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Postpartum Hemorrhage from Atony Unresponsive to First Line Uterotonics

Author: Efua Leke, MD

Mentor: Tiffany A. Moore-Simas, MD
Editor: Sangini Sheth, MD

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Primary postpartum hemorrhage (PPH), a leading cause of severe maternal morbidity in the US, is defined as cumulative blood loss of ≥1000 ml and signs of hypovolemia during the 24 hours following delivery. Uterine atony is the most common etiology of PPH, and risk can be decreased with active third stage labor management including oxytocin administration, uterine massage, and controlled cord traction. 

Initial efforts to achieve a firmly contracted uterus should simultaneously include bladder emptying, bimanual uterine examination with evacuation of clot and retained products, and fundal massage. Subsequent treatment options include administration of uterotonics, antifibrinolytic agents, tamponade of the uterus, surgical techniques to control bleeding, embolization of pelvic arteries, or ultimately hysterectomy. Less invasive methods are tried initially and if unsuccessful, more invasive measures may be required. Systematic approaches to PPH based on algorithms that utilize a multidisciplinary team with a multi-faceted, stepwise approach to detection and management are encouraged. IV access, hemodynamic monitoring, and anesthesia support should be established early.  Additionally, a formalized approach to blood loss quantification should be implemented.

In addition to oxytocin, supplemental uterotonics should be administered in rapid succession; no evidence supports greater efficacy of one over the other.

  • Repeat oxytocin (10-40 units/500-1,000 ML continuous IV infusion versus 10 units IM)
  • Methylergonovine (Methergine) 0.2 mg IM q 2-4 hours (avoid with hypertension)
  • 15-methyl PGF2α (Carboprost, Hemabate) 0.25 mg IM or directly into uterine myometrium q15 minutes up to 8 doses (avoid with asthma)

Misoprostol, oral or sublingual, should only be considered for patients with both asthma and hypertension due to high rates of side effects and efficacy that is inconsistent. The antifibrinolytic agent tranexamic acid should be given (1g IV) when initial medical therapy fails, as recent randomized trials support reduction in bleeding without adverse effects. When atony persists, prompt curettage should be performed in conjunction with ultrasound to ensure an empty uterus.

Uterine tamponade techniques should be considered next including manual compression, packing (typically with thrombin-soaked gauze), or insertion of a balloon device (Foley catheter, Sengstaken-Blakemore tube, or commercial products including Bakri balloon or the ebb uterine tamponade system). Balloon devices are typically kept in place between 6-48 hours with periodic reassessment and progressive deflation while clinical resolution is evaluated. A novel intrauterine vacuum device (Jada system) has also been demonstrated to induce rapid tamponade of bleeding due to atony. Choice of tamponade technique should be guided by product availability and provider experience. Antibiotics are often administered while tamponade products are in situ.

Vascular embolization by interventional radiology can be considered when available for stable patients with continued blood loss.  Arterial embolization has shown a median success rate of 89%.  Risk of harm including uterine necrosis, DVT, or peripheral neuropathy is low.

With failure of these lesser invasive efforts, exploratory laparotomy should be performed, typically via vertical midline skin incision to optimize exposure. In the setting of cesarean delivery, the existing surgical incision can be used.  Several techniques are available to control bleeding with limited evidence for each: 

  • Vascular Ligation: General aim is to diminish pulse pressure of blood flowing to uterus:
    • Bilateral uterine vessel ligation (O’Leary stitch technique)
    • Bilateral ligation of vessels within utero-ovarian ligaments
    • Internal iliac (hypogastric) artery ligation – less successful than previously thought and providers are frequently unfamiliar with this retroperitoneal technique
  • Uterine Compression Sutures:
    • B-Lynch technique
    • Hemostatic square suturing of the anterior and posterior uterine wall (Cho technique)

Hysterectomy is typically employed as a last resort after less morbid options have been exhausted. However, it may be necessary as a life-saving procedure.

Replacement of intravascular volume with fluids should be on-going.  In women with continued bleeding and current blood loss ≥ 1,500 ml, or abnormal vital signs, transfusion of blood products including the repletion of coagulation factors is needed.  Massive transfusion protocols with multicomponent therapy including fixed ratios of packed red blood cells, plasma, platelets, and cryoprecipitate should be part of a comprehensive management plan for PPH treatment.


Further Reading:

ACOG Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130(4):e168-e186. doi: 10.1097/AOG.0000000000002351.

California Maternal Quality Care Collaborative (CMQCC) Obstetric Hemorrhage 2.0 Toolkit. Available for download at

Initial Approval:  January 2017; Revised September 2018; Reaffirmed March 2020 and November 2021. Revised July 2023


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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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