk tie)
Instruments	Sponge holding forceps × 2, ovum forceps, Sims speculum, suture material
Drugs	Calcium gluconate 10% × 2, Adrenaline 1:1000 × 2, Atropine × 2
Monitoring	BP cuff, pulse oximeter, thermometer
Documentation	PPH checklist, observation chart, timer

3.3 INITIAL RESUSCITATION (FIRST 5 MINUTES)

A – Airway and Breathing

Action	Details
Position	Flat with legs elevated OR left lateral if still in labour
Airway	Ensure patent; suction if vomiting
Oxygen	8-10 L/min via face mask with reservoir (target SpO₂ ≥95%)

C – Circulation

Action	Details
IV Access	2 large-bore cannulas (16G or 18G) – antecubital fossa preferred
	If difficult: external jugular, femoral, or intraosseous (EZ-IO)
Bloods	CBC, Group & crossmatch, PT/aPTT/fibrinogen, RFT, LFT
	ABG with lactate if available
Crystalloid	1-2 L NS or RL rapid bolus (use pressure bag/hand squeeze)
Warming	Warm fluids if possible; warm blankets
Catheterize	Insert Foley; empty bladder (helps uterine contraction); monitor output

Fluid Resuscitation Strategy

Phase	Volume	Endpoint
Initial bolus	1-2 L crystalloid over 10-15 min	Assess response
Ongoing	Titrate to response	SBP >90, MAP ≥65, UO ≥0.5 mL/kg/hr
Caution	Avoid >2L crystalloid without blood	Dilutional coagulopathy, pulmonary oedema

⚠️ Crystalloid replaces volume, not oxygen-carrying capacity. In ongoing haemorrhage, early blood is critical.

SECTION 4: CAUSE IDENTIFICATION AND TARGETED TREATMENT

4.1 SIMULTANEOUS ASSESSMENT (While Resuscitating)

RAPID ASSESSMENT CHECKLIST:

□ UTERUS: Palpate fundus

- Soft/boggy → ATONY (most likely)

- Firm/contracted → Look for TRAUMA or TISSUE

□ VAGINA/PERINEUM: Inspect

- Active bleeding from tear → TRAUMA

- Clots in vagina → Empty and reassess

□ PLACENTA: Check

- Not delivered → Retained placenta

- Incomplete → Retained tissue

- Complete → Reassess cause

□ CERVIX: Speculum exam (if uterus contracted)

- Cervical tear → TRAUMA

□ BLEEDING CHARACTER:

- Clotting normally → Unlikely THROMBIN defect

- Not clotting, oozing from IV sites → THROMBIN issue

4.2 TREATMENT BY CAUSE

TONE – Uterine Atony Management

Step 1: Uterine Massage (Immediate)

TECHNIQUE – BIMANUAL UTERINE MASSAGE:

External only (initial):

- Cup hand over fundus through abdomen

- Firm, circular, rubbing motion

- "Rub up a contraction"

Bimanual (if no response):

- One hand: Fist in anterior vaginal fornix,

pushing up against lower segment

- Other hand: On abdomen, pressing down on fundus

- Compress uterus between both hands

- Maintain for several minutes until firm

- Can be tiring – may need to rotate personnel

Step 2: Empty Bladder

Insert Foley catheter if not already done
Full bladder prevents uterine contraction
Also allows urine output monitoring

Step 3: Uterotonics (Start All Indicated Simultaneously)

Drug	Dose & Route	Onset	Notes
Oxytocin (First line)	10 IU IM OR slow IV (over 1-2 min)	2-3 min (IM), immediate (IV)	Maximum bolus 10 IU
Oxytocin infusion	20-40 IU in 500 mL NS at 125-250 mL/hr	Continuous	Titrate to uterine tone; max ~60 IU total
Misoprostol	800 mcg sublingual (fastest) OR 1000 mcg rectal	10-15 min	Use if oxytocin unavailable or as add-on; SE: fever, shivering
Methylergometrine	0.2 mg IM (preferred) or slow IV	2-5 min	❌ Contraindicated: HTN, preeclampsia, cardiac disease
Carboprost (PGF2α)	250 mcg deep IM q15-20 min (max 8 doses = 2 mg)	5-15 min	❌ Contraindicated: asthma, pulmonary/cardiac/renal disease; store refrigerated
Carbetocin	100 mcg single IV/IM dose	Similar to oxytocin	Longer acting; may use instead of oxytocin infusion

Uterotonic Escalation Protocol:

TIME 0: PPH recognized

├── Oxytocin 10 IU IM/IV + Start oxytocin infusion

├── Continue uterine massage

│

+5 min: Assess – if still bleeding/atonic

├── Add Misoprostol 800 mcg SL

├── Consider Methylergometrine 0.2 mg IM (if no contraindication)

│

+10-15 min: Assess – if still bleeding/atonic

├── Add Carboprost 250 mcg IM (if no contraindication)

├── Prepare for mechanical/surgical interventions

│

+15-20 min: Assess – if still bleeding

├── Proceed to UBT or surgical options

🚨 Do NOT delay escalation. Time is critical. All uterotonics can be given together if needed.

