CCS Integrated Cases

CCS case: postpartum hemorrhage in the labor room

Clinical Overview and When to Suspect Postpartum Hemorrhage

— Secondary/late PPH: 24 h–12 weeks postpartum; think retained products, subinvolution, endometritis, von Willebrand disease

— Tone (uterine atony) — ~70–80% of cases, the default initial assumption

— Trauma (lacerations, hematoma, uterine rupture/inversion) — ~20%

— Tissue (retained placenta, accreta spectrum) — ~10%

— Thrombin (coagulopathy: DIC, HELLP, AFE, inherited bleeding disorders) — ~1%

— Prolonged or augmented labor, oxytocin use, chorioamnionitis

— Multiple gestation, polyhydramnios, macrosomia (overdistended uterus)

— Grand multiparity, prior PPH, prior cesarean (accreta risk)

— Preeclampsia/HELLP, IUFD, placental abruption, AFE

— Operative vaginal delivery, precipitous or prolonged second stage

— Quantitative blood loss (QBL) climbing past 500 mL vaginal or 1000 mL cesarean with ongoing bleeding

— Boggy uterus on fundal palpation

— Vital sign drift: HR rising before BP falls (young healthy parturients compensate, then crash)

— Tachycardia + narrowed pulse pressure in a postpartum patient = bleeding until proven otherwise

CCS pearl: Do not wait for hypotension. On the CCS interface, advance the clock only after you have placed two large-bore IVs, sent a type & crossmatch, and started uterine massage — the case clock is your enemy if you under-resuscitate.

Board pearl: PPH remains the #1 cause of maternal mortality worldwide and a leading preventable cause in the US; recognition delay, not unavailability of therapy, kills these patients.

Definition (ACOG 2017 reVITALize): Cumulative blood loss ≥1000 mL OR blood loss with signs/symptoms of hypovolemia within 24 h of birth, regardless of route of delivery

Primary PPH: <24 h postpartum (vast majority of cases on the CCS)

The "4 T's" mnemonic — memorize the order by frequency:

High-yield risk factors to flag in the stem:

When to suspect on a CCS labor-room case:

Presentation Patterns and Key History

— Antepartum: prior PPH, known placenta previa/accreta, anticoagulant use (enoxaparin for VTE prophylaxis), inherited bleeding disorder, Jehovah's Witness status

— Intrapartum: induction agents, labor duration, oxytocin dose/duration, magnesium for preeclampsia (relaxes uterus!), chorioamnionitis, instrumented delivery, episiotomy, shoulder dystocia

— Delivery details: placenta delivered intact? cord traction excessive? fundal pressure used?

— Estimated/quantitative blood loss to this point

— Atony pattern: boggy soft uterus, brisk continuous flow, risk factors of overdistension or prolonged labor

— Trauma pattern: firm well-contracted fundus but ongoing bright red bleeding → inspect cervix/vagina; consider concealed hematoma if rising pain, perineal bulge, tachycardia without external blood

— Tissue pattern: placenta delivered in fragments, succenturiate lobe noted, or placenta still undelivered at 30 minutes

— Thrombin pattern: oozing from IV sites, gums, surgical wound; preceding HELLP, abruption, severe preeclampsia, sepsis, or amniotic fluid embolism

— "Sudden cardiovascular collapse with hypoxia and coagulopathy" → amniotic fluid embolism

— "Painful tearing sensation, loss of station, fetal bradycardia before delivery" → uterine rupture

— "Fundus not palpable, mass in vagina" → uterine inversion (treat with immediate manual replacement; do not remove placenta first if still attached)

Key distinction: Atony bleeds from a soft uterus; trauma bleeds from a firm uterus. This single feature drives the first divergence in your CCS algorithm.

Classic labor-room vignette: G3P3 just delivered a 4200 g infant after a 22-hour induction with oxytocin; nurse reports "the pad is soaking through" and fundus is "soft and above the umbilicus"

Targeted history (ask or review chart in parallel with resuscitation — do not delay treatment):

Pattern recognition by the 4 T's:

Red-flag descriptors on Step 3 stems:

Physical Exam Findings and Hemodynamic Assessment

— Airway/Breathing: RR, SpO2 — sudden hypoxia + collapse = think AFE

— Circulation: HR, BP, capillary refill, mental status, urine output via Foley

— Quantitative blood loss (QBL): weigh pads/drapes (1 g = 1 mL); visual estimation underestimates by 30–50%

— Bimanual fundal palpation: boggy and above umbilicus → atony (start massage immediately while ordering uterotonics)

— Speculum inspection of cervix and vagina: look for lacerations (4th-degree, cervical, sulcus tears); use ring forceps and adequate retraction/light

— Inspect placenta: missing cotyledons, torn membranes, succenturiate lobe → retained products

— Vulvar/perineal/vaginal palpation: tense bluish mass = vulvovaginal hematoma; rectal exam for retroperitoneal/ischiorectal extension

— If fundus not palpable abdominally + vaginal mass: uterine inversion

— Shock index ≥0.9 → activate massive transfusion thinking

— Healthy parturients maintain BP until ~25–30% blood volume lost, then crash precipitously

— Pregnancy plasma volume is expanded ~40%; tachycardia is the first reliable sign

— Stage 1 (500–1000 mL vaginal or signs of instability): IV access ×2, fundal massage, uterotonics, QBL, type & screen confirmed

— Stage 2 (continued bleeding, total 1000–1500 mL): second-line uterotonics, mobilize OR, transfuse 2 units PRBC, call anesthesia and additional OB

— Stage 3 (>1500 mL, >2 U PRBC, unstable vitals, suspected DIC): massive transfusion protocol, escalate to surgical/IR management

— Stage 4: cardiovascular collapse → code obstetrics, hysterectomy on the table

CCS pearl: Order "vital signs q5min" and "urine output q1h via Foley" early — the CCS clock won't show deterioration unless you've ordered the monitoring to detect it.

