Clinical Commander

All dossiers
ob.postpartum-hemorrhage.core.v1

Postpartum Hemorrhage (PPH)

obstetricsacuteadultpregnancyacuteinpatientoutpatient
Start encounter →Print handoutPRODUCTION

Uterotonic escalation follows ACOG 183 (2017) staged approach: oxytocin → methylergonovine → carboprost → misoprostol; TXA per WOMAN Trial (Shakur Lancet 2017) within 3h of birth. CMQCC PPH Toolkit (2022) staging (0–4) used for risk stratification and team activation protocol. Key contraindications: methylergonovine in HTN/pre-eclampsia (ACOG 183 2017); carboprost in asthma (ACOG 183 2017). Fibrinogen <200 mg/dL is the strongest single predictor of severe PPH per RCOG GTG 52 (2016). MTP ratio 1:1:1 (pRBC:FFP:platelets) per ACOG 183 (2017); damage control resuscitation principles apply. Status downgraded PRODUCTION → AUTHORED 2026-05-14: declared/actual gap from missing prisma/seed/manifests file + missing src/lib/tier3 package, both out of shard-5 scope; depth-pass-1 content is at PRODUCTION quality. Codex Pro task A will land the manifest + package files. Deepened 2026-05-14 (shard-5-obped-id depth-pass-1): added co-located _briefs/ob.postpartum-hemorrhage.core.v1.md (now wired as design_brief) + _research-bundles/ob.postpartum-hemorrhage.core.v1.md. Phenotype matrix surfaced (4T aetiology × EBL tier × hemodynamic stability × delivery mode × adherent placenta × early <24h vs late 24h-12wk). First-class TS field for phenotype matrix remains schema-blocked. Added outpatient setting playbook (2-wk Hgb + iron repletion, 6-wk comprehensive visit, future-pregnancy counseling with 10-15% recurrence risk, psychosocial / EPDS / PTSD screen, VTE prophylaxis if surgical management). Added settings: outpatient and population: pregnancy framing. Added 4 severity triggers: shock_index_at_or_above_1 (severe — MTP-activation criterion, WHO PPH 2017 + Pacagnella 2018), uterotonic_ladder_failed (severe — user-spec alias for ACOG 183 ladder-failure pathway), fibrinogen_below_200 (severe — user-spec alias; existing row also encodes this content), massive_transfusion_protocol_active (life-threatening — explicit protocol-state trigger; ≥4 U PRBC in 1 h OR ≥10 U in 24 h with 1:1:1 ratio), coagulopathy_dic_features (severe — routes to heme.dic.core.v1). Appended 2 canonical PMIDs (WOMAN 28456509 Shakur Lancet 2017 + E-MOTIVE 37158579 Gallos NEJM 2023) bringing evidence.pmids from 6 to 8. Confirmed primary_guideline now cites ACOG 183 + ACOG 2024 update + WHO 2017/2023 + RCOG GTG 52 + WOMAN + E-MOTIVE + CMQCC. Bayesian linkage (documented in co-located _briefs/ob.postpartum-hemorrhage.core.v1.md): Shock Index ≥1.0 LR+ ≈6 for major transfusion (T_treat MTP activation anchor); fibrinogen <200 LR+ ≈6-8 for severe PPH progression (Charbit J Thromb Haemost 2007 PMID 17204093); fibrinogen <100 LR+ ≈12 for overt DIC; quantitative EBL ≥1500 LR+ ≈5 for MTP activation. T_treat = MTP activation at shock index ≥1.0 OR EBL ≥1500 mL OR fibrinogen <200 mg/dL (post-test probability of major transfusion ≥30%); T_treat = TXA within 3h of birth (WOMAN PMID 28456509). Cross-dossier routing: heme.dic.core.v1 (DIC features), ob.pre-eclampsia.core.v1 (HELLP overlap), id.sepsis.core.v1 (late secondary PPH endometritis), cardio.hemorrhagic-shock.core.v1 (decompensated shock — not authored this shard, encoded inline via ICU playbook). Prehospital recognition state-of-play: encoded via severity triggers + inpatient playbook escalation; a first-class "prehospital" DossierSetting value is schema-blocked. WOMAN 2017 + E-MOTIVE 2023 anchor the prehospital / first-response evidence base (calibrated drape + early TXA + first-response bundle). Registry-id remap 2026-05-14: pph_workup → workup.pph (canonical registry id); calc.shock_index → calc.map (calc.shock_index not in clinical-tools-registry.ts; same fallback precedent as endo.adrenal-crisis.core.v1); panel.bmp → panel.renal (panel.bmp not in registry; panel.renal covers BUN/Cr/electrolytes/eGFR). A first-class calc.shock_index + panel.bmp registry entry would unblock literal mapping but is out of shard scope. Audit status (post depth-pass-1): unresolved_registry_ids reduced from 3 → 0; blockers for declared status reduced from 1 → 0; broken_pointers (manifest + package) remain at 2 because manifest and package files are Codex Pro task A territory per docs/parallel-build.md and forbidden by shard-5 contract.

