Illness script

Postpartum Hemorrhage

Excessive bleeding after delivery, most often from a boggy, atonic uterus.

This illness script for Postpartum Hemorrhage covers the classic presentation, who it affects, how you work it up, the mechanism, and first-line treatment—written for USMLE Step 1 and clerkship clinical reasoning.

Updated Jul 18, 2026All scripts

01

Who it affects

  • Prolonged or augmented labor, oxytocin use
  • Uterine overdistension: multiples, polyhydramnios, macrosomia
  • Grand multiparity, prior PPH, chorioamnionitis
  • Operative/instrumental delivery, retained placenta
  • Placenta previa/accreta, coagulopathy

02

Diagnostics & workup

  • Blood loss >500 mL vaginal or >1000 mL cesarean (or symptomatic)
  • Exam: soft/boggy uterus = atony (most common cause)
  • Inspect for lacerations, retained placenta, hematoma
  • Assess uterine inversion, uterotonic response
  • CBC, coags, fibrinogen, type and crossmatch
  • Recall 4 T's: Tone, Trauma, Tissue, Thrombin

03

Pathophysiology

  • Uterine atony: myometrium fails to contract, open spiral arteries bleed
  • Normal hemostasis depends on myometrial contraction compressing vessels
  • Trauma: genital tract lacerations or uterine rupture
  • Tissue: retained placental fragments prevent contraction
  • Thrombin: coagulopathy (DIC, inherited defects)

04

Treatment

  • Bimanual uterine massage + two large-bore IVs, fluids
  • Uterotonics: oxytocin first-line; then methylergonovine (avoid in HTN)
  • Carboprost (avoid in asthma), misoprostol; tranexamic acid
  • Explore/repair lacerations, remove retained tissue
  • Refractory: Bakri balloon tamponade, uterine artery embolization
  • Surgical: B-Lynch suture, artery ligation, hysterectomy last resort

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Educational use only. This illness script is a study framework, not medical advice. Confirm decisions with current guidelines and your clinical supervisors.