🔴 Postpartum Hemorrhage
The leading cause of maternal death worldwide, and the first action is free: massage the fundus.
🧬 What counts, and why it happens
Blood loss over 500 mL after a vaginal birth, or 1000 mL after a cesarean — or any loss causing signs of hypovolemia.
The uterus stops bleeding by contracting. A uterus that will not contract cannot clamp the vessels where the placenta was.
⭐ The 4 Ts
| Cause | Recognize it by | Fix |
|---|---|---|
| Tone — atony (most common) | Boggy, soft uterus | Massage, then uterotonics |
| Trauma — laceration | FIRM uterus but still bleeding, bright red steady trickle | Surgical repair |
| Tissue — retained placenta | Uterus stays boggy despite treatment | Manual removal, D&C |
| Thrombin — clotting disorder | Oozing everywhere, no clots forming | Blood products |
If the uterus is FIRM and she is still bleeding bright red, think laceration. Massage will not fix that one — and that is a favorite exam question.
Who is at risk
- Overdistended uterus — twins, big baby, polyhydramnios
- Prolonged or very rapid labor; oxytocin augmentation
- Grand multiparity — the muscle is tired
- Retained placental fragments; previous PPH
- Chorioamnionitis; magnesium sulfate (it relaxes smooth muscle)
🩺 What to do, in order
The first action costs nothing and works most of the time.
⭐ The bladder clue
A uterus displaced to the RIGHT and sitting above the umbilicus means a full bladder. A distended bladder physically prevents the uterus from contracting down.
Boggy + deviated right = empty the bladder
Massage first, then bladder. Do not reach for a drug before doing the two things that cost nothing.
| Drug | Note |
|---|---|
| Oxytocin | First line; IV infusion or IM |
| Methylergonovine | Contraindicated in hypertension — it raises blood pressure |
| Carboprost | Contraindicated in asthma — causes bronchospasm |
| Misoprostol | Can be given rectally; useful when others are contraindicated |
Always check the blood pressure before methylergonovine and ask about asthma before carboprost. Both contraindications are heavily tested.
👀 Assessment and lochia
Fundal assessment
- Should be firm, midline, at or just below the umbilicus right after birth
- Descends about 1 cm per day
- Support the lower uterine segment with one hand while massaging with the other — otherwise you risk inverting the uterus
| Lochia | Days | Color | Abnormal if |
|---|---|---|---|
| Rubra | 1–3 | Dark red | Saturating a pad in under an hour; clots larger than a golf ball |
| Serosa | 4–10 | Pinkish-brown | Returns to bright red |
| Alba | 11–21+ | Creamy white | Foul odor = infection |
🚨 Signs she is decompensating
Tachycardia comes first. Blood pressure falls late. A young healthy postpartum woman can compensate for a large loss and then crash suddenly.
- Rising pulse, then falling BP
- Cool clammy skin, pallor
- Restlessness and anxiety — cerebral hypoxia
- Urine output below 30 mL/hr
Do not be reassured by a normal blood pressure in a bleeding postpartum patient. Watch the pulse.
🎯 NCLEX traps
- Massage the fundus first — always
- Firm uterus + bright bleeding = laceration, not atony
- Deviated right + boggy = full bladder
- Methylergonovine + hypertension = no. Carboprost + asthma = no
- Tachycardia is the early sign; hypotension is late