PODCAST: Life-Threatening Post-Partum Hemorrhage (PPH) with Cho Espinoza

Today, we talk severe post-partum hemorrhage with an amazing OB and intensive care doc…

Cholene “Cho” Espinoza

Former air force pilot flying combat missions to commercial airline pilot. Then war correspondent. What next–medical school of course. OB-GYN residency, but that certainly wouldn’t be enough, so… Surgical critical care fellowship! Now surgical and cardiac-surgical Intensive Care Staff and Critical Care OB & laborist at the Cleveland Clinic & Pennsylvania Air National Guard Critical Care Air Transport Physician.

Grand Rounds Video from Cho

Why This Episode Exists – Post-Partum Hemorrhage is Deadly!

At my shops, postpartum hemorrhage is someone else’s problem – 24-hour OB means these patients get whisked upstairs [Editors Note: Not anymore : ( ]
Across most of the country that is not true. Obstetric units keep closing (Sho watched ~18 close during her time in Iowa). Increasingly the only physician standing next to an exsanguinating post-partum patient is you.
Everything below is intended to be doable by an emergency physician, in a rural ED, with no OB in the building.

Guidelines for Post-Partum Hemorrhage

Definition & Recognition of Post-Partum Hemorrhage

The Numbers

ACOG: ≥1000 mL blood loss. (Older split: 500 mL vaginal / 1000 mL cesarean.)
Primary = first 24 hours. Secondary = 24 hours out to 12 weeks postpartum.
Cho: don’t over-index on the volume. Over-indexing on numbers ties your hands.

The Better Trigger

Any change in hemodynamics. Plus the LLS score (Looks Like Sh*t).
These patients behave like trauma patients – and worse. There is no class III. They go from class II straight off the cliff.
Shock index is useful. Yes, it’s “not validated in pregnancy” – nothing is validated in pregnancy. It still shows you the trend.

Risk Factors for Post-Partum Hemorrhage

Sho’s stratification: mom / uterus / baby.

Mom: pre-existing coagulopathy, factor deficiency, von Willebrand. Can present a week or two out.
Uterus – tone: the big one. 500 mL/min of blood flows to the pregnant uterus. Myometrial cells act as little tourniquets on the uterine arterioles. No contraction = a lake of blood.
Uterus – tissue: retained products, abnormal placentation, accreta spectrum disorders (increasingly common). She may have delivered and come back days later.
Uterus – trauma: lacerations, uterine trauma, abruption.
Setting: rural delivery, prior cesarean, unattended labor at home → uterine rupture / abruption with massive hemorrhage before anyone lays eyes on her.

Access and A-Line

IO should go above the umbilicus – use the humeral.
Same logic for central access: go up in the neck.
For me, it is just the movement of the legs, the actual veins should not be affected by the reproductive tract vasculature
Scott’s argument for an early common femoral arterial line (18 g or larger):
- Beat-to-beat monitoring
- Instant feedback on whether your aortic compression is actually working – no one palpating for a femoral pulse.
- It is the conduit for REBOA if you get there. Get it before the peri-arrest state, when the arterial system is still cannulatable.

The Nine Ts of Post-Partum Hemorrhage

The classic four are Tone, Tissue, Trauma, Thrombin. The Brits added Theatere. I think the mnemonic needs more work, so here is my expansion:

Tone
Tissue
Trauma
Thrombin
Transfuse – the unique aspects of massive transfusion in these patients deserve their own slot
Tube
Tamponade – uterine packing or a balloon device
Temporary Aortic Occlusion – external or internal aortic compression, or REBOA
Theater / Transfer – to the OR, to IR, or to another center

Tone

Assessment

Boggy fundus. Or a firm fundus with a floppy lower segment

Uterotonics

Oxytocin

10 units IM is going to be the standard rec
Or 10–40 units in 1 L, ~250 mL bolus up front, then run it.

