Postpartum Hemorrhage (PPH) is a critical emergency in obstetrics and one of the leading causes of maternal mortality. The level of its diagnosis and treatment directly relates to maternal and infant safety and the quality of obstetric care. 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, Obstetrics and Gynecology Network specially invited Professor Zhai Hongbo from Hangzhou First People's Hospital to elaborate on key points including prenatal management, delivery mode selection for elderly and scarred uterus pregnant women, as well as PPH treatment and referral in primary hospitals. Combining practical experience, experts provide core decision-making ideas to offer precise references for obstetric medical staff and help improve PPH treatment capabilities.

Expert Profile

Professor Zhai Hongbo

Chief Physician, Executive Director of Obstetrics, Master's Supervisor

Hangzhou First People's Hospital

• Member of the Preterm Birth Group, Perinatal Medicine Branch of Chinese Medical Association

• Vice Chairman of Perinatal Medicine Branch, Zhejiang Medical Doctor Association

• Member of Birth Defect Prevention and Control Professional Committee, Zhejiang Preventive Medicine Association

• Member of Perinatal Medicine Branch, Zhejiang Medical Association

• Member of Birth Defect Branch, Zhejiang Preventive Medicine Association

• Chairman of Perinatal Medicine Branch, Hangzhou Medical Association

• Standing Director of the 3rd Council, Hangzhou Association for Eugenics and Maternal-Child Health

• Main Research Directions: Genetic counseling for eugenics, assessment of fetal intrauterine growth abnormalities, multiple pregnancies, etc. Proficient in interventional prenatal diagnosis procedures.

Obstetrics and Gynecology Network

With the advancement of the three-child policy, the number of elderly pregnant women and those with scarred uterus has increased. These special groups face a significantly higher risk of PPH. For such pregnant women, how should individualized plans be formulated for prenatal management and delivery mode selection to reduce the risk of hemorrhage? When PPH occurs, how to adjust treatment strategies?

Professor Zhai Hongbo:

Elderly pregnant women and those with scarred uterus are high-risk groups for PPH. Individualized plans should be developed based on the core principles of "prevention is more important than treatment" and "multidisciplinary team (MDT) collaboration," covering four aspects: pre-pregnancy assessment, prenatal management, delivery mode selection, and PPH response. Details are as follows:

I. Pre-pregnancy: Precise Assessment to Identify Basic Risks

1. Pre-pregnancy Assessment for Scarred Uterus

Clarify previous cesarean section history: Including the reason for the first cesarean section, surgical indications, surgical smoothness, and postoperative recovery (e.g., presence of postoperative infection).

Imaging evaluation of uterine scar: Assess the thickness and continuity of the uterine scar via ultrasound; if necessary, further evaluate with magnetic resonance imaging (MRI) to rule out the risk of poor scar healing.

2. Pre-pregnancy Assessment for Elderly Pregnant Women

Screen for comorbidities: Focus on evaluating whether there are underlying diseases such as diabetes, hypertension, or anemia. Provide pre-pregnancy consultation and intervention for abnormalities in advance, and advise conception only after indicators are stably controlled.

II. Prenatal Period: Dynamic Monitoring to Reduce Risk Overlap

1. Prenatal Management for Scarred Uterus

Placental position monitoring: Assess the placental attachment site and its relationship with the uterine myometrium via ultrasound in the first and second trimesters to rule out placenta previa and placenta accreta (especially in women undergoing second or third cesarean section). These conditions are important inducements for PPH and should be marked as high-risk in advance.

2. Prenatal Management for Elderly Pregnant Women

Comorbidity control: Monitor blood glucose and blood pressure throughout the pregnancy; maintain indicators within the ideal range through diet, exercise, or medication intervention. Regularly check blood routine to correct anemia in a timely manner, reducing the risk of hemorrhage exacerbated by anemia.

Nutrition and weight management: Guide reasonable diet to avoid macrosomia (which can easily lead to prolonged labor, uterine atony, and increased bleeding risk) and control moderate weight gain during pregnancy.

III. Delivery Mode: Individualized Selection to Balance Risks and Benefits

The optimal plan should be selected by evaluating the risks of vaginal delivery and repeat cesarean section based on the specific conditions of the pregnant woman:

Important Note: Regardless of the delivery mode selected, MDT support (obstetrics, anesthesiology, neonatology, urology, etc.) is required. Especially for complex cases such as suspected placenta accreta, MDT discussions should be conducted in advance to develop surgical plans.

IV. When PPH Occurs: Standardized and Stepped Treatment Strategy Adjustments

For elderly pregnant women and those with scarred uterus, it is necessary to shift from "passive response" to "active defense," implementing a combined standardized and individualized stepped management approach:

1. Preoperative/Intrapartum Preparation (Active Defense)

Cross-matching blood: All high-risk pregnant women should undergo blood cross-matching before and during delivery; establish two venous accesses to prepare for massive hemorrhage emergency.

Availability of materials and personnel: Equip delivery rooms and operating rooms with regular PPH rescue carts, including potent uterotonics (e.g., oxytocin, carboprost), uterine balloon tamponade devices, etc.; clarify the division of labor among the rescue team.

2. Three-Level Early Warning Mechanism (Stepped Treatment)

Obstetrics and Gynecology Network:

In primary hospitals, limited by equipment and technical level, PPH treatment faces many challenges. Based on your experience, what key points should primary hospitals focus on in early identification of PPH, implementation of basic emergency measures, and referral to higher-level hospitals to maximize maternal safety?