Primary survey (simultaneous with resuscitation):

Obstetric exam — the focused sequence:

Hemodynamic staging (obstetric shock index = HR/SBP):

Stage-based response (CMQCC/ACOG):

Diagnostic Workup — Initial Labs and Bedside Studies

— CBC with platelets — baseline Hgb often unhelpful acutely (lags blood loss) but trend is critical

— Type and crossmatch for ≥2 units PRBC (upgrade to 4 units if Stage 2)

— PT/INR, aPTT, fibrinogen — fibrinogen <200 mg/dL in a postpartum patient is abnormal (normal pregnancy fibrinogen is 400–600); <200 predicts severe PPH

— Basic metabolic panel — baseline creatinine, K+, bicarbonate (lactic acidosis from hypoperfusion)

— Lactate if available

— DIC panel if oozing or thrombin pattern: fibrinogen, D-dimer, peripheral smear for schistocytes

— ABG if hemodynamically unstable or hypoxic

— Repeat QBL every 15 minutes

— Repeat vitals q5–15 min during active resuscitation

— Bedside ultrasound (FAST-like) for retained products in uterus, free fluid suggesting concealed hemorrhage or uterine rupture

— Coagulation studies take 30–45 min; don't withhold blood products waiting for them — clinical picture + MTP activation drives transfusion

— A normal initial Hgb does not exclude significant blood loss

— Continuous pulse oximetry, telemetry, q5min NIBP

— Foley catheter with hourly urine output (target ≥30 mL/h, ideally ≥0.5 mL/kg/h)

— Reassess fundal tone q15min

— Repeat CBC, fibrinogen, coags q30–60 min during active hemorrhage

Step 3 management: Fibrinogen is the single most predictive lab in PPH — drop to <200 mg/dL warrants cryoprecipitate or fibrinogen concentrate. Order it early and trend it; this is the lab the question stem hides as the "key data point."

Board pearl: A "normal" fibrinogen of 250 in a postpartum patient is actually low — interpret against pregnancy-adjusted ranges.

Immediate labs (order at the moment PPH is recognized — do not wait for second uterotonic):

Point-of-care tools (CCS interface analog — bedside reassessment):

What's NOT helpful early:

Monitoring orders to place on the CCS chart:

Diagnostic Workup — Advanced and Source-Localization Studies

— Retained products of conception: echogenic intracavitary mass, increased vascularity on color Doppler

— Hematoma: broad-ligament or retroperitoneal collection

— Uterine rupture: loss of uterine wall continuity, free intraperitoneal fluid (especially in TOLAC)

— Persistent bleeding despite two uterotonics

— Suspected high cervical or vaginal sulcus laceration not visualized at bedside

— Need for manual exploration of uterine cavity for retained tissue

— Suspected uterine inversion or rupture

— Ring forceps "walk" around cervix at 12 o'clock positions to inspect entire circumference

— Sweep vaginal sidewalls and fornices for sulcus tears

— Manual uterine cavity exploration with gauze sponge to detect retained tissue and assess wall integrity

— CT angiography of the abdomen/pelvis: localize active extravasation when patient is stable enough — guides interventional radiology embolization

— MRI: not acute; useful later for accreta evaluation in subsequent pregnancy

— Thromboelastography (TEG) or ROTEM when available — real-time guidance on fibrinogen, platelet, and clot strength deficits; increasingly standard in obstetric MTP

— Repeat fibrinogen is the highest-yield serial lab

— Vulvar/vaginal/retroperitoneal hematoma can hide 1–2 L; rising pain + tachycardia + falling Hgb with minimal external bleeding is the classic stem

— Broad-ligament hematoma after cesarean → CT or surgical re-exploration

CCS pearl: If bleeding continues after second-line uterotonics, "Move patient to Operating Room" is the correct CCS action — do not keep ordering more medications from the labor room. Location change unlocks the procedural management arm of the case.

Key distinction: Soft boggy uterus = think medical (uterotonics). Firm uterus with ongoing bleeding = think mechanical (laceration, retained tissue, hematoma) → EUA.