both of those are vague and in the case of IM, slow

The “3 for 3”: 3 units IV → wait 3 minutes → repeat if needed wait 3 minutes repeat if needed. This was done in healthy c-section patients not PPH. [10.1097/ALN.0000000000000682]
Why not just slam 10 units IV: hypotension, hyponatremia, and real arrests in patients getting spinal anesthesia
WHO recommends 10 IU administered over 1-2 minutes over IM [Source]
RCT of 10 IU pushed over 1 minute was superior for PPH prevention than IM [30181338]
Issues seem to be with C-Sections and spinals
This RCT included healthy volunteers who also got tachycardic and had BP drops, when the drug was pushed over 30 sec [18385263]
E-MOTIVE Trial in Africa used IV [37158447]
If doing any kind of push, dilute 1 ml of oxytocin in 9ml of NS (just like push-dose epi), label the syringe Oxytocin 0.1 IU/ml
Best route may be 10 IU in 100 ml of NS and let it free flow in
Follow with 5 IU/hour drip
Oxytocin receptors are not meaningfully active until ~13 weeks – oxytocin will not help your first-trimester bleeder.

Methylergonovine (Methergine)

0.2 mg IM. Onset within minutes. Redose interval 2–4 hours.
This RCT gave 0.2 mg IV over 30 sec [18385263]
Effective in the first trimester, unlike oxytocin.
Contraindications: significant hypertension, cardiac pathology. Cho still gives it to the hypertensive-disorder patient who is now hypovolemic and shocked – that’s not what’s going to arrest her.

Carboprost (Hemabate, 15-methyl PGF2α)

250 mcg IM. Takes ~30 minutes – so if you’re going to give it, give it early. Repeat dosing allowed.
Avoid in asthma or reactive airway disease. Cho has seen trouble even COVID.
Warn the team: profuse diarrhea may follow.

Misoprostol (Cytotec, off-label)

800–1000 mcg PR is the preferred route. ~30 minutes to effect.
400 mcg buccal/SL absorbs faster but Cho avoids it – you don’t want a mouth full of chalk in a patient who is heading toward intubation.
No bronchospasm contraindication, so it fills the gap when carboprost is off the table.

The Rule

Give everything that isn’t contraindicated. When these cases get reviewed, the question asked is exactly that.

TXA

1 g IV up front, with everything else. Second gram if needed.
WOMAN trial subanalysis showed a mortality signal. No excess thrombosis.

Bimanual Compression – the Actual Technique

Internal hand: gown up, into the vagina. Find the posterior lip of the cervix and flip it up out of the way. Give some ABX.
External hand: flat, fingers spread as if the uterus is a ball you are squeezing between your hands
Then scoop the hands together and squeeze. The goal is to appose the tissues – “like holding a holiday ham.” Sustained compression, not rhythmic massage. (Massage is fine if you’re not going internal.)
Be prepared to hold it for a while while uterotonics work and while the resuscitation catches up. Sho has done exactly this in tertiary centers.
Key concept: bleeding begets atony. Coagulopathy from hemorrhage worsens bleeding which worsenstone. Buying time with your hands lets you fix the blood, which then helps fix the uterus.
Antibiotics: Sho gives cefazolin 2 g if internal compression.

Analgesia for the Awake Patient

Mom is a passive participant at this stage – you are not asking her to push. Sedate her.
Or midazolam 2 mg +/- fentanyl 50 mcg. Cho likes the midazolam so she doesn’t remember any of it.
Ketamine

Tissue

Yes, the EM doc should sweep the uterus. This is palpation and visualization – it is within your skill set. Give ABX
Use ultrasound while you do it. Have a colleague scan externally while your hand is inside so you know when you’re at the fundus. A normal post-delivery uterus looks like a golf driver; endometrial stripe <2 cm suggests no retained clot. Some schmutz in the lower segment is common.
Placental inspection is worth doing – look for a divot, look at the membranes. Caveat: bilobed and otherwise abnormal placentas look intact while a piece is still inside.
The rate-limiting step is almost always analgesia/sedation, not skill. People delay because they don’t want to cause pain – and thereby delay the inevitable.

