Episode Overview

Title: Episode #11: Manage Postpartum Hemorrhage Like a Pro (Part 1): Prevention and Initial Management
Host: Dr. KC Miller
Date: May 10, 2025

This episode of The OB/GYN Resident Survival Guide delves into the critical topic of postpartum hemorrhage (PPH), focusing on its definition, risk factors, causes, prevention, and the crucial steps of initial management. Dr. KC Miller draws on ACOG guidelines, textbook pearls, and practical experience to provide high-yield tips for medical students and OB/GYN residents—arming listeners with actionable strategies to confidently recognize, prevent, and address early PPH in the clinical setting.

Key Discussion Points & Insights

1. Definition and Incidence of Postpartum Hemorrhage

• Definition (ACOG criteria):

  • PPH = Cumulative blood loss ≥1000 mL or any blood loss with signs/symptoms of hypovolemia within 24 hours of birth, regardless of delivery mode.
  • (01:00) Quote:
    “The definition of postpartum hemorrhage has varied over time. Most recently, the American College of Obstetricians and Gynecologists supports the criteria for postpartum hemorrhage as a cumulative blood loss of 1000 mL or greater or any blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process...regardless of the mode of delivery.” — Dr. KC Miller

• Incidence:

  • ~3–5% of all deliveries are complicated by PPH.
  • PPH remains the leading global cause of maternal mortality.

2. Normal Postpartum Blood Loss & Recognition

• Expected averages:

  • Vaginal delivery: ~500 mL
  • Cesarean: ~1000 mL

• Delayed clinical signs:

  • Due to physiologic changes in pregnancy, tachycardia and hypotension occur late—patients may lose up to 25% of blood volume (~1.5 L) before showing vital sign changes.
  • (03:00) Quote:
    “By the time a patient is tachycardic and hypotensive, they've actually already lost 25% of their blood volume, which is approximately one and a half liters. So it's very important to identify an evolving postpartum hemorrhage and intervene before the vital signs even start to deteriorate.” — Dr. KC Miller

3. Risk Factors for Postpartum Hemorrhage

• Common contributors:

  • Uterine overdistension (macrosomic baby, polyhydramnios, multifetal gestation, fibroids)
  • Prolonged use of pitocin
  • Intraamniotic infection (chorioamnionitis)
  • General anesthesia
  • Grand multiparity
  • Precipitous delivery

• Reference: Complete list in Table 1 of ACOG Practice Bulletin #183 (see show notes).

4. Categories and Causes of Hemorrhage

• Timing:

  • Primary (early) PPH: within 24 hours of birth
  • Secondary (late) PPH: 24 hours – 12 weeks postpartum

• Main causes of primary PPH:

  • Uterine atony (most common): failure of uterus to contract and compress blood vessels after placental separation
  • Lacerations (vagina, cervix, perineum)
  • Retained placental fragments
  • Abnormally adherent placenta (accreta spectrum)
  • Coagulation defects (ex: DIC)
  • Uterine inversion

• (07:10) Quote:
  “The number one cause of primary postpartum hemorrhage is uterine atony, which is the inability of the uterine myometrium to effectively contract.” — Dr. KC Miller

5. Prevention: Active Management of Third Stage of Labor

• Components:

  • Pitocin administration (after delivery of the baby)
  • Uterine massage
  • Umbilical cord traction to facilitate placental delivery

• (09:00) Quote:
  “We prevent postpartum hemorrhage via active management of the third stage of labor...by administering pitocin at the same time as performing uterine massage and umbilical cord traction to facilitate placental delivery.” — Dr. KC Miller

6. Initial Management Steps for Postpartum Hemorrhage

Dr. Miller outlines a systematic bedside approach to the bleeding patient post-delivery:

Step 1: Confirm Pitocin is Running

• Double check that postpartum pitocin is infusing—it is sometimes omitted or turned off inadvertently.