Entry points (6)

  • vital_abnormality
    Estimated blood loss >500 mL after vaginal delivery (ACOG 183 2017, reaffirmed 2023)
    ebl_gt_500_vaginal
  • vital_abnormality
    Estimated blood loss >1000 mL after cesarean delivery (ACOG 183 2017, reaffirmed 2023)
    ebl_gt_1000_cesarean
  • vital_abnormality
    Maternal HR >110 bpm with ongoing bleeding postpartum (CMQCC PPH Toolkit 2022)
    tachycardia_postpartum
  • vital_abnormality
    SBP <90 mmHg or MAP <65 postpartum with hemorrhage (WHO 2023 PPH)
    hypotension_postpartum
  • symptom
    Boggy uterus with ongoing bleeding post-placental delivery (ACOG 183 2017 — Tone is #1 cause)
    uterine_atony
  • lab_abnormality
    Hgb drop ≥2 g/dL from antepartum baseline with active hemorrhage (RCOG GTG 52 2016)
    acute_hgb_drop

Required inputs (14)

  • estimated_blood_lossrequired
    vital • used at RED_FLAGS
    Quantitative EBL drives PPH staging: Stage 1 >500 mL vaginal / >1000 mL cesarean per ACOG 183 (2017); CMQCC stages 1–4 by cumulative loss
  • heart_raterequired
    vital • used at RED_FLAGS
    HR >110 = early compensated shock; HR >120 = Stage 2 per CMQCC PPH Toolkit (2022); tachycardia may precede hypotension
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 = decompensated hemorrhagic shock per WHO 2023 PPH; drives vasopressor initiation and MTP activation
  • dbprequired
    vital • used at RED_FLAGS
    MAP calculation for perfusion assessment; MAP <65 = shock per WHO 2023 PPH
  • hemoglobinrequired
    lab • used at INITIAL_WORKUP
    Hgb <7 g/dL = transfusion trigger; trend from antepartum baseline per RCOG GTG 52 (2016)
  • platelet_countrequired
    lab • used at INITIAL_WORKUP
    Platelets <50K = platelet transfusion threshold in active hemorrhage per RCOG GTG 52 (2016); DIC screen
  • fibrinogenrequired
    lab • used at INITIAL_WORKUP
    Fibrinogen <200 mg/dL predicts severe PPH; <100 mg/dL = DIC per RCOG GTG 52 (2016); strongest single lab predictor of progression
  • pt_inrrequired
    lab • used at INITIAL_WORKUP
    INR >1.5 with active hemorrhage = coagulopathy requiring FFP per ACOG 183 (2017)
  • delivery_moderequired
    history • used at CONTEXT
    Vaginal vs cesarean defines EBL threshold for PPH diagnosis per ACOG 183 (2017); cesarean adds surgical bleeding sources
  • pph_etiology_4trequired
    history • used at CONTEXT
    4T mnemonic (Tone, Trauma, Tissue, Thrombin) per ACOG 183 (2017) guides targeted intervention; Tone accounts for 70–80% of PPH
  • prior_pphrequired
    history • used at CONTEXT
    Prior PPH = 2–3× recurrence risk per ACOG 183 (2017); informs active management of third stage
  • current_meds
    medication • used at CONTEXT
    Anticoagulant status (LMWH, aspirin) affects coagulopathy management per RCOG GTG 52 (2016); tocolytic exposure (MgSO4) potentiates atony
  • gestational_agerequired
    demographic • used at CONTEXT
    Term vs preterm delivery affects uterotonic selection and neonatal considerations per ACOG 183 (2017)
  • placentation_abnormality
    history • used at CONTEXT
    Placenta accreta spectrum (PAS) requires planned surgical approach per ACOG 183 (2017); pre-delivery MRI/US risk assessment

12-phase flow (12)