Third Stage & the Stuck Placenta

Active management: oxytocin + aggressive uterine massage (“like an aggressive back rub”) + gentle cord traction.
Preterm cords are friable and will avulse – then you have a second problem. Traction is not the be-all; the placenta is designed to separate.
30 minutes is the usual window for spontaneous separation.
If she is bleeding profusely before the placenta separates – get to the OR / get anesthesia now. Pulling a placenta out in bits and pieces is how you generate the massive hemorrhage.
Manual removal technique: gowned, sterile, lube on the back of the hand for dexterity. Find the plane. Dissect, dissect, dissect. Feel it release, grasp, deliver it whole.
OBs have D/C, we do not

Trauma

Who is likely to get it…

Abruption, MVC or other maternal trauma.
Cervical lacerations: pushing before complete dilation, or protracted labor – the cervix ends up “like hamburger.”
Sulcal tears (vaginal sidewall). Also non-obstetric vaginal trauma – the same techniques apply.

Getting Exposure – the Part Nobody Teaches

You need light, exposure, and suction. Sponge sticks to clear blood.
Trick: the disposable lighted speculum – pull the halves apart and use them as individual lighted retractors.
External aortic compression to see: put a helper on the code step to compress; check that the femoral pulse drops. You are dropping pulse pressure just long enough to identify the bleeding source.

Packing

Speculum in to open the canal, then roll in Kerlix or vaginal packing with a ring forceps – layer it in like taffy against the cervix.
± soak in betadine (squeezed out); some soak in TXA or thrombin.
This buys a lot of time in severe cervical lacs and sulcal tears while help arrives.
Cervical lacerations ultimately need suture – but packing is the temporizing move.
⚠ The trap: a well-packed vagina can conceal ongoing hemorrhage, especially in patients with obesity. You will recognize it by the hemodynamics, not by what you see on the pad.

Thrombin

Placental Abruption

Presentation: vaginal bleeding and pain. Posterior abruption may be painless – that’s the miss.
Mechanism: injury at the utero-placental interface dumps tissue factor → consumptive coagulopathy.
Definitive treatment is delivery. Abruption often drives rapid labor on its own; otherwise you’re looking at a crash cesarean – and in a critical access hospital, that may be the general surgeon.

Fibrinogen – the Lab That Matters

Pregnant patients run a fibrinogen around 400. That’s what nature intended for delivery.
<300 = 5th percentile. Fasten your seatbelt.
<200 is associated with badness. You now have medical bleeding on top of anatomic bleeding.

Amniotic Fluid Embolism

Newer framing: anaphylactoid syndrome of pregnancy. It is not about finding fetal hair in the lungs.
Behaves like a massive PE: abrupt hypoxia + abrupt loss of blood pressure. Right heart failure. Can be time-linked to rupture of membranes or induction agents.
Right heart failure is the final common pathway of maternal mortality – whatever the route in. (Cho’s plug for the Crager RV failure episode.)
Then everything that was clotty becomes bleedy: microthrombosis → DIC picture. But not always florid DIC.
Think common things first. Hypotensive obstetric patient = bleeding until proven otherwise. Then PE. AFE is the zebra, and the management differs.
Management otherwise doesn’t change: coagulopathy, RV protection, avoid the hypoxia/hypercarbia/acidemia spiral.

Fetal Demise

An underappreciated coagulopathy driver – particularly the PPROM patient managed expectantly (increasingly for legal rather than medical reasons) who then has a demise on top of a septic picture. She is auditioning for coagulopathy.

Transfuse

Replace blood with blood. Quoting COL Jennifer Gurney (Joint Trauma System): saltwater is good for cooking pasta.
1:1 is coagulopathic for moms – they start hypercoagulable, and you’ll dilute them into trouble.
Many centers run an OB hemorrhage pack instead of standard MTP: roughly 2 FFP : 2 RBC : 1 cryo, with local variation.
Get cryo in early. Better fibrinogen per unit volume: ~5 units cryo → +50 mg/dL fibrinogen vs. roughly 10 from a comparable FFP volume. Start with 5 units with the first MTP delivery, escalate from there.
In an active PPH, Cho targets >200. (Contrast with the trauma thresholds of 100, or 80 for some surgeons.)
Fibrinogen concentrate would be better; most US centers don’t have it. Whole blood would be better still, and even where it exists you run out after the first few units.
Don’t forget calcium. Cho: TXA and calcium are the no-brainers

