Postpartum hemorrhage (PPH) is a critical obstetric emergency and one of the leading causes of maternal mortality. Its diagnosis and treatment directly affect maternal and infant safety as well as obstetric care quality. With the increasing proportion of high-risk pregnant women (e.g., those with preeclampsia, advanced age, or scarred uterus), clinical management has become significantly more challenging. To address this, the Obstetrics and Gynecology Network specially invited Professor Peng Ting from Changning District Maternity and Child Health Hospital to share insights on early quantitative PPH assessment tools, hospital process optimization plans, and individualized choices for stepwise treatment. Combining practical experience, she provided core decision-making frameworks to offer precise references for obstetric healthcare providers and enhance PPH rescue capabilities.
Expert Profile
Professor Peng Ting
Vice President and Director of Obstetrics, Changning District Maternity and Child Health Hospital
Doctor of Clinical Medicine, Chief Physician
✿ Member of China Democratic League
✿ Recipient of the 5th "Changning Craftsman" Award (2024)
✿ Main research focus: Preterm birth and its mechanisms
✿ First/corresponding author of nearly 30 papers published in SCI journals and Chinese core journals
✿ Principal investigator of 2 National Natural Science Foundation projects, 1 Shanghai Municipal Health Commission project, 1 Shanghai Natural Science Foundation project, and 1 Shanghai Science and Technology Commission popular science project
✿ Key participant in national key projects (13th Five-Year Plan, 14th Five-Year Plan, etc.)
✿ Contributor to the compilation and translation of monographs including Williams Obstetrics and Chinese Obstetrics and Gynecology
✿ Former lecturer for 5-year and 8-year programs at Fudan University School of Medicine, and national standardized residency training examiner
✿ Current Member of the Maternal Safety Professional Committee, Chinese Maternal and Child Health Research Association
Obstetrics and Gynecology Network
Early accurate assessment of PPH is the foundation of standardized diagnosis and treatment. From an evidence-based perspective, which quantitative assessment tools have been proven to more accurately reflect actual blood loss? At the hospital level, how can process optimization ensure the timeliness and accuracy of assessment to support subsequent interventions?
Professor Peng Ting
➱ From an evidence-based medicine perspective, five types of commonly used quantitative assessment tools in clinical practice can accurately reflect actual blood loss, covering multi-dimensional evaluation of "volume - circulation - metabolism - speed - matching degree":
Basic measurement tools: Volume method and weighing method, often used in combination clinically. During delivery, blood is collected with perineal pads, and blood loss is calculated by volume measurement and weight conversion. These are fundamental methods for blood loss assessment, but standardized operation is required to reduce errors.
Shock Index (SI): The warning threshold is set at 0.9, calculated as heart rate/systolic blood pressure. Even if volume/weighing method shows blood loss < 1000ml, an SI ≥ 0.9 indicates blood loss has reached a dangerous threshold, requiring management according to severe PPH standards.
Laboratory monitoring indicators: Including regular hemoglobin testing (to dynamically observe anemia caused by blood loss) and blood gas analysis (to real-time monitor acidosis, pH value, and base excess, reflecting microcirculatory perfusion and metabolic changes). The latter is a key bedside indicator for microcirculation assessment.
Bleeding speed assessment: If bleeding is excessively rapid (e.g., massive hemorrhage in a short time), emergency management should be initiated directly as "severe PPH with blood loss > 1000ml" without waiting for measurement results, to avoid shock due to delayed intervention.
Matching degree assessment between blood loss and vital signs: Special attention should be paid to inconsistent cases. For example, patients with hypertension or preeclampsia may have a normal SI even with blood loss > 1000ml due to abnormal baseline blood pressure. However, these patients have lower organ tolerance to ischemia and hypoxia, requiring priority enhanced monitoring.
➱ At the hospital level, we ensure timely and accurate assessment through three-dimensional process optimization: "hierarchical activation - team collaboration - review and quality control":
Hierarchical activation mechanism: Blood loss serves as the core trigger. For vaginal delivery with blood loss > 500ml, a department-level rescue team (led by a physician with associate senior title or above) is activated. For cesarean section or any delivery mode with blood loss > 1000ml, a hospital-level rescue mechanism is initiated, with simultaneous reporting to the district-level Obstetric Safety Office, achieving "immediate activation upon reaching threshold blood loss".
