The 4 T’s of Postpartum Hemorrhage

A 28-year-old G4P3 at 41 weeks presents to the ED via EMS. She is in active labor. On exam, a neonatal head is visible. Two minutes later, you deliver a healthy vigorous baby boy and hand him to your colleague. You notice persistent bleeding from her vaginal canal. Her tachycardia climbs to 110 bpm and her latest blood pressure is 78/48 mm Hg. We review postpartum hemorrhage (PPH) and the 4 T’s – a memory aid to help ED providers manage this life-threatening presentation. Definition Postpartum hemorrhage is defined as > 500 cc of blood after a normal standard vaginal delivery (NSVD) or >1000 cc after a C-section. It occurs in almost 1 in 5 postpartum mothers and is the most frequent cause of maternal morbidity in the developed world.1,2 The most common etiologies can be recalled by remembering the 4 T’s:1,2 Tone: Uterine atony (70% of PPH worldwide) Trauma: Genital tract trauma Tissue: Retained products of conception (POC) Thrombin: Coagulopathy Other etiologies include uterine inversion, rupture, and abnormal placentation.1–3 PPH Management Critical management steps include access and ABCs. These patients require 2 large bore IVs and prompt type and cross for at least 4 units of blood or even activation of your department’s massive transfusion protocol. This will be dictated by the the clinical presentation. Emergent OB-GYN consultation is also paramount. The details will be dictated by your clinical environment – but in any ED the time to requesting blood products and coordinating a plan with OB-GYN cannot be overstated. If your initial steps are not successful, the patient may need an emergent hysterectomy and/or IR embolization. After these steps or in parallel, evaluate the uterus. Make sure the uterus is not inverted (occurs … Continue reading The 4 T’s of Postpartum Hemorrhage