Step 4: Tranexamic Acid (Give Early)

Parameter	Details
Dose	1 g (10 mL of 100 mg/mL solution) IV over 10 minutes
Timing	As soon as PPH diagnosed – within 3 hours of birth
Repeat	Second 1 g IV if bleeding continues after 30 minutes OR if bleeding restarts within 24 hours
Evidence	WOMAN Trial: 20-30% reduction in death from bleeding if given within 3 hours
Mechanism	Inhibits plasmin → reduces fibrin breakdown → stabilizes clot

🚨 TXA efficacy decreases 10% for every 15 minutes of delay. NO BENEFIT after 3 hours. Give EARLY.

Contraindications to TXA (rare in acute PPH):

Active thromboembolic disease
Clear contraindication to antifibrinolytics
In practice, these rarely apply in acute PPH – save life first

TRAUMA – Genital Tract Injury Management

Systematic Examination

EXAMINATION SEQUENCE:

1. GOOD LIGHTING – essential

2. ADEQUATE EXPOSURE – legs in lithotomy

3. ADEQUATE ANALGESIA – local, regional, or GA as needed

4. ASSISTANT – to hold retractors

Start from outside, work in:

□ PERINEUM:

- First/second degree tears → Repair

- Third/fourth degree → Senior surgeon, OT, proper repair

□ VAGINA:

- Use Sims speculum or retractors

- Inspect all walls systematically

- Pack and clamp bleeding areas

□ CERVIX:

- Use sponge-holding forceps to grasp lips

- Inspect entire circumference

- Common at 3 o'clock and 9 o'clock positions

□ UTERUS:

- If rupture suspected → laparotomy

- If inversion → manual replacement

Repair Principles

Injury	Management
Perineal tear (1st-2nd degree)	Suture in layers; vaginal mucosa → perineal muscle → skin
Perineal tear (3rd-4th degree)	OT, experienced surgeon, proper identification of anal sphincter, layered repair, antibiotics, laxatives postop
Vaginal tear	Suture from apex to avoid retraction and haematoma; continuous or interrupted
Cervical tear	Start suture above apex of tear; continuous locking or interrupted; may need traction with sponge forceps
Broad ligament haematoma	Laparotomy if expanding; evacuate, identify bleeding vessel, ligate; may need internal iliac ligation
Uterine rupture	See Section 7 of main document
Uterine inversion	See Section 8 of main document

⚠️ Always inspect placenta and genital tract even if uterus well-contracted – trauma can coexist with atony

TISSUE – Retained Products Management

Retained Placenta (Not Delivered by 30 min)

Situation	Management
Placenta not delivered, no haemorrhage	Ensure bladder empty; controlled cord traction; wait up to 30-60 min
Placenta not delivered, haemorrhage present	Manual removal under anaesthesia
Trapped placenta (cervix closing)	May need uterine relaxation (terbutaline, nitroglycerin, GA)
Morbidly adherent (accreta spectrum)	Senior surgeon, interventional radiology if available, prepare for hysterectomy

Manual Removal of Placenta – Technique:

PREREQUISITES:

- Anaesthesia (regional or GA)

- Aseptic technique

- IV access and resuscitation ongoing

- Empty bladder

TECHNIQUE:

1. One hand on abdomen, steadying fundus (counter-traction)

2. Other hand (surgeon's dominant): Cone shape, follow cord

through cervix into uterine cavity

3. Find placental edge – use side of hand to develop plane

between placenta and uterine wall

4. Work around circumference with gentle side-to-side motion

5. Once fully separated, grasp placenta and withdraw

6. Immediately explore cavity for remaining fragments

7. Administer uterotonic and massage uterus

8. Confirm complete removal (examine placenta)

9. Single dose antibiotics (Ceftriaxone 1g IV or Ampicillin 2g IV)

⚠️ If plane cannot be developed (rock-hard adherence) →

STOP – suspect placenta accreta → prepare for laparotomy/hysterectomy

Retained Tissue/Clots (Placenta Delivered but Incomplete/Uterus Full of Clots)

Situation	Management
Retained cotyledon/membranes	Explore uterine cavity under anaesthesia; gentle curettage with large blunt curette (avoid perforation)
Retained blood clots preventing contraction	Bimanual compression to express clots; may need manual exploration
Secondary PPH (>24h) with retained products	Ultrasound guidance; surgical evacuation; antibiotics