Professor Zhai Hongbo:

Primary hospitals are the "first line of defense" for maternal treatment. They need to focus on three core links—"early identification, rapid treatment, and safe referral"—and make up for resource shortages through standardized processes. Specific key points are as follows:

I. Early Identification: Active Monitoring to Avoid "Underestimating Hemorrhage"

The biggest risk in primary hospitals is underestimating the amount of postpartum bleeding (often by about 50%), leading to missed optimal intervention opportunities. The following measures should be taken:

1. Establish Active Monitoring Awareness

Abandon the mindset of "passively waiting for symptoms to appear"; integrate PPH risk assessment into pre-pregnancy and intrapartum periods—focus on marking high-risk groups (e.g., scarred uterus, advanced age, those with underlying diseases) before pregnancy, and continuously monitor maternal vital signs and bleeding during delivery.

2. Accurately Measure Bleeding Volume

Abolish the "visual estimation method" and adopt scientific measurement methods:

Volume method: Directly collect bleeding volume using containers or measuring cups (the most direct and effective method).

Weighing method: Estimate bleeding volume by weighing blood-stained dressings (blood weight = weight of soiled dressing - weight of dry dressing; 1g ≈ 1ml blood).

Shock index method: Refer to the 2023 China Postpartum Hemorrhage Guidelines (2nd Edition); regularly monitor blood pressure, heart rate, and respiratory rate. Judge the degree of blood loss using the "shock index (heart rate/systolic blood pressure)". (Tachycardia is the earliest sign of volume loss; hypotension usually indicates severe blood loss.)

3. Strengthen Vital Signs Monitoring

Routinely equip delivery rooms with electrocardiographic monitors to real-time monitor maternal heart rate, blood pressure, and blood oxygen saturation. Immediately alert for severe PPH if there is a sudden increase in heart rate (>100 beats per minute) or a drop in blood pressure (<90/60 mmHg).

II. Basic Emergency Treatment: Rapid and Orderly, Following the Principle of "Simple Before Complex"

Once severe PPH is identified, immediately activate the hospital emergency response team. Even with limited personnel, clarify the division of labor (1 person for documentation, 1 for hemostasis, 1 for medication administration, 1 for ensuring venous access, 1 for coordinating referral). Core measures are as follows:

1. Rapidly Identify the Cause of Hemorrhage

Immediately examine uterine contraction (to rule out uterine atony), presence of birth canal lacerations (especially scar site inspection for women with scarred uterus), and placental integrity (to rule out retained placenta) in the delivery room or operating room.

2. Basic Intervention Measures

Empty the bladder: Indwell a urinary catheter to monitor urine output (assess circulatory volume) and relieve bladder distension, which hinders uterine contraction.

Pharmacological hemostasis: Prioritize oxytocin; add potent uterotonics such as carboprost or ergometrine if ineffective. Administer tranexamic acid as early as possible (to reduce coagulation factor consumption).

Ensure access and oxygen supply: Rapidly establish two venous accesses to ensure smooth infusion of fluids and blood; provide oxygen to maintain tissue oxygenation.

3. Pre-reserve Emergency Supplies

Keep a "PPH emergency kit" in the delivery room, containing concentrated medications (uterotonics, tranexamic acid), instruments (uterine balloon tamponade, sutures), and documents (rescue records). Regularly inspect and replenish to ensure immediate availability.

III. Referral to Higher-Level Hospitals: Decisive Decision-Making to Ensure Transportation Safety

Referral is not a "failure of treatment" but a reflection of responsibility for maternal life. It is necessary to grasp the two principles of "timeliness and safety":

1. Decisive Decision-Making and Early Referral

If a primary hospital lacks the conditions to handle severe PPH (e.g., no massive blood transfusion capacity, no emergency cesarean section equipment) or bleeding cannot be controlled after basic emergency treatment, immediately decide to refer to avoid delaying the condition.

2. Adequate Preparation and Seamless Connection

Pre-referral communication: Contact the higher-level hospital (critical obstetric center, emergency center) in advance to inform them of the maternal gestational age, cause of bleeding, bleeding volume, vital signs, and implemented measures, allowing the higher-level hospital to activate the rescue process in advance.

Transportation guarantee: Arrange medical staff to accompany the patient throughout the journey, carrying emergency medications (uterotonics, hemostatics), electrocardiographic monitors, oxygen, etc. Continuously monitor vital signs during transportation; provide on-site emergency treatment immediately if critical conditions (e.g., sudden hypotension, altered mental status) occur.

IV. Long-Term Capacity Building in Primary Hospitals: Equal Emphasis on Prevention, Preparation, and Drills

1. Formulate Standardized Processes

Develop a "visual severe PPH emergency flow chart" and post it in key areas such as delivery rooms and rescue rooms to ensure all medical staff are familiar with the operation steps.

2. Regular Simulation Drills

Organize full obstetric staff (and anesthesiology, neonatology, and ICU teams if necessary) to conduct PPH simulation rescues. Clarify each person's role and tasks, focusing on "practicing processes and addressing weaknesses" rather than formalistic "acting" to improve team collaboration efficiency.

3. Establish a Referral Network

Maintain fixed communication channels with higher-level critical obstetric centers and conduct regular academic exchanges to ensure "smooth information flow and seamless connection" during referrals, minimizing transportation delays.

Primary medical staff are the "sentinels" guarding the lifeline of pregnant and puerperal women. Only by maintaining vigilance, improving rapid response capabilities, and strictly implementing standardized operations can PPH tragedies be effectively reduced, and maternal and infant safety be safeguarded.

Summary

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 Zhai Hongbo elaborated on prenatal management and delivery mode selection for elderly and scarred uterus pregnant women, as well as the challenges (hardware, personnel skills, blood supply, etc.) and referral key points in PPH treatment in primary hospitals. This provides references for obstetric medical staff and helps improve treatment levels.

Editor-in-Charge: Lily