Postpartum Hemorrhage: What OB-GYNs and Midwives Do to Prevent the Leading Cause of Maternal Death

Postpartum hemorrhage (PPH) is excessive bleeding after childbirth and remains the leading cause of maternal death worldwide. Effective postpartum hemorrhage prevention starts before labor and continues into the first 24 hours after birth. Here's how OB-GYNs and midwives work together to reduce risk and keep mothers safe.

1. Antenatal Risk Assessment and Preparation

Early identification of risk factors allows for tailored care plans:

• Review maternal history for prior PPH, anemia, preeclampsia, multiple pregnancy or uterine fibroids
• Screen for and treat anemia (iron, folate supplementation) to optimize blood reserves
• Monitor blood pressure and glycemic control in hypertensive or diabetic mothers
• Plan birth location with appropriate resources (blood bank access, skilled staff)
• Educate the birthing person on PPH signs and when to call for help

A clear antenatal plan is the first step in successful postpartum hemorrhage prevention.

2. Active Management of the Third Stage of Labor

The "third stage" is the interval between delivery of the baby and delivery of the placenta. Active management reduces blood loss by nearly 60% compared to expectant (watchful) management:

1. Uterotonic Drug Administration
   • Oxytocin (10 IU IM or IV) immediately after baby's birth
   • Alternative uterotonics (if oxytocin unavailable or contraindicated):
     • Misoprostol (600 – 1000 µg orally/rectally)
     • Ergometrine (200 µg IM) or combination (e.g., Syntometrine®)
     • Carboprost tromethamine (250 µg IM) in refractory cases
2. Controlled Cord Traction
   • Gentle, steady traction on the umbilical cord while supporting the uterine fundus to deliver the placenta
3. Uterine Massage
   • Immediate and regular massage of the uterine fundus to encourage firm contraction

By standardizing these steps, care teams significantly lower the incidence of PPH.

3. Pharmacological Adjuncts and Tranexamic Acid

In addition to first-line uterotonics, two key medications further improve outcomes:

• Tranexamic Acid (TXA)
  • An antifibrinolytic that helps stabilize clots
  • Administer 1 g IV as soon as PPH is recognized, ideally within 3 hours of birth
• Additional Uterotonics (if bleeding persists)
  • Repeat oxytocin infusion (10 IU in 500 mL IV fluid)
  • Higher doses of misoprostol or ergometrine as per hospital protocol

Timely use of TXA is endorsed by the WHO and ACOG for postpartum hemorrhage prevention and treatment.

4. Non-Pharmacological and Mechanical Measures

When drugs alone are not enough, OB-GYNs and midwives employ mechanical strategies:

• Uterine Balloon Tamponade
  • Insertion of a balloon device (e.g., Bakri® balloon) into the uterus, inflated with saline to apply direct pressure
• Non-Pneumatic Anti-Shock Garment (NASG)
  • A low-resource intervention that applies compression to lower limbs and abdomen to maintain blood flow to vital organs
• Bimanual Uterine Compression
  • Manual technique to compress the uterus internally and externally until definitive measures take effect

Choosing the right mechanical method depends on available resources and severity of bleeding.

5. Teamwork, Protocols, and Drills

Well-rehearsed emergency protocols ensure swift, coordinated care:

• Hemorrhage Response Teams
  • OB-GYN, anesthesiologist, midwife/nurse, blood bank staff on standby
• Standardized PPH Kits/Carts
  • Pre-assembled trays with uterotonics, IV fluids, TXA, balloon tamponade device, surgical instruments
• Simulation Drills and Checklists
  • Regular practice sessions to sharpen skills in recognizing and managing PPH
• Clear Communication Tools
  • Use of SBAR (Situation-Background-Assessment-Recommendation) for rapid hand-offs

These measures reduce delays in critical decision-making and treatment.

6. Postpartum Monitoring and Early Detection

Vigilant observation in the first 24 hours after birth allows for immediate intervention:

• Frequent Vital Signs Checks
  • Blood pressure, heart rate, respiratory rate every 15–30 minutes initially
• Quantification of Blood Loss
  • Use of calibrated drapes or weighing blood-soaked materials instead of visual estimates
• Fundal Checks
  • Palpate the uterine fundus to ensure it remains firm and contracted
• Fluid Balance Monitoring
  • Track intake/output (IV fluids, urine, estimated blood loss)

Early detection through diligent monitoring is a cornerstone of postpartum hemorrhage prevention.

7. Patient Education and Empowerment

Informed mothers and families contribute to safer outcomes:

• Explain normal postpartum bleeding versus warning signs (soaking > 1 pad/hour, dizziness, palpitations)
• Encourage reporting any sudden increase in bleeding or feeling faint
• Discuss the importance of staying near help (hospital room or reliable home visits)
• Provide written and verbal instructions before discharge

Clear communication helps birthing people recognize when to seek immediate help.

8. Special Considerations in Low-Resource Settings

Preventing PPH in settings with limited resources relies on creative strategies:

• Advance distribution of misoprostol to pregnant people for use if oxytocin is unavailable
• Training of traditional birth attendants and midwives in Active Management of Third Stage of Labor (AMTSL)
• Community health worker programs for early referral
• Use of the non-pneumatic anti-shock garment to stabilize women during transport

These interventions align with WHO guidelines for postpartum hemorrhage prevention where blood products and advanced care may not be immediately accessible.

9. A Note on Broader Health Screening

While focusing on PPH, comprehensive postpartum care includes screening for other conditions. If you're experiencing unexplained fever, fatigue, or flu-like symptoms during pregnancy or postpartum, consider using a free Acute HIV Infection symptom checker to understand your symptoms and determine if you need immediate medical attention.

10. When to Escalate Care

If bleeding continues despite first-line measures:

• Call for senior OB-GYN support
• Prepare for surgical interventions (e.g., uterine compression sutures, artery ligation, hysterectomy)
• Ensure availability of blood transfusion and intensive monitoring

Rapid escalation can be life-saving when conservative measures fail.

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Postpartum hemorrhage prevention is a multi-step process involving careful planning, active management of the third stage of labor, vigilant monitoring, and rapid response to bleeding. OB-GYNs and midwives rely on evidence-based protocols, teamwork, and clear communication to protect mothers from life-threatening complications.

If you or a loved one experience heavy bleeding after childbirth, or if you have questions about any part of your care, please speak to a doctor immediately. Always reach out for professional medical advice about anything that could be life-threatening or serious.