Primary postpartum haemorrhage — 4 Ts, uterotonics and tranexamic acid

Definition: Primary PPH is blood loss ≥500 mL within 24 h of birth (vaginal) or ≥1000 mL after caesarean; major/severe often framed as ≥1000 mL or any loss with shock. Secondary PPH is from 24 h to 6 weeks (usually infection/retained tissue).^[1][4]

Most likely cause — Tone (uterine atony, ~70%). Soft boggy uterus is pathognomonic. Apply the 4 Ts:

• Tone — atony (multiparity, prolonged labour, twins, polyhydramnios, chorioamnionitis, fibroids, tocolytics)
• Trauma — tears, extensions, rupture, inversion
• Tissue — retained placenta/clots
• Thrombin — coagulopathy (abruption, AFE, DIC, anticoagulation)

Immediate resuscitation (parallel, not sequential):

1. Call for help — obstetric emergency team, anaesthesia, blood bank, midwifery.
2. ABC, high-flow O₂, two large-bore IV cannulae, left lateral if still pregnant (not applicable postpartum), keep warm.
3. Bloods: FBC, coagulation, fibrinogen, U&E, ABG/lactate; crossmatch 4–6 units; activate major obstetric haemorrhage protocol.
4. IV crystalloid while blood arrives; early blood products aiming 1:1:1 RBC:FFP:platelets in massive haemorrhage; correct hypocalcaemia; target fibrinogen (often cryoprecipitate/fibrinogen concentrate if low).
5. Rub up a contraction — bimanual uterine compression; empty bladder (catheter); examine placenta and lower genital tract simultaneously.

Drug ladder (uterotonics) + TXA:

1. Oxytocin — 5 IU slow IV (or 10 IU IM) then infusion (e.g. 40 IU in 500 mL over 4 h) — first-line; avoid undiluted rapid boluses (hypotension).^[1]
2. Ergometrine 500 micrograms IM (or 250–500 micrograms) — contraindicated in hypertension/pre-eclampsia/cardiac disease.
3. Carboprost (15-methyl PGF2α) 250 micrograms IM every 15 min, max 8 doses — contraindicated in asthma.
4. Misoprostol 800 micrograms sublingual (or PR) — useful if no IV access / no cold chain; side effects pyrexia/shivering.
5. Tranexamic acid 1 g IV over 10 min as soon as possible, ideally within 3 h of birth; second 1 g if bleeding continues after 30 min or restarts within 24 h — WOMAN trial: reduces death due to bleeding.^[2]

If medical therapy fails — mechanical then surgical ladder:

• Intrauterine balloon tamponade (e.g. Bakri)
• Brace/compression sutures (B-Lynch)
• Stepwise devascularisation (uterine, tubo-ovarian, internal iliac artery ligation) / interventional radiology embolisation if available and stable enough for transfer
• Hysterectomy as life-saving last resort (do not delay too long)
• Always recheck trauma and retained tissue; correct coagulopathy (Thrombin)

Prevention note: active management of third stage (oxytocin at delivery) reduces PPH; E-MOTIVE bundle improves early detection/treatment in vaginal births.^[3]