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ob.postpartum-hemorrhage.core.v1PRODUCTION
ob.postpartum-hemorrhage.core.v1

Postpartum Hemorrhage (PPH)

obstetricsacuteadultpregnancy
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Frame

Detailed

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

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PPH diagnosis confirmed by quantitative EBL or clinical assessment

Patient inputs (14)

Vaginal vs cesarean defines EBL threshold for PPH diagnosis per ACOG 183 (2017); cesarean adds surgical bleeding sources

4T mnemonic (Tone, Trauma, Tissue, Thrombin) per ACOG 183 (2017) guides targeted intervention; Tone accounts for 70–80% of PPH

Prior PPH = 2–3× recurrence risk per ACOG 183 (2017); informs active management of third stage

Term vs preterm delivery affects uterotonic selection and neonatal considerations per ACOG 183 (2017)

Hgb <7 g/dL = transfusion trigger; trend from antepartum baseline per RCOG GTG 52 (2016)

Platelets <50K = platelet transfusion threshold in active hemorrhage per RCOG GTG 52 (2016); DIC screen

Fibrinogen <200 mg/dL predicts severe PPH; <100 mg/dL = DIC per RCOG GTG 52 (2016); strongest single lab predictor of progression

INR >1.5 with active hemorrhage = coagulopathy requiring FFP per ACOG 183 (2017)

Quantitative EBL drives PPH staging: Stage 1 >500 mL vaginal / >1000 mL cesarean per ACOG 183 (2017); CMQCC stages 1–4 by cumulative loss

HR >110 = early compensated shock; HR >120 = Stage 2 per CMQCC PPH Toolkit (2022); tachycardia may precede hypotension

SBP <90 = decompensated hemorrhagic shock per WHO 2023 PPH; drives vasopressor initiation and MTP activation

MAP calculation for perfusion assessment; MAP <65 = shock per WHO 2023 PPH

Anticoagulant status (LMWH, aspirin) affects coagulopathy management per RCOG GTG 52 (2016); tocolytic exposure (MgSO4) potentiates atony

Placenta accreta spectrum (PAS) requires planned surgical approach per ACOG 183 (2017); pre-delivery MRI/US risk assessment

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Severity triggers (11)

11 need judgement
  • informationallife_threateningmassive hemorrhage ebl gt 1500 — ACOG 183 2017
    Cumulative EBL >1500 mL or >2 units pRBCs transfused — CMQCC Stage 3 per CMQCC PPH Toolkit (2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdic coagulopathy — RCOG GTG 52 2016
    Fibrinogen <100 mg/dL + INR >1.5 + platelets <50K with active hemorrhage per RCOG GTG 52 (2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghemodynamic instability shock — WHO 2023
    SBP <90 mmHg or MAP <65 or Shock Index >1.0 or altered mental status with PPH per WHO 2023 PPH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghypothermia acidosis coagulopathy triad — RCOG GTG 52 2016
    Lethal triad: temperature <35°C + pH <7.2 + coagulopathy during massive hemorrhage per RCOG GTG 52 (2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_transfusion_protocol_active
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereconsumptive coagulopathy fibrinogen lt 200 — RCOG GTG 52 2016
    Fibrinogen <200 mg/dL with ongoing PPH — strongest single lab predictor of severe progression per RCOG GTG 52 (2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory to uterotonics — ACOG 183 2017
    Persistent hemorrhage despite oxytocin + second-line uterotonic (methylergonovine or carboprost) + misoprostol per ACOG 183 (2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereshock_index_at_or_above_1
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereuterotonic_ladder_failed
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefibrinogen_below_200
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecoagulopathy_dic_features
    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
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

PPH uterotonic escalation + adjuncts — stepwise per ACOG 183 (2017) + WOMAN Trial (Shakur Lancet 2017)
axis: pph_uterotonic_escalationstep 1 - Tier 1 — First-line uterotonic: oxytocin for uterine atony per ACOG 183 (2017)
Selected step "Tier 1 — First-line uterotonic: oxytocin for uterine atony per ACOG 183 (2017)" — PPH diagnosed with uterine atony (boggy uterus)
  • oxytocin
    first line
    uterotonic_oxytocic
    10–40 IU in 500–1000 mL NS/LR IV infusion; or 10 IU IM • IV/IM • continuous infusion titrated to uterine tone
    triggers: uterine_atony, pph_stage_1
    ACOG 183 (2017) — first-line uterotonic; WHO 2023 PPH; AMTSL standard
    rxcui 1733680

outpatient playbook — drug actions (4)