Bedside obstetric ultrasound (after initial uterotonics if bleeding persists):

Examination under anesthesia (EUA) in the OR — when to mobilize:

Cervical and vaginal inspection sequence (EUA):

Imaging beyond bedside:

Coagulation-focused testing:

Considerations specific to concealed bleeding:

Risk Stratification and First-Line Management Logic

— Stage 0: every birth — risk assessment, active management of third stage (oxytocin prophylaxis)

— Stage 1: cumulative loss 500–1000 mL or VS changes

— Stage 2: 1000–1500 mL or ≥2 uterotonics needed

— Stage 3: >1500 mL, >2 U PRBC, or unstable vitals/DIC

— Stage 4: cardiovascular collapse

— Call for help: second OB, anesthesia, charge nurse, blood bank notification

— Two large-bore IVs (16- or 18-gauge); if one already in place, place a second

— Begin fundal/bimanual uterine massage

— Empty bladder (Foley catheter) — full bladder impairs contraction

— IV fluids: warmed crystalloid (lactated Ringer's) bolus 1–2 L; avoid over-resuscitation with crystalloid alone (dilutional coagulopathy)

— First-line uterotonic: oxytocin 10–40 units in 500–1000 mL NS or LR, infused continuously; can give 10 U IM if no IV access

— Send labs (CBC, coags, fibrinogen, T&C)

— Quantify blood loss; place pad/drape weights

— Uterus firms up, bleeding slows → continue oxytocin infusion, monitor, transition to PP recovery with frequent reassessment

— Bleeding persists despite massage + oxytocin → assume insufficient atony control; add second-line uterotonic AND inspect for trauma/retained tissue in parallel

— Ongoing bleeding with estimated loss >1500 mL → start PRBC

— Hemodynamic instability not responding to 2 L crystalloid → start PRBC

— Activate MTP at Stage 3 (1:1:1 PRBC:FFP:platelets ratio)

Step 3 management: The single most common board error is escalating uterotonics without inspecting the cervix/vagina. If oxytocin + methylergonovine fail to firm the uterus or bleeding continues with a firm uterus, inspect the lower genital tract immediately — don't keep stacking drugs.

CCS pearl: Order "uterine massage" as a procedure on the CCS — it is recognized and credited.

Activate the OB hemorrhage bundle (ACOG/AIM/CMQCC framework) — this is the framework graders expect:

Simultaneous first-line actions (within the first 5 minutes — order all in parallel on CCS):

Decision branch after 5–10 minutes:

Transfusion triggers (don't wait for crashing Hgb):

Pharmacotherapy — Uterotonic Regimen and Adjuncts

— IV: 10–40 units in 500–1000 mL NS or LR, run wide open then titrate

— IM: 10 units if no IV access

— Avoid undiluted IV push (hypotension)

— Adverse: hypotension, hyponatremia with prolonged high-dose infusions (antidiuretic effect)

— 0.2 mg IM q2–4h (NEVER IV — severe hypertension)

— Contraindicated in hypertension, preeclampsia, Raynaud's, CAD

— Mechanism: ergot alkaloid → sustained uterine contraction

— 0.25 mg IM q15–90 min, max 8 doses (2 mg total)

— Contraindicated in asthma (bronchospasm); use cautiously in HTN, hepatic/renal/cardiac disease

— Adverse: diarrhea (pre-treat with antidiarrheal), fever, bronchospasm

— 800–1000 mcg rectally or 600–800 mcg sublingual/buccal

— Useful when IV access poor or other agents contraindicated; slower onset

— Adverse: fever, shivering, diarrhea

— 1 g IV over 10 min, repeat 1 g if bleeding continues after 30 min or recurs within 24 h

— WOMAN trial: reduces death from bleeding if given within 3 hours of onset

— Give as soon as PPH diagnosed, not as a last resort

— PRBC, FFP, platelets in 1:1:1 ratio per MTP

— Cryoprecipitate or fibrinogen concentrate if fibrinogen <200 mg/dL

— Calcium gluconate 1–2 g IV after every 4 units of citrated products (citrate chelates Ca2+ → cardiac dysfunction, worsens coagulopathy)

— Excessive crystalloid (>2 L) → dilutional coagulopathy, hypothermia, acidosis (the lethal triad)

Board pearl: Match contraindication to drug — asthma rules out carboprost; HTN/preeclampsia rules out methylergonovine. This is a near-guaranteed Step 3 question.

CCS pearl: Order TXA in the first wave of orders, not after multiple uterotonics fail.

First-line: Oxytocin (Pitocin)

Second-line: Methylergonovine (Methergine)

Third-line: Carboprost (Hemabate, 15-methyl PGF2α)

Fourth-line: Misoprostol (Cytotec, PGE1)

Tranexamic acid (TXA) — give early:

Blood products (Stage 2–3):

Avoid/limit:

Procedural and Surgical Management — Escalation Ladder

— Manual uterine exploration and removal of retained products under anesthesia

— Repair of cervical/vaginal/perineal lacerations with absorbable suture; ensure adequate exposure, lighting, and assistance

— Manual replacement of uterine inversion: push fundus through cervix with palm; halt uterotonics during replacement, then resume after restoration

— Intrauterine balloon tamponade (Bakri or Ebb balloon): inflate with 300–500 mL saline; leave 12–24 h

— Alternative: uterine packing with gauze if balloon unavailable

— Place broad-spectrum antibiotic prophylaxis (cefazolin 2 g IV)

— Uterine vacuum-induced hemorrhage control device (Jada System): newer FDA-cleared device, low-level suction collapses uterine cavity

— Uterine artery embolization — option for the hemodynamically stable patient with ongoing bleeding, preserves fertility

— Requires functioning IR suite and stable enough patient for transport

— Uterine compression sutures (B-Lynch, Hayman, Cho) — for atony at cesarean

— Bilateral uterine artery ligation (O'Leary) — stepwise devascularization

— Bilateral internal iliac (hypogastric) artery ligation — technically demanding; preserves fertility

— Hysterectomy — definitive; performed when fertility-preserving measures fail or in life-threatening hemorrhage (placenta accreta spectrum, uterine rupture)

— Medical (uterotonics + TXA) → Mechanical (balloon, compression sutures) → Vascular (UAE or surgical ligation) → Hysterectomy

— Suspected antenatally → planned cesarean hysterectomy at 34–35 6/7 weeks at a center of excellence with multidisciplinary team

Step 3 management: Do not delay hysterectomy in a coagulopathic, hemodynamically unstable patient hoping uterotonics will work — definitive surgery saves lives. Fertility preservation is secondary to maternal survival.