Multidisciplinary team (MDT) collaboration: Clear division of responsibilities is established. The nursing team reports the patient’s blood pressure, heart rate, and urine output every 15 minutes to realize real-time tracking of circulatory status. The blood transfusion process strictly requires "blood product preparation and transfusion completion within 30 minutes", with full coordination from laboratory and logistics departments. The anesthesiology team is responsible for internal jugular vein catheterization to monitor central venous pressure and blood gas analysis, providing data support for circulatory assessment.
Review and quality control system: A management loop of "department-level review + hospital-level quality control" is established. At the department level, the matching degree between blood loss assessment and hemoglobin decline is reviewed for each PPH case. At the hospital level, monthly assessment quality control indicators are set and incorporated into performance evaluations. Regular team drills are conducted to refine division of labor and advance the intervention window, ensuring the implementation of assessment and treatment processes.
Obstetrics and Gynecology Network
Regarding the stepwise treatment of PPH, how to accurately select first-line, second-line, and third-line interventions recommended by current guidelines based on individual differences such as the patient’s cause of bleeding and underlying diseases in clinical decision-making?
Professor Peng Ting
Stepwise PPH treatment should adhere to the principle of "guideline framework + individual adaptation". First, clarify the four core causes of bleeding (uterine atony accounts for 70%, birth canal laceration, placental factors, and coagulopathy account for 30%), then adjust the plan according to the patient’s baseline conditions. The specific implementation path is as follows:
1. Core Measures of Stepwise Treatment
First-line intervention (mainly for uterine atony): Focus on promoting uterine contraction, including active management of the third stage of labor (10 units of oxytocin injection, uterine massage, and controlled cord traction to facilitate placental delivery). Oxytocin is the most evidence-based drug for prevention and first-line treatment, improving approximately 50% of PPH cases.
Second-line intervention (when first-line fails): Upgrade to long-acting uterotonics such as carboprost tromethamine and carbetocin to further enhance uterine contractility, suitable for patients with persistent uterine atony or poor response to first-line drugs.
Third-line intervention (when drugs are ineffective or non-uterine atony causes): Include uterine packing, balloon tamponade (preferred over blood transfusion for vaginal delivery with blood loss of 500-1000ml to reduce transfusion dependence); precise exploration and suture for birth canal laceration (e.g., rapid vascular ligation for perineal laceration, repair of cervical/uterine body laceration after assessment, ultrasound-assisted localization for high-grade hematoma, and laparotomy if necessary); supplementation of blood products (e.g., platelets, fresh frozen plasma) to correct coagulopathy in patients with coagulation disorders.
2. Precise Adjustment Strategies Based on Individual Differences
Adaptation to underlying diseases: For patients with hypertension or preeclampsia, if SI is abnormal despite blood loss < 1000ml or there is inconsistency between blood loss and vital signs, third-line intervention should be initiated in advance, with enhanced monitoring of blood gas and coagulation function to avoid rapid progression to shock or coagulopathy due to low organ tolerance.
Adaptation to causes of bleeding:
Placental factors (e.g., adhesion, retention): High-risk groups are evaluated in advance during pregnancy. If the placenta is not delivered within 30 minutes or bleeding > 100ml occurs before placental delivery, prioritize placental management (e.g., manual removal, curettage) combined with uterotonics to avoid abnormal uterine contraction and sinusoid opening caused by retained placenta.
Birth canal laceration: If uterine contraction is good but persistent fresh vaginal bleeding occurs, immediately perform birth canal exploration to rule out cervical/paracervical high-grade laceration or hematoma, avoiding continuous bleeding due to missed diagnosis.
Rare cases (e.g., amniotic fluid embolism): Even with minimal bleeding but rapid onset of coagulopathy, immediately supplement blood products and initiate respiratory and circulatory support to prevent progression to severe disseminated intravascular coagulation (DIC) or cardiac arrest.
Adaptation to bleeding speed: In cases of excessively rapid bleeding, skip the conventional sequence of "drugs first, then instruments" and directly initiate third-line intervention (e.g., balloon tamponade, blood transfusion preparation) and hospital-level team activation, while implementing stepwise treatment to prevent shock caused by massive blood loss in a short time.
Postpartum hemorrhage is the leading cause of maternal death. The increasing number of high-risk pregnant women (e.g., those with preeclampsia, advanced age, or scarred uterus) makes single treatment ineffective. Professor Peng Ting shared early quantitative PPH assessment tools, hospital process optimization plans, and individualized choices for stepwise treatment, providing references for obstetric healthcare providers and helping improve rescue capabilities.
Editor-in-Charge: Lily