THROMBIN – Coagulopathy Management

Recognition

Sign	What It Means
Blood not clotting in wound/drapes	Clotting factor deficiency
Oozing from IV sites, gums, old punctures	Systemic coagulopathy
Ecchymoses appearing	Platelet/factor deficiency
Bedside clotting test abnormal	DIC or factor deficiency

Bedside Clotting Test (Modified Lee-White):

1. Take 5 mL blood in plain glass tube (red-top)

2. Hold at body temperature (in your armpit or hands)

3. Tilt gently every minute

4. Normal: Firm clot in <8-10 minutes

5. Abnormal: No clot or soft/friable clot by 10 minutes →

Suspect coagulopathy; treat empirically while awaiting labs

Treatment

Component	Product	Dose	Target
Red cells	PRBC	Transfuse for Hb <7-8 g/dL or ongoing bleeding	Hb >7-8 g/dL
Clotting factors	FFP	15-20 mL/kg (typically 4-6 units)	PT/aPTT <1.5× control
Fibrinogen	Cryoprecipitate	10 units (or 1 pool)	Fibrinogen >2 g/L
	Fibrinogen concentrate	2-4 g (if available)	Fibrinogen >2 g/L
Platelets	Platelet concentrate	1 adult dose (4-6 units or 1 SDP)	Platelets >50,000/μL (>75,000 if ongoing bleeding)

Massive Transfusion Protocol (MTP)

Definition: Anticipated need for ≥10 units PRBC in 24h OR ≥4 units in 1h OR entire blood volume replaced

Activation Criteria:

Shock Index ≥1.4
Clinical assessment suggests massive ongoing haemorrhage
Senior clinician decision

Protocol:

🚨 MASSIVE TRANSFUSION PROTOCOL

COMMUNICATION:

□ Call blood bank: "Activating MTP for PPH in [location]"

□ Designated person for blood collection/delivery

INITIAL PACK (while crossmatch pending):

- 4 units O-negative or group-specific PRBC

- 4 units FFP

- Arrange platelets

ONGOING (balanced resuscitation):

Ratio: PRBC : FFP : Platelets = 1 : 1 : 1

LABORATORY MONITORING (every 30-60 min):

- CBC

- PT/INR, aPTT

- Fibrinogen

- ABG with lactate

- Calcium (citrate in blood products chelates calcium)

TARGETS:

- Hb >7-8 g/dL

- Platelets >50,000/μL

- PT/aPTT <1.5× normal

- Fibrinogen >2 g/L

- Ionized Calcium >1.1 mmol/L (give Calcium gluconate if low)

- pH >7.2

- Temperature >35°C

ADJUNCTS:

- Tranexamic acid 1g IV if not already given

- Calcium gluconate 10 mL of 10% solution IV for hypocalcemia

- Warm all blood products and fluids

🚨 Hypothermia, acidosis, and hypocalcemia worsen coagulopathy. Treat aggressively.

SECTION 5: MECHANICAL AND SURGICAL INTERVENTIONS

5.1 TEMPORIZING MEASURES

External Aortic Compression

Indication: Temporizing measure during resuscitation or while preparing for surgery

TECHNIQUE:

1. Patient supine

2. Locate umbilicus

3. Make fist and place on midline, just above umbilicus

4. Press firmly downward toward vertebral column

5. Check femoral pulse with other hand – should be absent/diminished

6. Maintain until definitive measures instituted

7. Tiring – may need to rotate personnel

Bimanual Uterine Compression

Indication: Atony; temporizing while uterotonics take effect

TECHNIQUE:

1. One hand: Make fist, insert into anterior vaginal fornix

Push upward against lower uterine segment

2. Other hand: On abdomen, cup posterior wall of uterus

3. Compress uterus firmly between both hands

4. Maintain continuously until uterus contracts and remains firm

5. May need to continue for 15-30+ minutes

6. Continue uterotonics, prepare next steps

5.2 UTERINE BALLOON TAMPONADE (UBT)

Indication:

Atony unresponsive to uterotonics
Can be used while preparing for surgical intervention
“Tamponade test” – if bleeding stops with balloon, likely atony; if continues, consider other causes or proceed to surgery

Commercial Balloons

Product	Characteristics
Bakri balloon	Purpose-built, drainage channel, can measure ongoing loss
Ebb balloon	Dual balloon (uterine + vaginal)
BT-Cath	Similar to Bakri

Condom Catheter (Resource-Limited Alternative)

Equally effective as commercial balloons

MATERIALS:

- Foley catheter (22-24 Fr) or rubber catheter

- Condom (non-lubricated preferred)