CCS pearl: "Consult OB anesthesia" and "Consult interventional radiology" are recognized CCS actions — order both early at Stage 2.

Bedside/labor-room procedures (after medical therapy fails):

Uterine tamponade — first-line mechanical adjunct for atony refractory to drugs:

Interventional radiology:

Surgical management (laparotomy):

Logical escalation ladder on the CCS:

Accreta spectrum special note:

Special Populations — Renal, Hepatic, and Cardiac Impairment

— Often already on magnesium → contributes to uterine atony (Mg relaxes smooth muscle)

— Methylergonovine contraindicated (hypertensive crisis risk)

— Thrombocytopenia of HELLP may require platelet transfusion before procedures (typically if <50K for delivery, <20K spontaneously)

— Hepatic dysfunction worsens coagulopathy; replace fibrinogen aggressively

— Carboprost contraindicated in significant cardiac disease (pulmonary HTN risk)

— Volume resuscitation must be cautious — invasive monitoring (arterial line, central access) often needed

— Transfuse to maintain perfusion without precipitating pulmonary edema; balance carefully

— Rare in obstetric population but consider in preeclampsia with AKI

— Avoid nephrotoxic agents during recovery (NSAIDs for pain → use cautiously if Cr elevated)

— Profound coagulopathy from synthetic dysfunction

— Aggressive FFP and cryoprecipitate replacement

— Hypoglycemia is common — check glucose, give D10 infusion

— Document specific blood products refused (whole blood, PRBC, plasma, platelets) and accepted (some accept albumin, cell saver, recombinant factors)

— Optimize iron stores antepartum, consider erythropoietin

— Cell salvage (intraoperative autotransfusion) is often acceptable

— Earlier threshold for surgical/IR intervention since transfusion options limited

— Reverse: protamine for heparin/LMWH (partial for LMWH); 4-factor PCC for warfarin/DOACs as applicable

— Hold further dosing; reassess after hemorrhage controlled

Board pearl: A preeclamptic on magnesium with PPH — give calcium gluconate if you suspect Mg toxicity contributing to atony, and do not give methylergonovine. Choose carboprost or misoprostol instead.

Key distinction: Methergine bad in HTN; Hemabate bad in asthma. Misoprostol is the safe fallback in both.

Preeclampsia/HELLP — overlapping coagulopathy and end-organ injury:

Cardiac disease (congenital heart disease, peripartum cardiomyopathy, valvular):

Renal impairment:

Hepatic impairment / acute fatty liver of pregnancy:

Jehovah's Witness patient:

Anticoagulated patient (VTE prophylaxis or treatment dose):

Special Populations — Obesity, Multiple Gestation, and the Postpartum Cardiomyopathy Mimic

— Higher rates of atony, operative delivery, and difficult IV access — consider early central or intraosseous access

— Drug dosing for uterotonics is not weight-adjusted, but blood volume is larger → may underestimate severity of loss

— Mechanical and surgical interventions technically more difficult; mobilize OR team early

— Overdistended uterus → high atony risk; have second-line uterotonics drawn up at delivery

— Prophylactic high-dose oxytocin infusion postdelivery is standard

— Same mechanism — uterine muscle fatigue and stretch

— Active management of third stage of labor (oxytocin + controlled cord traction + uterine massage) is the universal preventive bundle

— Adolescents: counseling on contraception postpartum and trauma-informed care

— AMA (≥35): higher accreta and atony rates; lower threshold for hemorrhage protocol activation

— New-onset dyspnea, orthopnea, pulmonary edema postpartum — distinguish from volume overload from resuscitation

— Echo if persistent symptoms; EF <45% defines PPCM

— Standard heart failure therapy postpartum (ACE inhibitors are safe during breastfeeding: enalapril, captopril)

— Cocaine/methamphetamine: methylergonovine contraindicated (additive vasoconstriction → HTN crisis, MI)

— Counsel on safer dosing of analgesics; coordinate with addiction medicine

— Use certified interpreter (not family) for informed consent for blood products and hysterectomy — Step 3 vignette favorite

Step 3 management: In twins or higher-order multiples, treat prophylactically — have a second-line uterotonic ready at delivery rather than waiting for atony to declare itself.

Board pearl: Cocaine + postpartum bleeding → never methylergonovine.

