Management of Postpartum Hemorrhage: Recommendations From FIGO

Key points

• Oxytocin given between delivery of the infant and the placenta is the most effective intervention to prevent postpartum hemorrhage.
• Tranexamic acid, 1 g intravenously over 10 minutes within three hours of delivery, is recommended after at least 500 mL of blood loss after vaginal delivery or 1,000 mL after cesarean delivery, and reduces mortality by up to 30%.
• Uterine balloon tamponade used before shock controls more than 80% of hemorrhages that do not respond to initial interventions.
• The nonpneumatic antishock garment reduces maternal mortality by 48%.
• Until major bleeding is controlled, the target systolic blood pressure is 80 to 90 mm Hg.

Overview

This American Family Physician practice guideline summarizes the International Federation of Gynecology and Obstetrics (FIGO) recommendations on preventing and managing postpartum hemorrhage. The American College of Obstetricians and Gynecologists defines it as blood loss of at least 1,000 mL, or blood loss with signs of hypovolemia, within 24 hours of delivery. It complicates up to 1 in 10 deliveries, is the leading cause of maternal morbidity and mortality worldwide, and most cases occur unexpectedly despite known risk factors.

Prevention and causes

Uterotonics such as oxytocin given between delivery of the baby and the placenta are the key preventive step. Combining oxytocin with ergometrine or misoprostol may be more effective but causes more adverse effects; misoprostol may be used alone if oxytocin is not available. Sustained uterine massage is not recommended after oxytocin. Causes follow the four Ts: tone (uterine atony, 70%), trauma (birth canal injury, 20%), tissue (retained placenta or uterine clot) and thrombin (any coagulation problem).

Initial response and shock assessment

Treatment is stepwise, starting with the least invasive measures: uterine massage, two large-bore intravenous catheters, supplemental oxygen, strict monitoring, isotonic crystalloid infusion and avoidance of hypothermia. Safety bundles organize the response around readiness, recognition and prevention, response, and reporting and systems learning. Vital signs change late, so the shock index (heart rate divided by systolic blood pressure) is used: 0.9 or greater is associated with increased mortality, and greater than 1 makes transfusion more likely. Under the rule of 30, a 30% drop in hematocrit or hemoglobin, a 30 mm Hg fall in systolic pressure and a pulse increase of 30 beats per minute suggest 30% blood loss. A second tranexamic acid dose can be given 30 minutes after the first if bleeding continues.

Nonsurgical and surgical management

Balloon tamponade is both diagnostic and therapeutic and is recommended for bleeding that persists despite uterotonics and tranexamic acid; used before advanced shock, fewer than 1 in 5 patients need further intervention. The antishock garment compresses the lower body to stabilize the patient before surgery, transfusion or transfer. Where interventional radiology is immediately available, uterine artery embolization is at least 90% effective and likely to preserve fertility. Uterine compression sutures had a 92% success rate in studies; temporary uterine artery ligation and bilateral internal iliac artery ligation each succeed about 40% of the time; peripartum hysterectomy is definitive but has high morbidity. Massive transfusion means four or more units of packed red blood cells within 24 hours, and the mean arterial pressure target is 50 to 60 mm Hg until bleeding is controlled.

Frequently asked questions

What is the best way to prevent postpartum hemorrhage?

Giving a uterotonic such as oxytocin between delivery of the baby and the placenta is the most effective preventive intervention.

When should tranexamic acid be given?

For blood loss of at least 500 mL after vaginal delivery or 1,000 mL after cesarean delivery, as 1 g intravenously over 10 minutes within three hours of delivery.

Why are vital signs not enough to detect shock?

Vital signs change late, after high-volume blood loss, so tools such as the shock index and the rule of 30 are used.

Source

Hwang DS, Myers L. Management of Postpartum Hemorrhage: Recommendations From FIGO. American Family Physician. 2023;107(4):438-440. Summary of the International Federation of Gynecology and Obstetrics guideline published in Int J Gynaecol Obstet. 2022;157(suppl 1):3-50. Coverage of the guideline does not imply endorsement by AFP or the AAFP. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.