  1. 1. oral ferrous sulfate or ferrous gluconate
    325 mg PO BID-TID (65 mg elemental iron / dose); take with vitamin C • PO • BID-TID
    trigger: Mild postpartum anemia (Hgb 7-10 g/dL) tolerant of oral iron
    WHO 2017 PPH + ACOG 183 (2017) — first-line oral iron for mild postpartum anemia; continue until ferritin >50 ng/mL + Hgb >12 g/dL
  2. 2. IV iron (ferric carboxymaltose or iron sucrose)
    Ferric carboxymaltose 750 mg IV × 1-2 doses OR iron sucrose 200 mg IV q1-3 days × 3-5 doses; total dose per Ganzoni formula • IV • per protocol
    trigger: Severe postpartum anemia (Hgb <7 g/dL) OR oral-iron intolerance OR rapid replenishment needed (active lactation / planned pregnancy)
    WHO 2023 anemia guidance + RCOG GTG 52 (2016) — IV iron for severe postpartum anemia or oral-iron failure
  3. 3. enoxaparin VTE prophylaxis
    40 mg SC daily × 6 wk postpartum if surgical management or prolonged bed-rest • SC • daily
    trigger: Cesarean hysterectomy / B-Lynch / artery ligation / IR embolization / extended bed-rest >72h
    RCOG GTG 37a (2015) + ACOG 183 (2017) — post-surgical VTE prophylaxis for 6 wk postpartum; PPH itself is VTE risk factor
  4. 4. lactation-compatible analgesia transition
    Acetaminophen 1 g PO q6h scheduled; ibuprofen 600 mg PO q6h if no severe HTN/preeclampsia; avoid prolonged opioids • PO • q6h
    trigger: Post-surgical pain after laparotomy / hysterectomy
    ACOG 196 (2018) lactation-compatible analgesia; avoid codeine in breastfeeding mothers (ultrarapid metabolisers risk per FDA 2017)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Estimated blood loss >500 mL after vaginal delivery (ACOG 183 2017, reaffirmed 2023); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Postpartum Hemorrhage (PPH)** (ob.postpartum-hemorrhage.core.v1).
Phenotype framing: 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
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **PPH uterotonic escalation + adjuncts — stepwise per ACOG 183 (2017) + WOMAN Trial (Shakur Lancet 2017)** — step "Tier 1 — First-line uterotonic: oxytocin for uterine atony per ACOG 183 (2017)".
1. oxytocin 10–40 IU in 500–1000 mL NS/LR IV infusion; or 10 IU IM IV/IM continuous infusion titrated to uterine tone (uterotonic_oxytocic, first line) — ACOG 183 (2017) — first-line uterotonic; WHO 2023 PPH; AMTSL standard

Setting playbook (outpatient) — Post-discharge PPH recovery — 2-week postpartum Hgb check + iron repletion (oral if mild, IV iron if severe / non-tolerant), 6-week comprehensive postpartum visit (recovery, lactation, future-pregnancy counseling with recurrence ~10-15% per ACOG 183 (2017)), psychosocial screen (PPH increases PPD/PTSD risk per ACOG 183 (2017) + AHA postpartum mental-health guidance 2024), VTE prophylaxis assessment if extended bed-rest / surgical management per RCOG GTG 52 (2016)
2. oral ferrous sulfate or ferrous gluconate 325 mg PO BID-TID (65 mg elemental iron / dose); take with vitamin C PO BID-TID — Mild postpartum anemia (Hgb 7-10 g/dL) tolerant of oral iron (WHO 2017 PPH + ACOG 183 (2017) — first-line oral iron for mild postpartum anemia; continue until ferritin >50 ng/mL + Hgb >12 g/dL)
3. IV iron (ferric carboxymaltose or iron sucrose) Ferric carboxymaltose 750 mg IV × 1-2 doses OR iron sucrose 200 mg IV q1-3 days × 3-5 doses; total dose per Ganzoni formula IV per protocol — Severe postpartum anemia (Hgb <7 g/dL) OR oral-iron intolerance OR rapid replenishment needed (active lactation / planned pregnancy) (WHO 2023 anemia guidance + RCOG GTG 52 (2016) — IV iron for severe postpartum anemia or oral-iron failure)
4. enoxaparin VTE prophylaxis 40 mg SC daily × 6 wk postpartum if surgical management or prolonged bed-rest SC daily — Cesarean hysterectomy / B-Lynch / artery ligation / IR embolization / extended bed-rest >72h (RCOG GTG 37a (2015) + ACOG 183 (2017) — post-surgical VTE prophylaxis for 6 wk postpartum; PPH itself is VTE risk factor)
5. lactation-compatible analgesia transition Acetaminophen 1 g PO q6h scheduled; ibuprofen 600 mg PO q6h if no severe HTN/preeclampsia; avoid prolonged opioids PO q6h — Post-surgical pain after laparotomy / hysterectomy (ACOG 196 (2018) lactation-compatible analgesia; avoid codeine in breastfeeding mothers (ultrarapid metabolisers risk per FDA 2017))