- Silk suture or string

- NS for inflation

PREPARATION:

1. Cut distal tip of Foley (if using Foley)

2. Tie condom firmly onto catheter end with silk (double tie)

3. Check for leaks by inflating with water

INSERTION:

1. Confirm uterus is empty (no retained products/clots)

2. Aseptic technique

3. Insert catheter with condom into uterine cavity

(may use sponge forceps to guide)

4. Inflate with warm NS – typically 250-500 mL

5. Inflate until resistance felt OR bleeding stops

6. Clamp catheter

7. Pack vagina lightly with gauze to prevent expulsion (optional)

8. Start or continue oxytocin infusion

9. Tape catheter to thigh

MONITORING:

- Check pad for ongoing bleeding

- Monitor vitals continuously

- Check balloon is in place

REMOVAL:

- Leave in situ for 12-24 hours

- Deflate gradually (50-100 mL at a time over several hours)

- Have uterotonics, blood ready

- Remove once fully deflated and no bleeding

Positive “Tamponade Test”: Bleeding stops with balloon inflation → Confirms atony as cause; continue balloon therapy

Negative “Tamponade Test”: Bleeding continues → Other cause or need for surgical intervention

5.3 UTERINE COMPRESSION SUTURES

Indication: Atony at laparotomy; failed UBT

B-Lynch Suture (Most Common)

TECHNIQUE:

Prerequisites:

- Laparotomy performed

- Uterus exteriorized

- Bladder reflected down (if not already for CS)

Test compression first:

- Assistant compresses uterus bimanually

- If bleeding stops with compression, suture will likely work

Suture material: No. 1 or No. 2 absorbable suture (Chromic catgut,

Polyglactin) on large needle

Steps:

1. Enter uterus 3 cm below right edge of incision, 3 cm from

lateral border; exit 3 cm above incision

2. Pass suture over fundus to posterior wall (approximately

4 cm from cornua)

3. Enter posterior wall at level of uterosacral ligament

insertion, exit on same level on left side

4. Pass suture back over fundus on left side

5. Enter anterior wall 3 cm above left edge of incision;

exit 3 cm below incision

6. While assistant compresses uterus, pull both ends of suture

tight and tie securely

7. Close uterine incision (if CS)

Post-procedure:

- Confirm haemostasis

- May place drain

- Consider antibiotics

Other Compression Sutures

Suture	Description
Hayman	Simpler; does not require uterine incision; vertical sutures from anterior to posterior
Cho (Square sutures)	Multiple square sutures through full thickness; good for focal bleeding
Pereira	Combination of transverse and longitudinal sutures

5.4 VASCULAR LIGATION

Indication: Bleeding despite compression sutures or UBT; not involving uterine atony (e.g., trauma, extensions); desire to preserve fertility

Uterine Artery Ligation (O’Leary Sutures)

TECHNIQUE:

1. Identify uterine artery – runs along lateral aspect of lower

uterine segment (can often be seen pulsating)

2. Create window in broad ligament avascular area

3. Pass suture (No. 1 absorbable) through myometrium at level

of internal os, 2-3 cm medial to artery, from front to back

4. Tie on lateral side, including artery and veins

5. Repeat on other side

6. If bleeding continues, may ligate ascending branches higher

(at cornual level)

Internal Iliac (Hypogastric) Artery Ligation

Indication: Severe uncontrolled hemorrhage; experienced surgeon

TECHNIQUE OVERVIEW:

1. Open posterior peritoneum lateral to iliac vessels

2. Identify and retract ureter medially

3. Identify bifurcation of common iliac into external and

internal iliac arteries

4. Internal iliac is medial and posterior

5. Carefully dissect around internal iliac artery (avoid vein

posteriorly)

6. Pass right-angled clamp behind artery, 2-3 cm distal to

bifurcation (to preserve posterior division if possible)

7. Pass ligature and tie (do not cut artery)

8. Repeat on other side

Reduces pulse pressure by 85%, allowing clot formation

⚠️ Complications: Ureteric injury, venous injury, buttock

claudication (rare)

5.5 HYSTERECTOMY

Indication:

Life-threatening haemorrhage unresponsive to conservative measures
Placenta accreta spectrum with uncontrollable bleeding
Uterine rupture not amenable to repair
DO NOT DELAY when indicated – maternal life takes priority

When to Proceed to Hysterectomy

DECISION POINTS:

Consider hysterectomy when:

□ Massive haemorrhage despite optimal uterotonic therapy

□ Failed UBT and/or compression sutures

□ Failed vascular ligation

□ Uterine rupture with extensive damage

□ Placenta accreta/increta/percreta with uncontrollable bleeding

□ Total blood replacement approaching/exceeding

Decision must balance:

