Uterine Balloon (UBT) • NASG Garment • Surgery. If Shock Index persists > 1.1 → ACTIVATE MTP.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
Definition & Recognition
Cumulative blood loss ≥1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process (includes intrapartum loss) regardless of route of delivery.
When to Activate Protocol
Cumulative blood loss >500 mL in vaginal delivery or >1000 mL in Cesarean (Stage 1).
Vital sign instability (HR >110, BP <85/45, O2 sat <95%).
Visible brisk bleeding or boggy uterus unresponsive to initial massage.
Patient symptomatic of hypovolemia (lightheadedness, tachycardia, pallor).
Quantified Blood Loss (QBL) is superior to visual estimation (EBL), which typically underestimates loss by 30-50%.
Empty the bladder early; a full bladder displaces the uterus and inhibits effective contraction.
Bimanual massage must be maintained continuously while medications are being prepared.
TXA should be administered early in Stage 2 (within 3 hours of birth) as per the WOMAN trial data.
Critical Contraindications
Methergine is absolutely contraindicated in hypertensive disorders (Preeclampsia, Chronic HTN). Hemabate (Carboprost) is contraindicated in patients with reactive airway disease/asthma.
Section 4
Next Steps
Stage 1: Recognition & Initial Management
01
Quantify blood loss and increase IV fluids.
02
Fundal massage and verify bladder is empty.
03
Administer Oxytocin; consider Methergine if no HTN.
04
Type and Screen 2 units RBCs.
Stage 2: Refractory PPH (Blood Loss <1500 mL)
01
Mobilize PPH team (OB, Anesthesia, Nursing).
02
Administer 2nd/3rd line uterotonics (Hemabate, Misoprostol, TXA).
03
Escalate to bedside ultrasound to rule out retained products.
04
Prepare for intrauterine balloon tamponade (e.g., Bakri).
Stage 3: Massive Hemorrhage (>1500 mL or Instability)
01
Activate Massive Transfusion Protocol (MTP).
02
Move to Operating Room for surgical intervention.
03
Surgical options: B-Lynch suture, uterine artery ligation, or Hysterectomy.
Section 5
Evidence Appraisal
Core Guidelines
Practice Bulletin No. 183: Postpartum Hemorrhage.
ACOG • Obstetrics & Gynecology. 2017;Reaffirmed 2021. Provides the gold-standard algorithm for medical and surgical management in the US.
The WOMAN Trial
Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage.
WOMAN Trial Collaborators • The Lancet. 2017;Demonstrated that TXA reduced death due to bleeding by 31% if given within 3 hours of birth.
AWHONN Safety Bundle
The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) emphasizes that standardized unit protocols and drills significantly reduce maternal morbidity.
Section 6
Literature
Development of Modern Protocols
Postpartum hemorrhage remains the leading cause of maternal mortality worldwide. Modern "Stage-Based" protocols were developed to replace the chaotic "reflexive" management of the past with a structured, multidisciplinary approach similar to ACLS.
The CMQCC Influence
The California Maternal Quality Care Collaborative (CMQCC) was instrumental in developing the toolkits that pioneered the use of QBL (Quantified Blood Loss) and standardized PPH carts, which are now global standards.