Obesity (BMI ≥40):

Multiple gestation:

Polyhydramnios, macrosomia, prolonged induction:

Adolescent and advanced maternal age:

Peripartum cardiomyopathy unmasked by PPH:

Substance use disorders:

Language barriers and cultural considerations:

Complications and Adverse Outcomes

— Hypovolemic shock and end-organ ischemia: AKI, hepatic injury, mesenteric ischemia

— Dilutional/consumptive coagulopathy and DIC: prolonged PT/aPTT, low fibrinogen, elevated D-dimer, schistocytes

— Lethal triad: hypothermia + acidosis + coagulopathy — use warmed fluids, warming blankets, correct acidosis

— Cardiac arrest: PEA from hypovolemia is the typical mechanism; chest compressions with left lateral uterine displacement (for term/recent delivery)

— TRALI (acute lung injury within 6 h), TACO (circulatory overload — common with aggressive resuscitation), hemolytic reactions, hyperkalemia, hypocalcemia (citrate), hypothermia

— Hypotension/shock → ischemic necrosis of the enlarged pituitary

— Presents weeks to years later: failure of lactation (earliest sign), amenorrhea, fatigue, hypothyroid/adrenal insufficiency symptoms

— Diagnose with pituitary hormone panel and MRI; treat with hormone replacement

— Intrauterine adhesions from aggressive curettage for retained products

— Presents later with hypomenorrhea/amenorrhea and infertility

— Diagnose with hysteroscopy

— Massive resuscitation + prolonged bed rest + pregnancy hypercoagulability → very high VTE risk

— Start mechanical prophylaxis (SCDs) immediately; chemical prophylaxis (enoxaparin) once hemostasis is secure (typically 12–24 h after bleeding stops)

— Iron-deficiency anemia — supplement oral or IV iron postdischarge

— Postpartum depression, PTSD — screen at 2- and 6-week visits

— Recurrence risk: ~15% in next pregnancy after PPH

Board pearl: Failure to lactate after a hemorrhagic delivery = Sheehan until proven otherwise. Order prolactin, TSH/free T4, AM cortisol, FSH/LH.

CCS pearl: Order SCDs as soon as patient is hemodynamically stable; transition to LMWH prophylaxis within 24 h if hemostasis is durable.

Acute complications during active hemorrhage:

Transfusion-related complications:

Sheehan syndrome (postpartum pituitary necrosis):

Asherman syndrome:

VTE risk postpartum:

Long-term:

When to Escalate — ICU, Consults, and Inpatient Triage

— Estimated blood loss >1500 mL with ongoing bleeding

— ≥2 units PRBC already given with continued instability

— Hemodynamic instability not responding to initial resuscitation

— Clinical evidence of coagulopathy (oozing from IV sites, surgical wound)

— OB anesthesia — airway, vascular access, hemodynamic management

— Blood bank — confirm MTP activation, type-specific blood

— Interventional radiology — if stable enough for transport and bleeding ongoing

— General/gyn surgery backup — for hysterectomy if needed

— Critical care/MICU — for post-resuscitation ICU bed

— Hematology — for refractory coagulopathy or known bleeding disorder

— Failure of medical management (two uterotonics + TXA) with persistent bleeding

— Suspected high genital tract laceration not visualized at bedside

— Suspected retained products requiring exploration

— Suspected uterine rupture or inversion not reduced at bedside

— Vasopressor requirement

— Intubation/mechanical ventilation

— Massive transfusion received (≥10 U PRBC in 24 h or ≥4 U in 1 h)

— Ongoing coagulopathy/DIC requiring serial product replacement

— End-organ dysfunction (AKI, hepatic injury, altered mental status)

— Stage 1 controlled → standard postpartum floor with q15min vitals × 1 h, then q30min × 2 h, then q4h

— Stage 2 controlled → step-down or intermediate care, q1h vitals × 4 h

— Stage 3+ → ICU

— If at a Level I/II maternity unit without IR or blood bank capacity, stabilize and transfer to Level III/IV center; do not delay transport waiting for definitive control

Step 3 management: Calling for help is itself an action that scores on the CCS — order "Consult OB anesthesia," "Consult interventional radiology," "Activate massive transfusion protocol" as discrete orders.

CCS pearl: Move the patient to the OR before you "run out of options" in the labor room.

Activate Massive Transfusion Protocol (MTP) when any of:

Consults to order early (Stage 2 — don't wait for Stage 3):

Transfer to OR criteria:

Transfer to ICU criteria:

Disposition pathway on the CCS:

Inter-facility transfer:

Key Differentials — Same-Category (Obstetric) Causes

— Tone (atony): soft, boggy uterus; bleeding diffuse and continuous — responds to massage + uterotonics

— Trauma (lacerations, hematoma): firm uterus, ongoing bright-red bleeding from cervix/vagina/perineum, or rising pain with concealed hematoma — needs surgical repair

— Tissue (retained POC, accreta): firm uterus with bleeding from cavity, placenta delivered incomplete or not at all — needs manual extraction or curettage; accreta needs hysterectomy

— Thrombin (coagulopathy): oozing from IV sites, gums, surgical wound; abnormal labs — replace factors and treat underlying cause

— Risk: prior cesarean (especially classical), prior myomectomy, prostaglandin use in TOLAC

— Presents pre-delivery with sudden fetal bradycardia, abdominal pain, loss of station, maternal tachycardia/hypotension

— Postpartum: persistent bleeding with firm fundus, hemoperitoneum on FAST

— Treatment: emergent laparotomy with repair or hysterectomy

— Risk: excessive cord traction, fundal placentation, accreta, short umbilical cord

— Triad: hemorrhage + shock (often out of proportion to blood loss, vagal) + absent fundus on abdominal palpation with vaginal mass

— Immediate manual replacement (Johnson maneuver); halt uterotonics during replacement, resume after

— If not reducible: tocolytics (terbutaline, nitroglycerin) to relax uterus, then replace

— Sudden hypoxia + cardiovascular collapse + DIC during labor or immediately postpartum

— Clinical diagnosis; supportive care, MTP, often ECMO

— High mortality even with optimal care

— Antepartum or intrapartum onset; rigid tender uterus, fetal distress, coagulopathy

Key distinction: Soft uterus → atony. Firm uterus with external bleeding → trauma/tissue. Firm uterus + shock out of proportion + DIC → think AFE or rupture with hemoperitoneum.