Tube

See hemodynamically intubation neutral video and remember 3rd trimester patients may be difficult airways

Tamponade

Bakri balloon: ~500 mL is the reference volume.
- Bakri balloon vid & another one
Jada is another purpose-built option that sucks down the uterus rather than filling it
- Quick Jada Vid
Improvised, for the place that has neither:
- Scott’s pick: the gastric balloon of a Blakemore/Minnesota tube. Large volume, and every rural ED should have one for variceal bleeding anyway. Cho notes she learned the GI balloon because it looked like a Bakri – just use saline, not air. Inflate to the same 500 ml
- Cut the tip or fold it back
The real mechanism: less about pure tamponade, more about changing the pulse pressure delivered from the aorta to the uterine artery.
If the uterus spits the balloon out, that’s a win – it means the uterus contracted down and delivered it like a baby.

Temporary Aortic Occlusion

External Aortic Compression

Fist, offset just to the left of the umbilicus, compressing straight down. Confirm by loss/decrease of femoral pulse (or by the femoral art line trace).
Free, immediate, requires nothing but a helper and a step stool.
Video on External Aortic Compression

Internal Aortic Compression

If the belly is already open: palpate the sacrum, feel the aorta pulsating against it, and compress. Anyone can find a sacrum.
Sho has held this for 40 minutes while anesthesia caught up – and has done it from below, through the uterus, during a hysterectomy.
Think of it as a poor man’s REBOA. And it is lifesaving in the critical access hospital where the general surgeon is doing the case.

REBOA (Zone 3)

My contention: underutilized, and called for too late. By the time someone says the word, arterial access has become the rate-limiting step. Patients go to the OR for uterine artery ligation who should have had a balloon up first.
Sho’s framing, from the military: get left of bang. If you’re anticipating a difficult case – accreta spectrum, or a site where the platelets are in the next county – place it or plan for it.
Why uptake is poor: one negative study in accreta spectrum gets cited as a reason not to do it.
Not mutually exclusive with uterine artery embolization. But source control remains the main event – sometimes that means the general surgeon doing a hysterectomy.
Earlier is better, for a physiologic reason: the more she bleeds, the worse the tone and the worse the coagulopathy.

Stensæth KH, Carlsen MIS, Løvvik TS, et al. Resuscitative endovascular balloon occlusion of the aorta as adjunct treatment in life-threatening postpartum hemorrhage: fourteen years’ experience from a single Norwegian center. Acta Obstet Gynecol Scand. 2024;103(5):965-969. DOI: 10.1111/aogs.14767.

Stensaeth KH, Sovik E, Haig INY, et al. Fluoroscopy-free resuscitative endovascular balloon occlusion of the aorta for controlling life-threatening postpartum hemorrhage. PLoS One. 2017;12:e0174520. DOI: 10.1371/journal.pone.0174520.

Kamijo K, Nakajima M, Shigemi D, et al. Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: a nationwide observational study in Japan. J Trauma Acute Care Surg. 2022;93(3):418-423. DOI: 10.1097/TA.0000000000003650.

Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum. Journal of Trauma and Acute Care Surgery 94(5):p 710-717, May 2023. | DOI: 10.1097/TA.0000000000003917

Theater / Transfer

Ask where anesthesia would want to resuscitate this patient. The answer is the operating room. If an OR is available, Sho goes – unless there is truly no time.
IR for uterine artery embo
Triggers to go: placenta that won’t come out whole; profuse bleeding before placental separation; anything requiring cervical laceration repair or laparotomy.
Sometimes there is no time at all. Sho’s case: trauma patient with abruption, exsanguinating – stat cesarean where she lay, aorta compressed against the sacrum. Mom lived. The baby did not.

Cho’s Closing Distillation

Early recognition. Source control. Kitchen Sink Uterotonics. Nice Massage. Aortic compression in you back pocket. Blood early. Cryo early. TXA and calcium.

Quotable

“There is no class III – they go from two straight off the cliff.”
“Saltwater is good for cooking pasta.” – COL Jennifer Gurney
“When people don’t want to do something, they cite a study that shows it doesn’t work.”
“Bleeding begets atony.”