Step 2: Assess for Uterine Atony

• Perform a bimanual exam:
  • One hand internal (cervix/lower uterine segment), one hand external (fundus).
  • Assess if uterus is firm. If not—perform bimanual massage.
• Remove any palpable clots that may prevent uterine contraction.

Step 3: Address Bladder Status

• Bladder distension can impede uterine contractility—drain if necessary.

• (12:40) Quote:
  “Oftentimes patients have been pushing for many hours without a Foley or the chance to empty their bladder. So if this is the case, just go ahead and drain the bladder so we can at least eliminate that as a contributing factor.” — Dr. KC Miller

Step 4: Ongoing Assessment & Team Activation

• Monitor blood loss (quantify, not just estimate).
  • If rapid or approaching 500 mL, escalate care:
    • Initiate postpartum hemorrhage protocol
      • Secure two IV lines
      • Administer IV fluid boluses (500 mL–1 L NS or LR)
      • Bring hemorrhage medications to bedside
      • Maintain normothermia (blankets, warming)

Step 5: Rule Out and Repair Lacerations

• Systematically inspect vagina, cervix, perineum for trauma as bleeding source.

Step 6: Uterine Sweep

• If atony persists and no lacerations are found, insert a (gloved) hand into the uterus to feel for and remove any retained placental tissue or membranes.

• (16:50) Quote:
  “If there are no hemorrhaging lacerations and the uterus is still atonic, you should consider performing a uterine sweep...to palpate for any remaining placental fragments or membranes that could be stuck inside and remove them.” — Dr. KC Miller

Notable Quotes & Memorable Moments

• (01:00) “Postpartum hemorrhage...is the leading cause of maternal mortality worldwide.”
• (03:20) “Identify an evolving postpartum hemorrhage and intervene before the vital signs even start to deteriorate.”
• (07:10) “The number one cause of primary postpartum hemorrhage is uterine atony...”
• (09:00) “We prevent postpartum hemorrhage via active management of the third stage of labor...”
• (12:40) “Just go ahead and drain the bladder so we can at least eliminate that as a contributing factor.”

Summary & Review (20:45)

• Definition: Cumulative blood loss ≥1000 mL, or any significant loss with hypovolemia within 24 hours post-birth.
• Primary PPH: <24 hours post-birth (main focus of this episode)
• Most common cause: Uterine atony
• Prevention: Active management of third stage (pitocin, massage, controlled cord traction)
• First response:
  • Bimanual exam & massage
  • Drain bladder
  • Assess for and repair lacerations
  • Confirm no retained placental tissue

Next episode: Dr. Miller will discuss pharmacologic, mechanical, and intraoperative PPH interventions.

Timestamps for Key Segments

| Segment | Timestamp | |----------------------------------------------------|-----------| | Definition & incidence | 01:00 | | Blood loss assessment & vital signs | 03:00 | | Risk factors | 04:10 | | Types of PPH and causes | 07:10 | | Prevention: Active management | 09:00 | | Initial management steps (practical approach) | 11:30 | | Addressing bladder status | 12:40 | | Team activation and escalation | 14:30 | | Uterine sweep for retained products | 16:50 | | Summary review | 20:45 |

Tone and Takeaways

Dr. Miller’s approach is concise, practical, and filled with actionable advice, reflecting her recent residency experience and focus on efficient, safe patient care.

Memorable Close: “Stay tuned for next week's episode where we will review the pharmacologic, mechanical and intraoperative interventions that can be used to manage postpartum hemorrhage.” (21:30)

Further Resources

• ACOG Practice Bulletin #183
• OB/GYN Residency Starter Pack (link in show notes)
• Follow Dr. KC Miller (@drkcmiller) on social media for more tips

This summary delivers the key learning points and bedside strategies for initial recognition, prevention, and management of primary postpartum hemorrhage, making it a valuable standalone resource for medical trainees and clinicians alike.