Board pearl: Vagal bradycardia with hypotension after delivery + absent fundus = uterine inversion, not hypovolemic shock alone.

Differentiating the 4 T's at the bedside:

Uterine rupture:

Uterine inversion:

Amniotic fluid embolism (AFE):

Placental abruption with concealed hemorrhage:

Key Differentials — Non-Obstetric Causes of Postpartum Bleeding or Shock

— Von Willebrand disease (most common inherited bleeding disorder): often presents as secondary/late PPH at 7–14 days postpartum as pregnancy-elevated vWF levels normalize

— Hemophilia carriers: factor levels normalize postpartum; bleeding 1–4 weeks after delivery

— Platelet function disorders, ITP

— Workup: vWF antigen and activity, factor VIII, PT/PTT, platelet count, peripheral smear; refer to hematology

— Severe preeclampsia/HELLP, AFE, sepsis, retained dead fetus, massive transfusion–induced dilutional coagulopathy

— Fever, uterine tenderness, foul lochia; risk factors include prolonged ROM, cesarean delivery, retained products

— Can present concurrently with secondary PPH due to subinvolution

— Treat with broad-spectrum IV antibiotics: clindamycin + gentamicin (gold standard) or ampicillin-sulbactam

— Heavy bleeding days to weeks postpartum; ultrasound shows intracavitary material

— Treat with uterotonics + suction curettage; cover with antibiotics

— Late PPH with normal-appearing endometrium on imaging

— Treat with uterotonics; rarely needs procedural intervention

— Sudden dyspnea, chest pain, hypotension postpartum — not bleeding-related but on the differential of postpartum collapse

— High pretest probability + hemodynamic instability → consider empirical anticoagulation if bleeding ruled out, or thrombolysis vs surgical/IR thrombectomy if unstable

— Warm shock with fever, leukocytosis, hypotension — broad antibiotics, fluids, vasopressors

Step 3 management: Late PPH (after 24 h, especially at 7–14 days) with normal coagulation studies on initial screen → workup for von Willebrand disease. This is a classic Step 3 stem.

Key distinction: Primary PPH = atony/trauma/tissue. Secondary PPH = retained products, endometritis, vWD.

Inherited bleeding disorders unmasked by delivery:

Acquired coagulopathies:

Endometritis (postpartum infection):

Retained products presenting late (secondary PPH):

Subinvolution of placental site:

Pulmonary embolism mimicking shock:

Septic shock (chorioamnionitis progressing, endometritis):

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Continue oxytocin infusion 10–20 U/L NS at 125 mL/h for 4–24 h depending on severity

— Serial CBC at 6 and 24 h; fibrinogen if coagulopathy was present

— Continue Foley until ambulating and hemodynamically stable

— Mechanical VTE prophylaxis immediately; pharmacologic prophylaxis within 12–24 h of hemostasis

— Pain control: acetaminophen + NSAIDs (avoid NSAIDs if AKI); opioids sparingly

— Oral iron (ferrous sulfate 325 mg daily or every other day for better absorption) if Hgb 8–10 and tolerating PO

— IV iron (ferric carboxymaltose, iron sucrose) if Hgb <8, severe symptoms, or intolerant of oral iron — much faster repletion

— Goal Hgb >11 by 6 weeks postpartum

— Inform patient of products received

— Check post-transfusion CBC and metabolic panel

— Document any reactions

— Warning signs requiring return: heavy bleeding (soaking pad >1/hour), large clots, fever, foul lochia, leg pain/swelling, chest pain, dyspnea

— Lochia expectations: rubra → serosa → alba over 4–6 weeks

— Activity restrictions per delivery mode

— Lactation support — significant blood loss can delay lactogenesis; reassure and provide LC follow-up

— Discuss options before discharge; LARC (IUD, implant) can be placed immediately postpartum

— Combined hormonal contraception delayed 3 weeks (VTE risk), 6 weeks if other VTE risk factors

— Recurrence risk ~15%

— Recommend delivery at center with blood bank and OB anesthesia

— Antepartum CBC, type and screen

— Avoid pregnancy <12–18 months (interpregnancy interval); discuss thoughtful timing

Step 3 management: Every PPH patient gets iron repletion at discharge — IV iron if Hgb <8 or severely symptomatic. Don't send them out on "diet."

Board pearl: LARC placed immediately postpartum (within 10 min of placental delivery or before discharge) has higher continuation rates than delayed placement.