- Rate of ongoing bleeding

- Resources available (blood, surgical expertise)

- Patient stability

- Future fertility wishes (discuss if time permits, but life > fertility)

⚠️ A timely subtotal hysterectomy is better than a delayed total

hysterectomy in a dying patient

Subtotal vs Total Hysterectomy

Type	Advantages	Disadvantages
Subtotal (Supracervical)	Faster, less urological injury, less blood loss	Cervical stump may bleed if placenta praevia/accreta
Total	Definitive; no cervical stump issues	Longer, more technically demanding, higher complication risk

Choice depends on:

Source of bleeding (low = total may be needed)
Patient stability (unstable = subtotal and pack)
Surgical expertise

Damage Control Surgery Concept

In extreme haemorrhage with coagulopathy, hypothermia, acidosis:

DAMAGE CONTROL APPROACH:

1. Abbreviated surgery:

- Control bleeding (hysterectomy if needed, or packing)

- Pack pelvis and close abdomen

2. ICU resuscitation:

- Warm patient

- Correct coagulopathy

- Correct acidosis

- Massive transfusion

3. Re-look surgery (24-48h):

- Remove packs

- Complete definitive repair

- Close abdomen definitively

5.6 INTERVENTIONAL RADIOLOGY (Where Available)

Procedure	Indication
Uterine artery embolization	Atony, accreta (pre-planned), AV malformation, pseudo-aneurysm
Internal iliac artery embolization	Broader haemorrhage control
Balloon occlusion (planned)	Anticipated accreta; placed before CS

Prerequisites:

Haemodynamically stable enough to tolerate procedure (~1h)
Interventional radiology available 24/7
Hybrid OR ideal

SECTION 6: BLOOD TRANSFUSION PROTOCOLS

6.1 INDICATIONS FOR TRANSFUSION

Product	Indication	Dose
PRBC	Hb <7 g/dL (or <8 g/dL in cardiac disease or ongoing bleeding)	1 unit raises Hb by ~1 g/dL
FFP	PT/INR or aPTT >1.5× normal; empiric in massive transfusion	15-20 mL/kg
Platelets	<50,000/μL with bleeding; <75,000/μL in ongoing haemorrhage	1 adult dose
Cryoprecipitate	Fibrinogen <2 g/L	10 units

6.2 EMERGENCY BLOOD

Situation	Action
Crossmatch available	Crossmatched blood (safest)
No time for crossmatch	Type-specific uncrossmatched blood (Group compatible)
Unknown blood group, life-threatening	O-negative PRBC (or O-positive if Rh-neg unavailable)

🚨 Never delay transfusion for crossmatch in life-threatening haemorrhage. O-negative or group-specific blood is acceptable.

6.3 TRANSFUSION COMPLICATIONS TO WATCH FOR

Complication	Signs	Management
Transfusion reaction	Fever, chills, rash, dyspnoea, hypotension	Stop transfusion; supportive care; notify blood bank
TACO (overload)	Dyspnoea, hypertension, JVP elevated	Slow/stop transfusion; diuretics
TRALI	Acute lung injury within 6h; bilateral infiltrates, hypoxia	Supportive; oxygen; may need ventilation
Hypocalcemia	Citrate toxicity; prolonged QT, tetany	Calcium gluconate 10 mL 10% IV
Hypothermia	Cold products	Use blood warmer
Hyperkalaemia	Especially old blood	Monitor potassium; treat if symptomatic

SECTION 7: POST-RESUSCITATION CARE

7.1 IMMEDIATE POST-EVENT (First 2-6 Hours)

Action	Details
Monitoring	ICU/HDU level care if severe PPH; q15-30 min vitals initially
Uterine tone	Continue to assess; continue oxytocin infusion for minimum 4 hours
Urine output	Target ≥0.5 mL/kg/hr; Foley remains in situ
Bleeding	Monitor pad/drapes; ongoing bleeding → reassess
Labs	Repeat CBC, coagulation at 2-4 hours; ABG if was acidotic
VTE prophylaxis	Graduated compression stockings; mechanical prophylaxis while bleeding risk persists

7.2 INVESTIGATIONS TO EXCLUDE ONGOING ISSUES

Investigation	Purpose
Serial CBC	Confirm Hb stable; may continue to drop with fluid shifts
Coagulation (PT, aPTT, fibrinogen)	Ensure normalized; guide further blood products
RFT	Exclude acute kidney injury
LFT	Baseline; especially if HELLP/preeclampsia
ABG/Lactate	Ensure clearance of acidosis
Echo	If suspected cardiac injury (AFE, massive transfusion)

