Here are some very-quick and easy-to-read pearls to remember for the dangerous immediate postpartum complication of postpartum hemorrhage.


Most common causes

  • Uterine atony (by far)
  • Trauma (i.e. lacerations, surgical incisions, uterine rupture)
  • Coagulopathy (persistent heavy bleeding can lead to consumption of clotting factors)


  1. Uterine massage. Tamponade bleeding from uterine cavity.
  2. Two large-bore IV lines. Make airway preparations. Make blood bank preparations. Alert appropriate consultants.
  3. Start fluid resuscitation (SBP >90)
    1. Blood products transfusion if hemodynamics do not improve with 2-3 L isotonic crystalloid
  4. Uterotonic drugs
    1. Oxytocin – 40 U in 1 L NS, then 40 mU/min (expect rapid response); or 10 U IM (response within 3-5 min)
    2. Other supplemental agents: Methylergonovine/Ergonovine, Carboprost
  5. Repair any vaginal or cervical lacerations. Evacuate retained POC. Replace uterus if inverted.
  6. Arrange for transarterial embolization if patient stable and IR available
  7. Arrange for laparotomy (can ligate bleeding sites, ligate uterine artery, or perform hysterectomy if needed)

Additional pearls

  • Bleeding may not be visible. Boggy and dilated uterus may contain significant amount of blood.
  • Young patients may not show altered hemodynamics at the outset.
  • HCT/HGB drop may be delayed and not representative of blood loss.
  • Most significant risk factors: retained placenta/membranes, failure to progress during the 2nd stage of labor (Sheiner E, et al. Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study. J Matern Fetal Neonatal Med. 2005;18(3):149)

Also check out Megha and Brendan’s EMdocs post on Postpartum Emergencies: