Treat underlying cause: Tone, Trauma, Tissue, Thrombosis
Consider Fluid resuscitation vs blood products for hemodynamic instability
Early tranexamic acid (TXA) reduces death due to bleeding
Give as soon as possible relative to bleeding onset
1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose
No difference between placebo and TXA in adverse events, including thromboembolism
All-cause mortality and hysterectomy not reduced with TXA
Give as soon as possible relative to bleeding onset
1 g IV of TXA over 10 min, with 2nd dose 30 min later if continual bleed OR bleed restarts within 24 hrs after 1st dose
No difference between placebo and TXA in adverse events, including thromboembolism
All-cause mortality and hysterectomy not reduced with TXA
Uterine atony (boggy uterus)
Bimanual Massage
Oxytocin (Pitocin) 1st-line and most important drug
IV options:
20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) 
80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). 
IM option (if no IV):
10 IU IM x 1
Misoprostol (Cytotec)
600mcg SL or 1000 mcg rectally
Methylergonovine (Methergine)
0.2mg IM q2-4 hrs
Relative contraindication in patients with hypertension or Preeclampsia; may consider in severely unstable BP
Carboprost (Hemabate)
250mcg IM q15 min (avoid in patients with asthma)
Bakri balloon placement
Fill with warm 500ml NS (or large/multiple Foleys or pack)
Use US to place to top of fundus and ensure no retained placenta
IV options:
20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) 
80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). 
IM option (if no IV):
10 IU IM x 1
20 IU in 1 L of NS at 250 mL/hr (up to 500 mL over 10 minutes if necessary) 
80 IU in 500 cc NS bag run wide open (decreased the need for additional oxytocin and the risk of a 6% or greater decline in hematocrit). 
10 IU IM x 1
600mcg SL or 1000 mcg rectally
0.2mg IM q2-4 hrs
Relative contraindication in patients with hypertension or Preeclampsia; may consider in severely unstable BP
250mcg IM q15 min (avoid in patients with asthma)
Fill with warm 500ml NS (or large/multiple Foleys or pack)
Use US to place to top of fundus and ensure no retained placenta
Genital tract tear
Examine for tears under good lighting and suction
Suture lacerations - figure of eight with 3-0 or 2-0 absorbable
Deep lacerations such as those by the cervix may require OR
Drain hematomas >3 cm
Retained placental tissue
Evaluate placenta for retained products
Pelvic exam may be normal other than blood
Detect with US
Manual removal
Curettage
Reverse any coagulopathies
Labs - platelets, coags, fibrinogen, d-dimer
Replace appropriate blood components
Manually replace placenta OR do not remove placenta until uterus has been replaced:
Place hand inside the vagina and push the fundus cephalad along long axis of vagina
Prompt replacement important since cervix contracts over time creating a constriction ring
Discontinue uterotonic meds (oxytocin) if uterus not reduced, and consider uterine relaxant options::
Nitroglycerine IV 50-250 mcg bolus over 1-2 min, then up to x3-4 additional doses q3-5 min to relax uterus
Magnesium 4-6 g IV over 15 min
Terbutaline 0.25mg IV or SQ
After replacement:
Fundal massage ± bimanual massage/compression
Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr
Nitroglycerine IV 50-250 mcg bolus over 1-2 min, then up to x3-4 additional doses q3-5 min to relax uterus
Magnesium 4-6 g IV over 15 min
Terbutaline 0.25mg IV or SQ
Fundal massage ± bimanual massage/compression
Then oxytocin infusion with 40 units in 1 L of NS at 200-1000 cc/hr
Postpartum hemorrhage
Amniotic fluid embolus
Postpartum endometritis
Chorioamnionitis
Preeclampsia
Acute fatty liver of pregnancy
Septic abortion
Eclampsia