In-hospital recovery orders (after hemorrhage controlled):

Iron repletion (essentially every PPH patient):

Transfusion-related follow-up:

Counseling before discharge:

Contraception counseling:

Future pregnancy counseling:

Follow-Up, Monitoring, and Postpartum Rehabilitation

— Day 1: vitals q4h, fundal checks, lochia assessment, CBC, ambulation, lactation support, iron started

— Day 2–3 (vaginal) / 3–4 (cesarean): discharge criteria: hemodynamically stable, tolerating diet, ambulating, voiding, Hgb trending up or stable, lochia appropriate, pain controlled on oral meds

— 48–72 hours: nurse phone call or in-person check (especially after Stage 2–3 hemorrhage) — review symptoms, bleeding, medications

— 1–2 weeks: in-person visit if severe hemorrhage, cesarean, or perineal repair concerns — CBC if anemia was significant

— 3 weeks: ACOG-recommended initial comprehensive postpartum visit (replacing the older "6-week only" model) — assess mood, bleeding, lactation, contraception, BP if hypertensive disorders

— 6 weeks: comprehensive postpartum visit — pelvic exam, contraception confirmation, depression screen (Edinburgh Postnatal Depression Scale or PHQ-9), repeat CBC

— 12 weeks: if HELLP/preeclampsia/Sheehan concern — pituitary panel, kidney function, BP recheck

— Hgb/iron studies at 6 weeks; ferritin to confirm repletion

— Thyroid panel at 6 weeks if Sheehan suspected

— Mental health screening at every postpartum visit — PPH is associated with PTSD and PPD

— Pelvic floor assessment especially after large perineal lacerations or hematomas — refer to pelvic floor PT

— Severe blood loss can delay lactogenesis II; aggressive lactation support and consider galactogogues (metoclopramide, domperidone where available)

— Failure to lactate at 1–2 weeks → check pituitary axis for Sheehan

— Communicate to PCP and OB the details of the hemorrhage event, stage, products transfused, complications

— Subsequent pregnancy planning visit recommended before next conception

Step 3 management: The 3-week visit is the new standard — don't wait 6 weeks after a major hemorrhage. Order it.

CCS pearl: "Schedule follow-up in 1 week" is a valid CCS order and is expected after significant PPH.

Inpatient day-by-day plan (CCS continuation):

Post-discharge cadence:

Specific monitoring parameters:

Lactation follow-up:

Outpatient handoff:

Ethical, Legal, and Patient Safety Considerations

— Implied consent doctrine applies in life-threatening hemorrhage when patient is unable to consent and no surrogate is immediately available — proceed with life-saving measures including transfusion and hysterectomy

— Document the emergency and inability to obtain consent

— When time permits (Stage 1–2), discuss escalation steps including possible hysterectomy with the patient

— Document specific products refused/accepted on a signed advance directive antepartum (during prenatal care, not in crisis)

— Court orders to transfuse against patient's wishes are not appropriate for competent adults

— For minors or incapacitated patients, ethics consult and possibly court involvement

— Use alternatives: cell salvage, recombinant factor VIIa, aggressive iron/EPO antepartum, earlier surgical/IR intervention

— Unexpected hysterectomy, ICU admission, or complications → transparent disclosure to patient and family per institutional disclosure policy

— Document discussion

— Every L&D unit should have a posted OB Hemorrhage Bundle (AIM) with hemorrhage cart, MTP protocol, drill simulations

— Quantitative blood loss is now standard; visual estimation is a safety hazard

— Postpartum hemorrhage drills q6–12 months reduce maternal morbidity

— Hand-offs between L&D, OR, ICU, postpartum floor are high-risk moments — use structured SBAR handoff

— Communicate ongoing transfusion, anticoagulation status, follow-up labs

— Severe maternal morbidity events (>4 U PRBC transfused or ICU admission) trigger institutional and state-level maternal mortality review board reporting in many states

— These events feed into AIM safety bundles and CMS quality measures

— Black women experience 3–4× higher maternal mortality from PPH; recognize implicit bias in pain and bleeding assessment

Step 3 management: Antepartum advance directives for Jehovah's Witness patients are a Step 3 patient-safety favorite — confirm during prenatal care, not in the labor room.

Board pearl: Implied consent covers emergency life-saving transfusion only when no competent refusal is documented.

Informed consent in emergencies:

Jehovah's Witness patients:

Disclosure of adverse events:

Patient safety bundles:

Transition-of-care risks:

Mandatory reporting and quality:

Health equity:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: If a vignette mentions asthma → never Hemabate. If it mentions HTN/preeclampsia → never Methergine. If it mentions both → choose misoprostol or skip to mechanical/surgical.

Key distinction: Soft uterus = atony; firm uterus + bleeding = trauma or tissue; oozing from sites = thrombin.

The 4 T's order by frequency: Tone (70%) > Trauma (20%) > Tissue (10%) > Thrombin (1%)

First-line uterotonic: oxytocin (10–40 U in IVF, or 10 U IM)

Methylergonovine contraindication: hypertension, preeclampsia, Raynaud's, CAD, cocaine use

Carboprost (Hemabate) contraindication: asthma

Misoprostol: safe across most contraindications; slower onset

TXA dose: 1 g IV over 10 min, give within 3 h of bleeding onset (WOMAN trial)

MTP ratio: 1:1:1 PRBC:FFP:platelets

Fibrinogen threshold for cryo/concentrate: <200 mg/dL (remember pregnancy-elevated baseline)

Citrate toxicity: give 1–2 g calcium gluconate per 4 U citrated products

Bakri balloon volume: 300–500 mL

B-Lynch suture: compression suture at cesarean for atony

O'Leary stitch: bilateral uterine artery ligation

Definitive surgical management: hysterectomy

Uterine inversion treatment: immediate manual replacement (Johnson maneuver); halt uterotonics; tocolytics if needed

