Postpartum Haemorrhage (PPH): The 4 Ts and Emergency Management

Postpartum haemorrhage (PPH) is excessive bleeding after childbirth. It is the leading cause of maternal death worldwide, and an important cause in Pakistan. Most deaths are preventable with good care in the third stage of labour, rapid recognition and a well-practised team response.

Definitions

• Primary PPH: blood loss of 500 mL or more within 24 hours of birth (WHO).
• Severity (RCOG):
  • minor PPH: 500–1000 mL
  • major PPH: more than 1000 mL
• Secondary PPH: abnormal bleeding from 24 hours to 12 weeks after birth, often due to infection or retained tissue.

Visual estimates often underestimate blood loss. Measuring it (for example with a calibrated drape) and watching vital signs is better. Anaemic women tolerate blood loss poorly.

Causes: the "4 Ts"

• Tone — uterine atony, the most common cause.
• Trauma — tears of the perineum, vagina or cervix, uterine rupture, haematoma.
• Tissue — retained placenta or membranes, or abnormally invasive placenta.
• Thrombin — clotting disorders, for example from placental abruption, pre-eclampsia or HELLP syndrome, sepsis, amniotic fluid embolism, or anticoagulants.

Risk factors

• Previous PPH.
• Multiple pregnancy.
• Large baby.
• Polyhydramnios.
• Prolonged or induced labour.
• Instrumental or caesarean birth.
• Placenta praevia or accreta.
• Grand multiparity.
• Anaemia.
• Obesity.
• Chorioamnionitis.

Many women who have a PPH have no risk factors.

Prevention

• Active management of the third stage of labour with a uterotonic for every woman: oxytocin 10 IU IM/IV is first choice (WHO). Alternatives are carbetocin, misoprostol or ergometrine-containing drugs (avoid ergometrine in hypertension and pre-eclampsia).
• Treat anaemia in pregnancy.
• Plan delivery in an appropriate facility for high-risk women.

Management: act early, work as a team

WHO now recommends a first-response bundle, given together as soon as PPH is diagnosed:

• uterine massage
• oxytocic drugs
• tranexamic acid (1 g IV, given within 3 hours of birth)
• IV fluids
• examination of the genital tract
• escalation of care

1. Call for help (midwives, obstetrician, anaesthetist, blood bank). Use an ABC approach.
2. Resuscitate:
   • two large-bore IV cannulas
   • bloods: full blood count, clotting, fibrinogen, cross-match
   • warmed fluids
   • blood products according to the major haemorrhage protocol
3. Treat the cause:
   • Tone: bimanual uterine compression; empty the bladder; uterotonics (oxytocin infusion, ergometrine, carboprost — avoid carboprost in asthma — and misoprostol).
   • Trauma: repair tears.
   • Tissue: remove a retained placenta or tissue in theatre.
   • Thrombin: correct clotting with blood products.
4. If bleeding continues, use refractory measures:
   • intrauterine balloon tamponade
   • surgical options (B-Lynch compression suture, uterine artery ligation)
   • interventional radiology (embolisation)
   • hysterectomy as a life-saving last resort

Exam pearls

• Uterine atony is the most common cause. Rub up a contraction and give oxytocin.
• Tranexamic acid works best given early, within 3 hours of birth.
• Avoid ergometrine in hypertension and carboprost in asthma.

For more, see our Obstetrics & Gynaecology Companion (obstetric emergencies chapter) and Exam Night Notes: Gynae & Obs.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Most common cause of primary PPH:

   1. Trauma
   2. Clotting disorder
   3. Uterine atony
   4. Uterine inversion
   5. Retained tissue
   Show answer

   Answer: C. Uterine atony
   Tone (atony) is the most common of the 4 Ts.

2. WHO first-choice uterotonic for preventing PPH:

   1. Tranexamic acid only
   2. Misoprostol only
   3. Ergometrine
   4. Oxytocin 10 IU IM/IV
   5. Carboprost
   Show answer

   Answer: D. Oxytocin 10 IU IM/IV
   Oxytocin is recommended for every woman in the third stage of labour.

3. Which drug should be avoided in a woman with PPH and asthma?

   1. Oxytocin
   2. IV fluids
   3. Tranexamic acid
   4. Misoprostol
   5. Carboprost
   Show answer

   Answer: E. Carboprost
   Carboprost (PGF2α) can cause bronchospasm.

4. Which drug should be avoided in PPH with severe hypertension or pre-eclampsia?

   1. Tranexamic acid
   2. Ergometrine
   3. Crystalloid
   4. Misoprostol
   5. Oxytocin
   Show answer

   Answer: B. Ergometrine
   Ergometrine causes vasoconstriction and severe hypertension.

5. When should tranexamic acid be given in PPH?

   1. As early as possible, within 3 hours of birth
   2. After 12 hours
   3. Only after hysterectomy
   4. Never
   5. Only before delivery
   Show answer

   Answer: A. As early as possible, within 3 hours of birth
   Benefit is greatest when given early (WOMAN trial); WHO includes it in the first-response bundle.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.