Non-pharmacologic actions:
- Iron-rich diet counseling (red meat, leafy greens, legumes; vitamin C co-administration) per WHO 2017
- Pelvic rest and progressive activity per surgical recovery timeline (no heavy lifting > 4-6 wk if hysterectomy / laparotomy)
- Contraception counseling at 6-week visit — short interval (<18 mo) increases recurrent PPH risk per ACOG 736 (2018)
- Lactation support + referral to lactation consultant if delayed lactogenesis (common after severe PPH) per ACOG 183 (2017)
- Mental health support — refer to perinatal mental health if EPDS ≥10 or PTSD screen positive; PPH is a recognised PPD/PTSD precursor per ACOG 757 (2018)
- Future-pregnancy aspirin / pregnancy-planning consult if PPH related to PAS / pre-eclampsia / chronic medical condition
- Document PPH cause + management for next-pregnancy delivery planning (e.g., uterotonic-resistance, surgical-history alert)

AVOID / contraindication checks:
- Methylergonovine contraindicated in hypertension/pre eclampsia (ACOG 183 2017)
- Carboprost contraindicated in asthma (ACOG 183 2017)
- TXA must be given within 3h of birth for mortality benefit (WOMAN Trial Shakur Lancet 2017)
- Do not delay hysterectomy if life threatening hemorrhage refractory to all measures (ACOG 183 2017)
- Avoid excessive crystalloid resuscitation — dilutional coagulopathy risk (RCOG GTG 52 2016)
- Recombinant factor VIIa only as last resort due to thrombotic risk (RCOG GTG 52 2016)

Monitoring

Regimen monitoring:
- Quantitative EBL using calibrated drapes and gravimetric weighing per CMQCC PPH Toolkit (2022)
- Vitals q5–15 min during active hemorrhage per CMQCC (2022)
- CBC + coags + fibrinogen q30–60 min during MTP per RCOG GTG 52 (2016)
- Urine output q1h target ≥30 mL/h per ACOG 183 (2017)
- Uterine fundal tone q15 min per ACOG 183 (2017)
- Lactate and ABG q2–4h in hemorrhagic shock per WHO 2023 PPH
- Temperature monitoring — hypothermia worsens coagulopathy per RCOG GTG 52 (2016)

Setting (outpatient) monitoring:
- 2-week Hgb / ferritin / iron studies; repeat at 6 weeks if iron-deficient
- EPDS + PTSD screening at 2-wk + 6-wk visits per ACOG 757 (2018)
- Lochia and fundal assessment at 2-wk visit per ACOG 183 (2017) — rule out subinvolution / retained products / endometritis (late secondary PPH risk window through 12 wk)
- Wound assessment if surgical management (laparotomy / cesarean) at 2-wk visit
- BP screen at every visit (postpartum hypertension up to 6 wk per AHA 2021 — overlap with pre-eclampsia surveillance)

Follow-up plan: 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)
- Close-out criterion: Postpartum recovery plan + recurrence counseling documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Post-discharge PPH recovery — 2-week postpartum Hgb check + iron repletion (oral if mild, IV iron if severe / non-tolerant), 6-week comprehensive postpartum visit (recovery, lactation, future-pregnancy counseling with recurrence ~10-15% per ACOG 183 (2017)), psychosocial screen (PPH increases PPD/PTSD risk per ACOG 183 (2017) + AHA postpartum mental-health guidance 2024), VTE prophylaxis assessment if extended bed-rest / surgical management per RCOG GTG 52 (2016)

Disposition criteria:
- 6-week postpartum visit: Hgb >10 g/dL trend, ferritin >50 ng/mL, EPDS <10, wound healed, no active bleeding, contraception/future-pregnancy plan documented → transition to routine primary care + annual well-woman care per ACOG 736 (2018)
- Iron repletion completed (ferritin >50 ng/mL + Hgb >12 g/dL stable × 4 wk) → discontinue iron supplementation
- VTE prophylaxis completed at 6 wk post-surgical management → discontinue enoxaparin

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] SBP <90 mmHg or MAP <65 or Shock Index >1.0 or altered mental status with PPH per WHO 2023 PPH

Citations

- 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) [PMID:28937571](https://pubmed.ncbi.nlm.nih.gov/28937571/)
- Cited evidence (PMID 29100880) [PMID:29100880](https://pubmed.ncbi.nlm.nih.gov/29100880/)
- Cited evidence (PMID 34736271) [PMID:34736271](https://pubmed.ncbi.nlm.nih.gov/34736271/)
- Cited evidence (PMID 28456509) [PMID:28456509](https://pubmed.ncbi.nlm.nih.gov/28456509/)
- Cited evidence (PMID 37158447) [PMID:37158447](https://pubmed.ncbi.nlm.nih.gov/37158447/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 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) — PMID:28937571
  • Cited evidence (PMID 29100880) — PMID:29100880
  • Cited evidence (PMID 34736271) — PMID:34736271
  • Cited evidence (PMID 28456509) — PMID:28456509
  • Cited evidence (PMID 37158447) — PMID:37158447