AFE clue: sudden collapse + hypoxia + DIC during/after delivery

Sheehan syndrome first sign: failure to lactate

Asherman syndrome cause: aggressive curettage → adhesions → infertility

Secondary PPH timing: 24 h to 12 weeks

Late PPH + normal initial workup: consider von Willebrand disease

Endometritis abx (gold standard): clindamycin + gentamicin

Active management of third stage: prophylactic oxytocin + controlled cord traction + uterine massage — reduces PPH by 60%

Shock index trigger: HR/SBP ≥0.9 = consider MTP

Postpartum BP medications safe in lactation: labetalol, nifedipine, enalapril/captopril

Iron repletion: IV iron if Hgb <8 or severe symptoms

3-week postpartum visit: new ACOG standard after significant complications

Recurrence risk in next pregnancy: ~15%

Black maternal mortality disparity: 3–4× higher — implicit bias awareness

Board Question Stem Patterns

— G3P3 after 22-h induction with oxytocin, macrosomic infant, brisk vaginal bleeding, boggy uterus

— Next step: uterine massage + oxytocin (already running → increase dose or add second agent)

— Trap: choosing carboprost before checking asthma history

— Preeclamptic patient on magnesium with atony unresponsive to oxytocin

— Next step: carboprost (NOT methylergonovine) — magnesium relaxes uterus, contributes to atony

— Trap: ordering methylergonovine because it's "second-line"

— Asthmatic patient with atony refractory to oxytocin and methylergonovine

— Next step: misoprostol 800–1000 mcg PR

— Firm well-contracted uterus, continued bright-red bleeding postvaginal delivery

— Next step: inspect cervix and vagina under adequate exposure; suspect laceration

— Trap: adding more uterotonics

— Placenta delivered "in fragments," ongoing bleeding, firm uterus

— Next step: manual exploration and curettage

— Brisk bleeding, bradycardia + hypotension out of proportion, fundus not palpable abdominally, mass in vagina

— Next step: immediate manual replacement; stop uterotonics during reduction

— Sudden hypoxia, hypotension, seizure, then DIC during/after delivery

— Next step: supportive (intubation, vasopressors, MTP); call code obstetrics

— Heavy bleeding 10 days postpartum, prior history of menorrhagia/easy bruising, normal coags on initial check

— Next step: vWF antigen and activity, factor VIII; treat with desmopressin or vWF concentrate

— Months postpartum after severe PPH, fails to lactate, fatigue, amenorrhea

— Next step: pituitary hormone panel, MRI pituitary

— Antepartum advance directive details, ongoing PPH refractory to medical management

— Next step: earlier surgical/IR intervention, cell salvage; do not transfuse against documented refusal

Step 3 management: When the stem buries a contraindication (asthma, HTN, preeclampsia, cocaine), the right answer is the uterotonic those rules out — the test rewards you for catching the contraindication.

Stem pattern 1 — Classic atony:

Stem pattern 2 — Methergine contraindication:

Stem pattern 3 — Hemabate contraindication:

Stem pattern 4 — Trauma masquerade:

Stem pattern 5 — Retained products:

Stem pattern 6 — Uterine inversion:

Stem pattern 7 — AFE:

Stem pattern 8 — Late PPH with VWD:

Stem pattern 9 — Sheehan syndrome:

Stem pattern 10 — Jehovah's Witness:

One-Line Recap

Postpartum hemorrhage is a time-critical obstetric emergency in which simultaneous resuscitation, stage-based escalation through the 4 T's framework (Tone, Trauma, Tissue, Thrombin), early TXA, and a logical ladder from uterotonics to mechanical tamponade to vascular/surgical control — including timely hysterectomy when necessary — saves lives.

Board pearl: The single highest-yield decision rule in PPH — soft uterus calls for uterotonics and massage; firm uterus with ongoing bleeding demands you inspect for trauma or retained tissue, not more drugs.

CCS pearl: Order set first, drug ladder second, location change (to OR) third, definitive procedure fourth — and consults at every stage.

Recognize early: Quantitative blood loss, shock index, and clinical pattern of soft vs firm uterus drive the initial branch. Don't wait for hypotension in a healthy parturient — they crash precipitously after compensating.

Treat in parallel, not in series: Within the first 5 minutes — two IVs, type and crossmatch, fundal massage, empty bladder, oxytocin infusion, TXA, labs (CBC, fibrinogen, coags), call for help. The CCS rewards parallel ordering.

Match the uterotonic to the patient: Oxytocin first → methylergonovine (avoid in HTN/preeclampsia) → carboprost (avoid in asthma) → misoprostol (universal fallback). TXA within 3 hours.

Escalate decisively: Failed medical → mechanical (Bakri, B-Lynch, Jada) → vascular (UAE, O'Leary) → hysterectomy. Move to OR before you exhaust labor-room options. Activate MTP at >1500 mL with ongoing loss or instability; transfuse 1:1:1.

Anticipate and prevent downstream complications: Sheehan (failure to lactate), Asherman (post-curettage adhesions), VTE (prophylax once hemostatic), iron-deficiency anemia (IV iron if Hgb <8), and PTSD/PPD (screen at every postpartum visit).

Close the loop: Discharge with iron, contraception plan, warning signs, 1-week and 3-week visits after significant hemorrhage, multidisciplinary preconception counseling for future pregnancies given 15% recurrence risk.