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Postpartum haemorrhage
Postpartum haemorrhage usually comes from a uterus that has not contracted; the cause is sought with the four Ts and treated in steps — massage and drugs, then mechanical measures, and finally surgery — while resuscitating with blood products.
Why it matters in the exam
Postpartum haemorrhage is a leading cause of maternal death worldwide. Questions show a woman who has just delivered, a soft enlarged uterus and bleeding that will not stop, and ask for the next step. Remember the order: uterine massage and oxytocin, and if there is no response, another uterotonic chosen according to the woman's contraindications. A favourite question is which drug is forbidden: methylergonovine in hypertension or preeclampsia, and carboprost in asthma.
Other questions test the definition (1000 mL or signs of hypovolaemia in the first 24 hours), the difference between primary and secondary haemorrhage (from 24 hours up to 12 weeks), the role of tranexamic acid within 3 hours of birth, and the conditions that mimic atony: a genital tract tear when the uterus is firm, retained placenta, uterine inversion and DIC. A late complication that is often asked is Sheehan syndrome — failure of lactation and amenorrhoea after a massive bleed.
Key points
- Postpartum haemorrhage = 1000 mL or more, or signs of hypovolaemia.
- The four Ts: Tone, Trauma, Tissue, Thrombin; atony is about 70%.
- Steps: massage and oxytocin → further uterotonics → balloon → surgery.
- Tranexamic acid 1 g IV within 3 hours.
- Sheehan: failure of lactation and amenorrhoea after a massive bleed.
Summary table
| Cause (T) | Frequency and signs | Deciding check | Treatment |
|---|---|---|---|
| Tone — atony | About 70%; soft, large uterus above the umbilicus | Palpate the uterus | Massage, oxytocin, methylergonovine, carboprost, misoprostol |
| Trauma — tear | Well-contracted uterus yet still bleeding | Inspect cervix, vagina and perineum; suspect uterine rupture or haematoma | Repair; drain the haematoma; uterine inversion — immediate manual replacement |
| Tissue — retained | Incomplete placenta or placenta not delivered | Inspect the placenta and ultrasound | Manual removal or curettage; suspect placenta accreta |
| Thrombin — coagulation | Bleeding from everywhere, blood that does not clot | Fibrinogen, platelets, PT and aPTT | Balanced blood products; fibrinogen below 2 g/L predicts severe bleeding |
| Definition | 1000 mL or more, or signs of hypovolaemia | Primary up to 24 hours; secondary from 24 hours to 12 weeks | Prevention: oxytocin 10 units IM or IV after delivery of the shoulder |
A free exam question
A woman is hypotensive 30 minutes after delivery. Examination reveals increase vaginal bleeding. Which of the following is the most likely cause of this condition?
- A. Uterine atony
- B. Vaginal tears
- C. Retained uterine placenta
- D. Coagulation disorder
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Sources
- ACOG Practice Bulletin No. 183, 2017 — Postpartum Hemorrhage
- WHO recommendations on the assessment of postpartum haemorrhage and the use of tranexamic acid, 2017 — Tranexamic acid for the treatment of postpartum haemorrhage
- RCOG Green-top Guideline No. 52, 2016 — Prevention and Management of Postpartum Haemorrhage
- Williams Obstetrics, 26th edition (2022) — Obstetrical Hemorrhage
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.