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Postpartum hemorrhage (PPH) is defined as blood loss exceeding 500 mL after vaginal delivery or 1000 mL after cesarean section, or any blood loss causing hemodynamic instability. It remains one of the leading causes of maternal morbidity and mortality worldwide, occurring in approximately 3-5% of deliveries. Early recognition and prompt management are critical to prevent severe complications including shock, coagulopathy, and maternal death.
PPH occurs due to four primary mechanisms: uterine atony (failure of uterine contraction accounting for 70-80% of cases), retained placental tissue, genital tract trauma, or coagulation disorders. Uterine atony results from inadequate myometrial contraction after delivery, preventing compression of spiral arteries and leading to continued bleeding. Risk factors include prolonged labor, macrosomia, multiparity, chorioamnionitis, and certain medications that affect uterine contractility.
Clinical assessment focuses on rapid identification of bleeding source and hemodynamic status through vital signs monitoring, visual estimation of blood loss, and physical examination including bimanual uterine massage. Initial management involves immediate uterine massage, administration of uterotonics (oxytocin, methylergonovine, misoprostol), and IV fluid resuscitation while preparing for potential surgical intervention. Systematic evaluation following the '4 Ts' framework (Tone, Tissue, Trauma, Thrombin) guides targeted treatment and helps identify the underlying cause requiring specific intervention.