Definition and Classification
Primary PPH: ≥500 ml blood loss within 24 hours of delivery (vaginal birth); ≥1000 ml (caesarean section). Major PPH: >1000 ml.
Secondary PPH: abnormal or excessive bleeding from 24 hours to 12 weeks postpartum — usually due to retained products or infection.
PPH complicates approximately 1–5% of deliveries in the UK and is a leading cause of maternal mortality. Recognising it early and acting systematically is the focus of this OSCE station.
The 4Ts — Causes of PPH
| T | Cause | Frequency |
|---|---|---|
| Tone | Uterine atony (failure to contract) | 70–80% |
| Trauma | Lacerations (perineal, vaginal, cervical, uterine rupture) | 10–20% |
| Tissue | Retained placenta/membranes | 5–10% |
| Thrombin | Coagulopathy (DIC, pre-existing clotting disorder) | 1–2% |
💡 Tip
Tone (atony) is by far the most common cause — always address this first. Bimanual uterine massage and uterotonics are first-line.
Immediate Management — ABCDE Approach
Shout for Help
"I need help — this is a major obstetric haemorrhage. Please call the obstetric consultant, anaesthetist, midwife in charge, and haematologist."
A — Airway and B — Breathing
High-flow oxygen via non-rebreather mask (15 L/min)
C — Circulation
- Two large-bore IV cannulae (14–16G)
- Take bloods: FBC, coagulation, group and crossmatch (6 units), fibrinogen, U&E, LFTs
- Begin IV crystalloid resuscitation; consider transfusion early
- Activate major haemorrhage protocol
Treat the cause (4Ts)
Tone: Bimanual uterine compression; oxytocin 10 units IV (slow bolus); ergometrine 500mcg IM (if not hypertensive); oxytocin infusion 40 units in 500ml over 4 hours; carboprost (Hemabate) 250mcg IM every 15 min (max 8 doses, avoid in asthma); misoprostol 1000mcg PR; tranexamic acid 1g IV
Trauma: Direct pressure on perineal tears; repair lacerations; theatre if uterine rupture suspected
Tissue: Examine placenta for completeness; manual removal under anaesthesia if retained
Thrombin: Fresh frozen plasma, cryoprecipitate, platelets (replace 1:1:1 ratio with PRBCs)
Communication During the Emergency
Clear team communication is marked in OSCE stations:
- Use closed-loop communication: state name of person you're addressing + task + confirmation back
- Designate roles: one person leads, one documents, one manages IV access
- Call early — do not delay calling for help until the situation is critical
⚠️ Red Flag
PPH can deteriorate rapidly — a patient who appears stable can decompensate within minutes. Call for help early, even if you're not yet certain the blood loss is major.
Mark Scheme Checklist
- ✓Recognises PPH and calls for help immediately
- ✓ABCDE approach with oxygen, IV access, bloods
- ✓Activates major haemorrhage protocol
- ✓Bimanual uterine compression performed
- ✓Uterotonics given in correct order (oxytocin → ergometrine → carboprost)
- ✓Addresses all 4Ts systematically
- ✓Clear team communication throughout
- ✓Monitors vital signs and documents blood loss
Frequently Asked Questions
"What are the 4Ts of postpartum haemorrhage and what is the most common cause?"
The 4Ts are the four main causes of PPH: Tone (uterine atony), Trauma (lacerations or uterine rupture), Tissue (retained placenta or membranes), and Thrombin (coagulopathy including DIC). Tone — specifically uterine atony, where the uterus fails to contract adequately after delivery — accounts for 70–80% of all PPH cases. The uterus normally contracts to compress the spiral arteries following placental separation; if it remains flaccid, blood loss is rapid and can be life-threatening. All management of suspected PPH should begin by addressing tone: bimanual uterine compression and the administration of uterotonics.
"What is the correct order of uterotonics in PPH management?"
First-line: oxytocin 10 units IV as a slow bolus (given at the time of birth to all women, or as treatment if bleeding occurs). Second-line: ergometrine 500 mcg IM or IV (contraindicated in hypertension or pre-eclampsia — causes vasoconstriction). An oxytocin infusion (40 units in 500 ml over 4 hours) should be started concurrently. If bleeding continues: carboprost (Hemabate) 250 mcg IM every 15 minutes, up to 8 doses — contraindicated in asthma (causes bronchospasm). Misoprostol 1000 mcg rectally is used if carboprost is unavailable or contraindicated. Tranexamic acid 1 g IV should be given within 3 hours of birth. If uterotonics fail, surgical intervention (B-Lynch suture, uterine artery ligation, hysterectomy) may be required.
"When should you activate the major haemorrhage protocol?"
The major haemorrhage protocol should be activated when blood loss exceeds 1000 ml, when blood loss is rapid and ongoing regardless of volume, when there are signs of haemodynamic compromise (hypotension, tachycardia, pallor, reduced consciousness), or when you anticipate that the patient will require blood transfusion. Activating the protocol early triggers: release of group O negative blood immediately (before crossmatch), FFP and platelets from the blood bank, haematology phone support, and a coordinated response from the wider team including anaesthetics and ITU. Do not wait until the patient is in cardiac arrest — early activation saves lives.
"What is bimanual uterine compression and how is it performed?"
Bimanual uterine compression is a manual technique to stimulate uterine contraction by direct mechanical pressure. The technique: one hand is placed inside the uterus (anteriorly, as a fist) via the vagina, while the other hand presses firmly on the fundus abdominally (posteriorly). The uterus is compressed between the two hands. This is performed simultaneously with administering uterotonics. It provides immediate tamponade of bleeding while drugs take effect. In an OSCE simulation, describe the technique clearly even if performing on a mannequin — examiners mark the description and the rationale as much as the physical technique.
"What blood products are used in major PPH and in what ratio?"
In major PPH, the aim is to maintain haemostasis while replacing volume. Red blood cells (PRBCs) restore oxygen-carrying capacity. Fresh frozen plasma (FFP) replaces clotting factors — DIC is a common complication of major haemorrhage. Cryoprecipitate provides fibrinogen (target >2 g/L in obstetric haemorrhage). Platelets are transfused when the count falls below 75 × 10⁹/L in active haemorrhage. The current major haemorrhage protocol recommends transfusion in a 1:1:1 ratio of PRBCs:FFP:platelets (the so-called "damage control resuscitation" approach). Fibrinogen replacement is particularly important in obstetric haemorrhage — request cryoprecipitate (each pool contains approximately 3–4 g fibrinogen) early.
"What are the surgical options if uterotonics fail in PPH?"
If medical management fails, escalate promptly to surgical intervention. Options in order of invasiveness: intrauterine balloon tamponade (e.g., Bakri balloon) — inflated with saline to tamponade the uterine cavity; B-Lynch compression suture — a brace suture placed around the uterus at laparotomy to cause sustained compression; uterine artery ligation — bilateral ligation reduces uterine blood supply by 90%; internal iliac artery ligation — technically demanding, reduces pelvic blood flow; and hysterectomy — the definitive treatment when all else fails. In interventional radiology centres, uterine artery embolisation (UAE) may be used in haemodynamically stable patients. The decision to proceed must be made early by the senior obstetrician — delay is dangerous.
Related guides: Gynaecology and Obstetric History OSCE · Shock Assessment OSCE · Blood Transfusion OSCE · Clinical Handover and Escalation OSCE · Fluid Balance OSCE