Early PPH — Assessment & Recognition
A postpartum patient soaking a pad in 15 minutes may not look pale or hypotensive yet — by the time vital signs crash, she's already lost over a liter. Catching early PPH is about what you see before the numbers change.
Core Concept
Early postpartum hemorrhage occurs within 24 hours of delivery. The classic definition is blood loss ≥500 mL after vaginal birth or ≥1,000 mL after cesarean, but quantitative blood loss (QBL) measurement — weighing pads and collecting drapes — is the current standard because visual estimation underestimates loss by 30–50%. The leading cause is uterine atony (soft, boggy, displaced fundus), responsible for roughly 80% of cases. Assessment starts with the fundus: it should be firm, midline, and at or below the umbilicus. A fundus that is boggy, deviated to one side (often by a full bladder), or rising above the umbilicus signals blood pooling. Assess lochia quantity, color, and clot size — saturating more than one pad per hour, bright red flow with large clots (>golf ball), or a steady trickle that doesn't stop between fundal checks are red flags. Tachycardia is the earliest vital sign change — it precedes hypotension. A rising heart rate in the first hours postpartum should trigger immediate fundal and lochia reassessment. Additional risk factors you identify before delivery — overdistended uterus (multiples, polyhydramnios, macrosomia), prolonged labor, chorioamnionitis, magnesium sulfate use, and grand multiparity — raise your index of suspicion.
Watch Out For
Don't confuse uterine atony (boggy fundus, heavy bleeding) with retained placental fragments (partially firm uterus, continued bleeding despite massage) — both cause early PPH but present differently. Students think hypotension is the first warning sign; tachycardia appears first because compensatory mechanisms maintain blood pressure until ~15–20% volume is lost. A fundus deviated to one side signals a full bladder, not necessarily atony — catheterize before assuming hemorrhage.
Clinical Pearl
Tone, tachycardia, trickle: check the fundus, watch the heart rate, weigh the pads. A boggy uterus plus rising pulse is PPH until proven otherwise.
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