ICU Basics

Hemorrhage and transfusion

Postpartum Hemorrhage Algorithm

Quantify and stage, treat the 4 Ts, escalate early

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Call for help and quantify: which stage?

  • Call the obstetric provider, anesthesia and the charge nurse; activate the hemorrhage protocol
  • Quantify, do not estimate: weigh pads and sponges (1 g = 1 mL), calibrated drapes and canisters; call out the running total
  • Two large-bore IVs with warmed crystalloid, monitor, oxygen; type and crossmatch, CBC, fibrinogen, coagulation; keep her warm
  • PPH (ACOG): 1,000 mL or more, or any loss with signs of hypovolemia, within 24 hours; WHO 2025 acts at 500 mL, or 300 mL with abnormal vital signs

Stage 1: over 500 mL vaginal or 1,000 mL cesarean, or HR 110 or more, BP 85/45 or less, SpO₂ under 95% → step 2Stage 2: still bleeding, total under 1,500 mL → step 3Stage 3: over 1,500 mL, over 2 units given, unstable, or DIC suspected → step 4Stage 4: cardiovascular collapse → step 5

2 Stage 1: massage, oxytocin, tranexamic acid

  • Firm fundal massage; empty the bladder
  • Oxytocin 10–40 units in 500–1,000 mL IV as a continuous infusion, or 10 units IM if no IV
  • Tranexamic acid 1 g IV over 10 minutes within 3 hours of birth; repeat once after 30 minutes if bleeding continues (WOMAN, WHO)
  • Vital signs every 5–15 minutes with the running blood loss total

Uterus still soft → step 6Uterus firm, still bleeding → step 7Bleeding controlled → step 8

3 Stage 2: bimanual compression, balloon, blood

  • Bring in a second obstetric provider, anesthesia and the OR team; blood bank on alert
  • Bimanual uterine compression by the provider while drugs and devices are readied
  • Intrauterine balloon (Bakri up to 500 mL) or vacuum device (Jada): record fill volume and hourly drain output; watch fundal height
  • Transfuse red cells by clinical signs without waiting for labs; TXA (within 3 hours of birth) and second-line drugs if not yet given

Bleeding controlled → step 8Look for the cause: 4 Ts → step 7Over 1,500 mL, unstable, or DIC suspected → step 4

4 Stage 3: massive transfusion

  • Activate the massive transfusion protocol: red cells, plasma and platelets near 1:1:1
  • Fibrinogen under 200 mg/dL: cryoprecipitate 10 units or fibrinogen concentrate
  • Calcium with transfusion (keep ionized calcium over 1.1 mmol/L); warm every product; labs every 30–60 minutes
  • Rapid infuser, arterial line, urinary catheter with hourly output; move to the OR

Next: definitive control → step 9Cardiovascular collapse → step 5

5 Stage 4: cardiovascular collapse

  • Pulseless: CPR and ACLS; code team, obstetric surgeon and anesthesia to the bedside
  • Massive transfusion through rapid infusers with calcium; hypovolemia is the usual cause
  • Immediate surgical control, usually hysterectomy
  • Sudden collapse with hypoxemia and DIC out of proportion to the bleeding: think amniotic fluid embolism (MTP, TXA, VA-ECMO)

End of this path.

6 Second-line uterotonics: check contraindications

  • Methylergonovine 0.2 mg IM every 2–4 hours; not with hypertension, preeclampsia or strong CYP3A4 inhibitors
  • Carboprost 0.25 mg IM every 15–90 minutes, max 8 doses; not with asthma
  • Misoprostol 600–1,000 mcg PO, SL or rectal, once; fever and shivering are common
  • Keep the oxytocin running; the provider checks for other causes meanwhile

Still bleeding → step 3Bleeding controlled → step 8

7 Find the cause: the 4 Ts

  • Tone: a soft uterus (atony) is the most common cause: massage and uterotonics
  • Trauma: inspect cervix, vagina and perineum with good light and analgesia; repair tears; drain an expanding hematoma
  • Tissue: check the placenta is complete; retained pieces need manual removal; an adherent placenta (accreta) goes to the OR
  • Inversion (no fundus felt, mass in the vagina): stop uterotonics; the provider replaces it at once, then restarts them
  • Thrombin: oozing sites or blood that will not clot: send fibrinogen; think abruption, amniotic fluid embolism or DIC

Atony: second-line uterotonics → step 6Still bleeding → step 3

8 Bleeding controlled: watch closely

  • Vital signs, fundal height and bleeding every 15 minutes at first; report a rising fundus or new bleeding
  • Keep oxytocin running; recheck hemoglobin, fibrinogen, coagulation and ionized calcium
  • Watch for TACO or TRALI, AKI, Sheehan syndrome and VTE; start VTE prophylaxis once bleeding risk allows
  • Debrief the team; explain what happened to the patient and family

End of this path.

9 Definitive control: OR or interventional radiology

  • Unstable or bleeding fast: OR for compression sutures (B-Lynch) and uterine or internal iliac artery ligation
  • Stable, with IR ready now: uterine artery embolization
  • Hysterectomy without delay when these fail; it is the planned route for accreta

Bleeding controlled → step 8Collapse or arrest → step 5

Drugs in this algorithm

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