Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

PPH · Postpartum Hemorrhage

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In one line

·Losing more than 1000 mL of blood after delivery — or any amount that makes the heart race and blood pressure drop — is postpartum bleeding (hemorrhage).

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Normal physiology

·After delivery, the uterus clamps down tight like a fist, the placenta peels off and comes out, and the open blood vessels where the placenta was stuck close off so bleeding stops. This squeeze-and-seal is called hemostasis, and it is the normal job that keeps blood loss under 500 mL for vaginal birth and under 1000 mL for cesarean birth.

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What goes wrong

·The uterus stays soft and baggy instead of squeezing down, so the open blood vessels keep pouring out blood. This is called uterine atony, and it causes most postpartum bleeding (hemorrhage). Other causes include tears in the vagina or cervix from delivery, pieces of placenta or membranes left stuck inside the uterus, or problems with the blood's clotting system that stop plugs from forming.

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Hallmark signs

·Heavy bleeding that soaks one pad in under an hour or big clots the size of a lemon or larger
·A soft, puffy, or "boggy" uterus when the doctor or nurse presses on the belly
·Bright red blood that keeps flowing in a steady stream
·Fast heartbeat (tachycardia)
·Low blood pressure (hypotension)
·Feeling dizzy, weak, or light-headed
·Pale, cool, or clammy skin
·Visible tears in the vagina, cervix, or perineum (the area between the vagina and anus)

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Red flags · escalate now

·Bleeding that soaks more than one pad per hour or produces clots bigger than a golf ball
·Blood pressure dropping below 90/60 or heart rate climbing above 110 beats per minute
·Confusion, severe dizziness, fainting, or trouble staying awake
·The uterus stays soft and will not firm up even with massage
·Signs of shock: cold clammy skin, rapid weak pulse, very pale face, gasping for air

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Workup

·Complete blood count (CBC) with hemoglobin and hematocrit
·Type and crossmatch (blood bank hold)
·Prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR)
·Fibrinogen level
·Platelet count
·Bedside clot observation test (if lab unavailable)
·Arterial blood gas (ABG) or venous blood gas (VBG) with lactate

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Treatment

·Bimanual uterine massage + IV oxytocin 10 units slow push or 10–40 units/L continuous infusion
·IV tranexamic acid (TXA) 1 gram over 10 minutes, given within 3 hours of birth
·Massive transfusion protocol (MTP): packed red blood cells, fresh frozen plasma, platelets in 1:1:1 ratio
·Add methylergonovine 0.2 mg IM or carboprost 250 µg IM if oxytocin alone does not work
·Manual exploration of the uterus to remove retained placental fragments; repair all lacerations with sutures under good light
·Intrauterine balloon tamponade (Bakri balloon) inflated with 300–500 mL sterile saline
·Uterine artery embolization (interventional radiology) or surgical ligation of uterine arteries; emergency hysterectomy if all else fails

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NCLEX trap

·PPH is bleeding, not infection. Infection (endometritis) causes fever and slow oozing bleeding over days. PPH is fast, heavy bleeding happening right now — more than 1,000 mL (a big soda bottle) in the first 24 hours or any bleeding that makes the mom's heart race and pressure drop. Give fluids and blood first to keep the brain and organs alive. Find the cause second. Antibiotics come later only if you find actual infection (fever, foul smell, uterus tender days later).
·Ergot raises blood pressure fast — it squeezes every blood vessel, not just the uterus. In a mom whose pressure is already climbing from the stress of blood loss, or a mom with preeclampsia or chronic high blood pressure (hypertension), ergot can cause stroke or heart attack. Check the blood pressure first. Use oxytocin (Pitocin) first — it squeezes the uterus without spiking blood pressure. Add methylergonovine only if blood pressure is under 140/90 and the uterus still will not squeeze after oxytocin.
·Massage the uterus hard and fast — rub it through the belly like you are trying to make it into a hard grapefruit. A soft, boggy uterus is bleeding because the blood vessels inside are wide open. A hard, contracted uterus clamps those vessels shut. Gentle does not work. The discomfort matters less than the bleeding right now — PPH kills in minutes if the uterus stays soft.
·In severe PPH (bleeding that soaks through pads in seconds, bleeding from IV sites and gums, blood pressure dropping), you cannot wait 30–60 minutes for labs. If the mom is bleeding from everywhere and the uterus is already hard, her clotting system is broken — she has DIC (disseminated intravascular coagulation, when clots form everywhere and use up all the clotting pieces). Give tranexamic acid (TXA), fibrinogen (cryoprecipitate), and FFP now while you wait for the lab to catch up. The standard is 1:1:1 packed red cells : FFP : platelets in massive transfusion.
·A hard uterus stops bleeding from uterine atony (the muscle not squeezing), but PPH has four causes — Tone (atony), Tissue (leftover placenta), Trauma (tears in the cervix or vagina), and Thrombin (clotting broken). A hard uterus rules out only Tone. If bleeding continues despite a firm uterus, look for the other three. Also, the uterus can relax again (atony can come back). Keep watching heart rate, blood pressure, and bleeding for at least 4–6 hours. PPH is not over until the bleeding stops and stays stopped.
·Low blood pressure from PPH means she is in bleeding-driven (hemorrhagic) shock — the blood volume is too low to fill the blood vessels, so organs (brain, heart, kidneys) are starving for oxygen. Give IV fluids wide open (crystalloid like normal saline or lactated Ringer's, 1–2 liters fast) and give blood transfusions (packed red cells) as fast as you can get them. Less fluid makes shock worse, not better. The only way to fix low pressure from blood loss is to replace the lost volume.

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