Obstetric Hemorrhage — PPH

The four Ts: early uterotonics, massage, and surgical escalation without hesitation.

Killers — rule out first

Uterine atony (Tone)
Behind 70% of cases — massage + oxytocin immediately.
Retained products (Tissue)
Inspect the placenta — a uterus will not contract on retained tissue.
Genital tract trauma (Trauma)
A contracted uterus with ongoing bleeding = hunt for a tear.
Coagulopathy (Thrombin)
Abruption, sepsis, or consumptive massive bleeding.

Call for help and activate the hemorrhage protocolAction
Obstetrics + anesthesia + blood bank simultaneously.
Fundal massageAction
Reassess tone continuously — the simplest, fastest intervention.
Oxytocin then additional uterotonicsDrug
Oxytocin 10 IU IM/infusion; add ergometrine or misoprostol per protocol.
Tranexamic acid 1 g IVDrug
Within 3 hours of onset — repeat after 30 minutes if bleeding continues.
Two lines + early blood + warmthAction
Inspect placenta and tract in parallel; escalate to balloon tamponade then surgery.

A mother compensates through major loss then collapses suddenly — treat the trend, not the number.

A calibrated drape prevents underestimating loss.

Massage during transport, oxytocin when available, and a delivery-room pre-alert.

Condition	Clues	Urgency
Atony	A soft, high uterus.	Immediate
Tear / hematoma	Contracted uterus with ongoing bleed or severe pain.	Immediate
Retained products	Incomplete placenta on inspection.	Urgent
Coagulopathy	Oozing puncture sites, no clots.	Immediate

Drug	Dose	Route	Notes
Oxytocin⚠ Critical	10 IU IM then infusion	IM/IV	Always first line
Misoprostol	800 mcg sublingual	Sublingual	Where cold-chain injectables are unavailable
Tranexamic acid⚠ Critical	1 g IV over 10 min	IV	Within 3 h; repeat once

Subject to clinical review and local protocol.

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This content is an educational reference and does not replace clinical judgement or local protocols.