7.3 LONGER TERM CARE

Issue	Management
Anaemia	Oral iron supplementation; may need continued transfusion if symptomatic/Hb <7
Sheehan syndrome	Suspect if failure to lactate; test pituitary function (TSH, cortisol, etc.)
Thromboprophylaxis	Low molecular weight heparin once haemostasis secured (usually 24-48h post); balance bleeding vs clot risk
Psychological	Debrief patient; watch for PTSD; offer counseling
Contraception	Discuss timing of future pregnancy; may need interval for recovery

7.4 IRON REPLACEMENT THERAPY

Route	Indication	Options
Oral	Mild-moderate anaemia, tolerating oral	Ferrous sulfate 200 mg TDS (60 mg elemental iron TDS); take with vitamin C; avoid with tea/antacids
IV	Severe anaemia (Hb <8), intolerance to oral, rapid correction needed	Ferric carboxymaltose 1000 mg single dose (or 500 mg × 2); Iron sucrose 200 mg × 5 doses

SECTION 8: SPECIAL SITUATIONS

8.1 SECONDARY PPH (>24 Hours – 12 Weeks)

Causes

Cause	Frequency
Subinvolution of placental site ± infection	Most common
Retained products of conception	Common
Endometritis	Common
Pseudoaneurysm of uterine artery	Rare
Gestational trophoblastic disease	Rare

Management

ASSESSMENT:

□ Vitals, shock assessment

□ Bleeding – amount, clots

□ Signs of infection – fever, offensive lochia, uterine tenderness

□ Speculum – source of bleeding, cervical os open?

□ Bimanual – uterine size, tenderness

INVESTIGATIONS:

□ CBC, Group & Save

□ Ultrasound – retained products? Endometrial thickness >10mm?

□ βhCG if GTD suspected

TREATMENT:

1. Resuscitation if needed (as per primary PPH)

2. Uterotonics:

- Oxytocin 10 IU IM + infusion

- Misoprostol 400-600 mcg SL/PO

3. Antibiotics (presumptive infection):

- Ampicillin + Gentamicin + Metronidazole

- OR Amoxicillin-clavulanate + Metronidazole

4. Surgical evacuation if retained products:

- Ultrasound-guided if possible

- Gentle suction curettage

- Risk of perforation (soft postpartum uterus)

5. Consider embolization if AV malformation/pseudoaneurysm

6. Rarely → hysterectomy if uncontrolled

8.2 JEHOVAH’S WITNESS (REFUSAL OF BLOOD)

Principles

Respect autonomy if competent adult with informed refusal
Document advance directive clearly
Optimize alternatives
Discuss with hospital ethics/legal if needed

Alternatives to Blood Transfusion

Intervention	Details
Cell salvage	May be acceptable to some JW (own blood recycled)
Tranexamic acid	Give early
IV Iron	Pre-operatively if time
Erythropoietin	Pre-operatively if time (EPO 40,000 units SC weekly)
Minimize blood loss	Meticulous haemostasis, UBT, compression sutures
Tolerate lower Hb	May tolerate Hb as low as 5-6 g/dL if normovolemic and not bleeding
Minimize phlebotomy	Paediatric tubes; minimize testing

8.3 PPH AFTER CAESAREAN SECTION

Additional Considerations	Details
Higher expected blood loss	1000 mL threshold for “severe”
Visible causes	Extensions of incision, broad ligament haematoma, coagulopathy
Lower segment atony	May need figure-of-8 sutures at angles
Placenta accreta spectrum	Higher risk if previous CS + anterior placenta
Rapid access to abdominal cavity	Already open or can re-open quickly

8.4 JEERING WITH PLACENTA ACCRETA SPECTRUM

Risk Factors

Factor	Relative Risk
Previous CS + Placenta praevia	Highest risk
1 prior CS + praevia	~3% accreta
2 prior CS + praevia	~11% accreta
≥3 prior CS + praevia	~40% accreta
Previous myomectomy	Increased risk
Previous curettage	Increased risk

Pre-operative Planning (Suspected Accreta)

MULTIDISCIPLINARY PLANNING:

Team:

□ Senior obstetrician (experienced in accreta)

□ Senior anaesthetist

□ Blood bank (crossmatch ≥6 units PRBC, FFP, platelets on standby)

□ Interventional radiology (if available)

□ Urology (if bladder involvement suspected)

□ ICU

Pre-operative:

□ Confirm diagnosis (MRI if unclear on USS)

□ Counseling – high likelihood of hysterectomy

□ Consent for hysterectomy

□ Cell salvage available

□ Adequate IV access (large bore × 2, ± central line)

□ Arterial line

□ Warm products and fluids

Operative strategy:

□ Midline vertical incision (adequate access)

□ Classical uterine incision (avoid placenta)