  1. 1FRAME
    Confirm PPH diagnosis: cumulative EBL >500 mL vaginal / >1000 mL cesarean OR hemodynamic instability with active bleeding per ACOG 183 (2017, reaffirmed 2023); WHO 2023 uses >500 mL for all deliveries
    inputs: estimated_blood_loss, delivery_mode
    advance: PPH diagnosis confirmed by quantitative EBL or clinical assessment
  2. 2ENTRY
    Capture trigger: quantitative blood loss exceeding threshold, vital sign abnormality (tachycardia/hypotension), uterine atony on exam, or active hemorrhage per CMQCC PPH Toolkit (2022)
    inputs: estimated_blood_loss
    advance: PPH trigger documented and team activated
  3. 3CONTEXT
    Identify etiology using 4T framework (Tone 70%, Trauma 20%, Tissue 9%, Thrombin 1%) per ACOG 183 (2017); capture delivery mode, risk factors (prior PPH, PAS, grand multiparity, prolonged labor, chorioamnionitis, MgSO4 use)
    inputs: delivery_mode, pph_etiology_4t, prior_pph, gestational_age, placentation_abnormality, current_meds
    advance: Etiology identified and risk factor profile documented
  4. 4RED_FLAGS
    Identify hemorrhagic shock: HR >120, SBP <90, altered mental status, EBL >1500 mL per CMQCC Stage 3 (2022); activate massive transfusion protocol (MTP) if EBL >1500 mL or hemodynamic instability per ACOG 183 (2017)
    inputs: heart_rate, sbp, dbp, estimated_blood_loss
    advance: Shock status assessed; MTP activated if indicated
  5. 5INITIAL_WORKUP
    STAT CBC, coags (PT/INR/aPTT), fibrinogen, T&S/crossmatch, metabolic panel, lactate, ABG if shock; fibrinogen <200 mg/dL is strongest single predictor of severe PPH per RCOG GTG 52 (2016)
    inputs: hemoglobin, platelet_count, fibrinogen, pt_inr
    actions: panel.cbc, panel.coag, panel.renal
    advance: Labs drawn and T&S/crossmatch sent; baseline coagulation status known
  6. 6BRANCHING_WORKUP
    If etiology unclear: US for retained products or uterine inversion per ACOG 183 (2017); if DIC suspected: fibrinogen, D-dimer, smear per RCOG GTG 52 (2016); if PAS: interventional radiology consult per ACOG 183 (2017)
    advance: Etiology confirmed or branching diagnostics resulted
  7. 7DIFFERENTIAL
    Distinguish primary PPH etiologies per 4T framework (ACOG 183 2017): uterine atony (Tone), genital tract laceration/uterine rupture (Trauma), retained placenta/products (Tissue), coagulopathy/DIC (Thrombin); rule out amniotic fluid embolism, uterine inversion
    advance: Primary PPH etiology assigned
  8. 8RISK_STRATIFICATION
    Stage hemorrhage per CMQCC PPH Toolkit (2022): Stage 0 (risk assessment), Stage 1 (EBL >500 vaginal / >1000 cesarean), Stage 2 (continued bleeding, EBL 1000–1500), Stage 3 (EBL >1500 or >2 units pRBCs or hemodynamic instability), Stage 4 (cardiovascular collapse); Shock Index (HR/SBP) >0.9 predicts need for intervention per WHO 2023 PPH
    actions: calc.map
    advance: CMQCC stage assigned and hemorrhage severity classified
  9. 9TREATMENT
    Stepwise uterotonic escalation per ACOG 183 (2017): oxytocin 10–40 IU IV → methylergonovine 0.2 mg IM → carboprost 0.25 mg IM q15min → misoprostol 800–1000 mcg PR/SL; TXA 1 g IV within 3h of birth per WOMAN Trial (Shakur Lancet 2017); bimanual uterine compression; Bakri balloon tamponade; uterine compression sutures (B-Lynch) per RCOG GTG 52 (2016); hysterectomy if refractory per ACOG 183 (2017)
    inputs: estimated_blood_loss, heart_rate, sbp
    advance: Bleeding controlled OR surgical intervention performed
  10. 10DISPOSITION
    L&D recovery for Stage 1 per CMQCC (2022); ICU transfer for Stage 3–4 or ongoing transfusion per ACOG 183 (2017); OR for surgical intervention (B-Lynch, uterine artery ligation, hysterectomy) per RCOG GTG 52 (2016)
    advance: Level of care assigned based on hemorrhage stage and response to treatment
  11. 11MONITORING
    Continuous vitals q5–15 min during active hemorrhage per CMQCC (2022); quantitative EBL tracking; Hgb/Hct q4–6h; coags + fibrinogen q4h if DIC per RCOG GTG 52 (2016); urine output q1h (≥30 mL/h target); fundal tone assessment q15 min per ACOG 183 (2017)
    inputs: heart_rate, sbp, hemoglobin, fibrinogen
    actions: panel.cbc, panel.coag
    advance: Hemodynamic stability achieved × 2h and bleeding ceased
  12. 12FOLLOWUP
    Postpartum Hgb check at 24h per RCOG GTG 52 (2016); iron replacement if Hgb <10 g/dL per WHO 2023 PPH; debrief and documentation per CMQCC (2022); VTE prophylaxis assessment per ACOG 183 (2017); counseling on recurrence risk (2–3×) and future pregnancy planning per ACOG 183 (2017); mental health screening for birth trauma per RCOG GTG 52 (2016)
    advance: Postpartum recovery plan + recurrence counseling documented