Patient handout

Postpartum Hemorrhage (PPH)

PRODUCTION

1. Your condition

This handout is for postpartum hemorrhage (pph). Your care team identified this based on: estimated blood loss >500 ml after vaginal delivery (acog 183 2017, reaffirmed 2023).

Other reasons your team may use this plan: estimated blood loss >1000 ml after cesarean delivery (acog 183 2017, reaffirmed 2023); maternal hr >110 bpm with ongoing bleeding postpartum (cmqcc pph toolkit 2022); sbp <90 mmhg or map <65 postpartum with hemorrhage (who 2023 pph).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
oxytocin	10–40 IU in 500–1000 mL NS/LR IV infusion; or 10 IU IM	IV/IM	continuous infusion titrated to uterine tone	ACOG 183 (2017) — first-line uterotonic; WHO 2023 PPH; AMTSL standard

Plan: PPH uterotonic escalation + adjuncts — stepwise per ACOG 183 (2017) + WOMAN Trial (Shakur Lancet 2017)

3. When to call your provider

Contact your care team if any of the following happen:

New vaginal bleeding >menstrual volume after 24 h postpartum → ED / L&D — late secondary PPH (RCOG GTG 52 2016)
Fever ≥38°C + foul lochia → endometritis workup → broad-spectrum antibiotics (overlap with id.sepsis.core.v1)
Hgb <7 g/dL despite oral iron → IV iron OR transfusion if symptomatic per RCOG GTG 52 (2016)
EPDS ≥13 or active suicidal ideation → urgent perinatal mental health referral per ACOG 757 (2018)
Postpartum severe HTN ≥160/110 → ED — postpartum pre-eclampsia surveillance through 6 wk per ACOG 222 (2020)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Cumulative EBL >1500 mL or >2 units pRBCs transfused — CMQCC Stage 3 per CMQCC PPH Toolkit (2022)(life-threatening)
Fibrinogen <100 mg/dL + INR >1.5 + platelets <50K with active hemorrhage per RCOG GTG 52 (2016)(life-threatening)
Fibrinogen <200 mg/dL with ongoing PPH — strongest single lab predictor of severe progression per RCOG GTG 52 (2016)
Persistent hemorrhage despite oxytocin + second-line uterotonic (methylergonovine or carboprost) + misoprostol per ACOG 183 (2017)
SBP <90 mmHg or MAP <65 or Shock Index >1.0 or altered mental status with PPH per WHO 2023 PPH(life-threatening)
Lethal triad: temperature <35°C + pH <7.2 + coagulopathy during massive hemorrhage per RCOG GTG 52 (2016)(life-threatening)
Shock Index (HR/SBP) ≥1.0 in active PPH — bedside MTP-activation trigger per WHO PPH 2017 + CMQCC PPH Toolkit (2022) + Pacagnella Reprod Health 2018 / Borovac-Pinheiro AJOG 2018 derivation cohorts; often precedes hypotension by 30-60 min
Persistent hemorrhage despite full uterotonic ladder: oxytocin 10-40 IU IV/IM + second-line (methylergonovine 0.2 mg IM if no HTN OR carboprost 0.25 mg IM if no asthma) + misoprostol 800-1000 mcg PR/SL within 30 min of PPH diagnosis per ACOG 183 (2017); user-spec alias for the existing refractory-to-uterotonics row
Fibrinogen <200 mg/dL with ongoing PPH — user-spec id; existing row also encodes this content via "consumptive coagulopathy fibrinogen lt 200 — RCOG GTG 52 2016"; strongest single lab predictor of severe PPH progression per RCOG GTG 52 (2016) + Charbit J Thromb Haemost 2007 PMID 17204093
Massive transfusion protocol (MTP) active state: ≥4 U PRBC in 1 h OR ≥10 U PRBC in 24 h with 1:1:1 PRBC:FFP:platelets ratio per ACOG 183 (2017) + RCOG GTG 52 (2016)(life-threatening)
Coagulopathy / DIC features in PPH: fibrinogen <100 mg/dL OR INR >1.5 OR platelets <50K with active bleeding OR schistocytes on smear OR D-dimer markedly elevated per RCOG GTG 52 (2016) + ISTH DIC score 2024

5. Follow-up

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)

6. Sources

Guideline: ACOG Practice Bulletin 183 (2017, reaffirmed 2023) + WHO 2017 TXA recommendation + CMQCC PPH risk-assessment (2021) + WOMAN Trial (Shakur Lancet 2017) + E-MOTIVE Trial (Gallos NEJM 2023)