□ Deliver baby

□ DO NOT attempt to remove placenta if accreta confirmed

□ Hysterectomy with placenta in situ

□ Consider ureteric stents pre-op if percreta

□ Consider iliac balloon catheters (IR)

SECTION 9: DOCUMENTATION

9.1 ESSENTIAL DOCUMENTATION

PPH DOCUMENTATION CHECKLIST:

□ Time PPH recognised

□ Estimated blood loss (method used)

□ Vitals at recognition and serially

□ Shock Index

□ Team members present

□ Call for help time

□ Uterotonic drugs given (drug, dose, route, time)

□ Tranexamic acid (dose, time)

□ IV fluids (type, volume, time)

□ Blood products (type, units, time)

□ Procedures performed:

- Uterine massage

- Bimanual compression

- UBT (type, volume, time in/out)

- Examination under anaesthesia

- Surgical procedures (detail technique, suture material)

□ Cause identified (Tone/Trauma/Tissue/Thrombin)

□ Placenta and membrane – complete/incomplete

□ Repairs performed (tears – degree, location)

□ Total blood loss

□ Vital signs at end

□ Transfer to ICU/HDU (time, receiving team)

□ Communication with family

9.2 DEBRIEF

TEAM DEBRIEF (Within 24 hours):

1. What went well?

2. What could be improved?

3. Were protocols followed?

4. Any equipment/supply issues?

5. Any communication issues?

6. Learning points for the team

7. Support for team members (especially if adverse outcome)

Document key learning points and action items

9.3 PATIENT DEBRIEF

Component	Details
Timing	Before discharge and at postnatal follow-up
What happened	Explain events in understandable terms
Why it happened	Cause if known
What was done	Interventions, transfusions, surgery
Implications	Effect on future fertility/pregnancies
Emotional support	Acknowledge trauma; offer counseling if needed
Written summary	Provide discharge summary with key details
Follow-up plan	When to return, red flags

SECTION 10: SIMULATION AND DRILLS

10.1 IMPORTANCE OF DRILLS

PPH is unpredictable and progresses rapidly
Team coordination is critical
Regular drills improve response time and outcomes
Identifies system gaps (equipment, protocols, communication)

10.2 RECOMMENDED DRILL FREQUENCY

Type	Frequency
PPH simulation	Monthly at minimum
MTP activation drill	Quarterly
Full team drill with debrief	Quarterly

QUICK REFERENCE CARDS

📋 PPH QUICK CARD (PRIMARY CARE)

🚨 PPH RECOGNISED – START CLOCK

□ CALL FOR HELP + ACTIVATE REFERRAL

□ A – Airway, Breathing, Oxygen (8-10 L/min)

□ C – 2 large-bore IV (16-18G)

Crystalloid 1-2 L rapid bolus

Bloods: Group, X-match, CBC, Coag

□ M – MASSAGE uterus (bimanual)

□ O – OXYTOCIN 10 IU IM + infusion 20-40 IU in 500 mL NS

MISOPROSTOL 800 mcg SL (if oxytocin inadequate)

□ T – TRANEXAMIC ACID 1 g IV over 10 min (within 3h)

□ I – Identify cause (Tone / Trauma / Tissue / Thrombin)

Empty bladder (catheterize)

Examine placenta, genital tract

□ V – Vital signs q5-15 min; Shock Index

□ E – Escalate / Transfer if:

- Bleeding continues despite above

- Shock Index ≥1.0

- Needs transfusion or surgery

□ NASG if available during transfer

□ Continue massage, uterotonics, IV during transport

RECEIVING FACILITY: _______________

CONTACT: _______________

ETA: _______________

📋 PPH QUICK CARD (SECONDARY/TERTIARY)

🚨 SEVERE PPH / REFRACTORY TO FIRST-LINE

TIME: _____ TEAM LEADER: _____

□ CONFIRM adequate resuscitation:

- 2 large IV, rapid crystalloid 1-2L

- Tranexamic acid 1g given

- Oxytocin loading + infusion running

- Misoprostol given

- Uterine massage ongoing

□ ADD second-line uterotonics:

- Methylergometrine 0.2 mg IM (if no HTN)

- Carboprost 250 mcg IM q15min (if no asthma)

□ IDENTIFY CAUSE:

- Atony → continue massage, bimanual compression

- Trauma → EUA, repair

- Tissue → MVA/curettage under anaesthesia

- Thrombin → blood products (FFP, cryo, platelets)

□ ACTIVATE MTP if Shock Index ≥1.4 or massive ongoing loss

- PRBC : FFP : Platelets = 1:1:1

- Target Hb >8, Plt >50k, Fib >2, Ca++, correct acidosis

□ UTERINE BALLOON TAMPONADE:

- Bakri or condom catheter

- Inflate 250-500 mL NS

- If bleeding stops → leave 12-24h

- If bleeding continues → OT

□ LAPAROTOMY if UBT fails or cause surgical:

- Compression sutures (B-Lynch, Hayman)

- Uterine artery ligation

- Internal iliac ligation

- HYSTERECTOMY (don't delay if life-saving)

□ POST-RESUSCITATION:

- ICU/HDU transfer

- Continue uterotonics 4h

- Serial labs

- Debrief patient and team

TOTAL BLOOD LOSS: _____ mL

PRODUCTS GIVEN: _____

PROCEDURES: _____

📚 REFERENCES FOR PPH PROTOCOL
INTERNATIONAL GUIDELINES (Primary Evidence Base)

Reference Year Key Content Used

1 WHO recommendations for the prevention and treatment of postpartum haemorrhage 2012, Updated 2023 Uterotonics, TXA, UBT, AMTSL, overall management algorithm
2 WHO recommendations on tranexamic acid for the treatment of postpartum haemorrhage 2017 TXA dosing, timing (within 3 hours)
3 FIGO recommendations on the prevention and treatment of postpartum hemorrhage 2022 Stepwise approach, second-line uterotonics, surgical interventions
4 RCOG Green-top Guideline No. 52: Prevention and Management of Postpartum Haemorrhage 2016 (under review) Risk stratification, mechanical interventions, surgical techniques
5 ACOG Practice Bulletin No. 183: Postpartum Hemorrhage 2017, Reaffirmed 2019 Quantitative blood loss, massive transfusion
6 International Society of Blood Transfusion (ISBT) – Massive Transfusion Guidelines 2020 MTP ratios, targets
KEY TRIALS

Trial/Study Journal/Year Key Finding Used

7 WOMAN Trial (World Maternal Antifibrinolytic Trial) Lancet 2017 TXA reduces death from bleeding by ~20-30% if given within 3 hours
8 WOMAN-2 Trial Lancet Global Health 2023 TXA in anaemic women (ongoing/results)
9 WHO Multicountry Survey on Maternal and Newborn Health BJOG 2014 PPH epidemiology, risk factors
10 Cochrane Review: Uterotonic agents for preventing PPH Cochrane 2018, Updated 2020 Comparative effectiveness of uterotonics
11 Cochrane Review: Uterine balloon tamponade for PPH Cochrane 2020 Evidence for UBT effectiveness
12 ESA-ESICM Guidelines on Massive Hemorrhage Eur J Anaesthesiol 2023 Coagulopathy management, transfusion targets
INDIAN GUIDELINES & GOVERNMENT DOCUMENTS

Reference Issuing Body Year Key Content

13 FOGSI GCPR on Prevention and Management of PPH Federation of Obstetric & Gynaecological Societies of India 2016, Updated 2021 India-specific recommendations, drug availability
14 LaQshya – Labour Room Quality Improvement Initiative Guidelines Ministry of Health & Family Welfare, Government of India 2017 Labour room protocols, emergency management
15 Skilled Birth Attendant (SBA) Training Module Government of India 2010, Revised AMTSL, initial PPH management at primary level
16 Guidelines for BEmONC (Basic Emergency Obstetric and Newborn Care) Government of India 2010 Primary care level management
17 Guidelines for CEmONC (Comprehensive Emergency Obstetric and Newborn Care) Government of India 2010 Referral level management, surgical interventions
18 Maternal and Newborn Health Toolkit Ministry of Health & Family Welfare 2013 Operational guidelines for facilities
19 FOGSI Position Paper on Use of Tranexamic Acid in PPH FOGSI 2018 TXA adoption in India
20 National Guidelines for Blood Transfusion Services NACO/NBTC 2020 Blood transfusion protocols for India
21 Maternal Death Surveillance and Response (MDSR) Guidelines Government of India 2017 Reporting, review of maternal deaths
22 ICMR-FOGSI Guidelines on Iron Deficiency Anaemia in Pregnancy ICMR/FOGSI 2021 Anaemia management context
TEXTBOOKS & ADDITIONAL RESOURCES

Reference Details

23 Williams Obstetrics 26th Edition (2022) Chapter on Obstetric Hemorrhage
24 Arias’ Practical Guide to High-Risk Pregnancy and Delivery 4th Edition PPH management
25 DC Dutta’s Textbook of Obstetrics 9th Edition (2018) Commonly used Indian textbook
26 Management of Labour – FOGSI Focus Series Practical guidance
27 B-Lynch Suture Technique – Original description B-Lynch et al., BJOG 1997
ONLINE RESOURCES

Obstetrics

Emergency Protocols

Obstetric emergencies