Postpartum hemorrhage (PPH) is an obstetric emergency and a leading cause of maternal mortality, directly impacting maternal and infant safety as well as the quality of obstetric care. With the rising incidence of high-risk pregnancies—such as placenta previa, placenta accreta, and scarred uteri—the difficulty of precise clinical prevention and treatment has increased significantly.
To address this, Obstetrics and Gynecology Network invited Professor Xu Qian from Qingdao Women and Children's Hospital focused on the standardization of PPH medication, the construction of standardized thinking, and sequential rescue strategies for overlapping high-risk factors. Grounded in real-world practice, she distilled core diagnostic and therapeutic concepts to provide precise references for obstetric staff, aiming to enhance PPH rescue capabilities and safeguard maternal and infant safety.
Expert Profile
Xu Qian, Professor
Director of the Obstetrics Center, Director of Obstetrics Ward III, Chief Expert, Chief Physician, Professor, Doctoral Supervisor at Qingdao Women and Children's Hospital.
• Vice Chairman, Perinatal Medicine Branch, Shandong Medical Association
• Deputy Director, Shandong Provincial Obstetric Quality Control Center
• Chairman, Perinatal Medicine Branch, Qingdao Medical Association
• Vice Chairman, Labor Analgesia Committee, Qingdao Medical Association
• Vice Chairman, Reproductive Medicine Branch, Qingdao Medical Association
• Member, Qingdao Critical Maternal Rescue Expert Panel
• Member, Qingdao Perinatal Collaboration Expert Panel
Q: From the perspective of obstetric quality control and critical maternal rescue management, what are the most important points regarding the standardized use of drugs for PPH? How can we help frontline doctors quickly establish a standardized medication mindset?
Professor Xu Qian:
Part 1: Core Points of Standardized Pharmacotherapy for PPH
From the dual perspectives of obstetric quality control (QC) and critical rescue management, the core of standardized PPH treatment is safe, regulated, effective, orderly, and individualized care. It must balance national QC standards with rescue demands. Specific points are as follows:
A. Key Points from the Obstetric QC Dimension
1. Standardization of Medication Timing & Proactive Prevention
Follow PPH prevention guidelines by initiating prophylactic medication immediately after fetal delivery, making active prevention the first QC checkpoint. Intervene early for high-risk populations to avoid passive treatment after bleeding occurs. Strictly adhere to the "golden window" for rescue; define the initiation timeline for uterotonics and hemostatics; and incorporate medication timing into departmental assessments to eliminate hesitation that increases blood loss.
2. Stratified Drug Selection to Eliminate Random Prescribing
Strictly follow the hierarchical indications for first-, second-, and third-line drugs. Avoid off-label or blind medication.
◦ First-line Uterotonics: Oxytocin, Carbetocin (preferred for prevention and minor bleeding).
◦ Second-line Drugs: Prostaglandin preparations (requires clear indication for PPH and awareness of contraindications).
◦ Hemostatics: Use early, strictly controlling dosage and infusion rates. Manage incompatibilities (e.g., interaction between oxytocin and certain vasopressors). Incorporate medication compliance into case QC.
3. Standardization of Dosage, Frequency, and Route of Administration
Define specifications for all drugs: control the maximum dose of oxytocin, observe frequency intervals for prostaglandins, and fix the single dose and infusion duration for Tranexamic Acid. Eliminate dosage adjustments based on individual experience and treat standard medication as a core QC indicator.
4. Individualized Stratified Management for High-Risk Groups
For patients with gestational hypertension, hepatic/renal insufficiency, etc., prostaglandin preparations are contraindicated to avoid exacerbating their condition. Complete medication assessments before surgery for high-risk patients and formulate individualized plans to achieve dual coverage of time-based QC and personalized medication.
5. Closed-Loop Monitoring and Adverse Event Management
Monitor blood loss, vital signs, and adverse reactions in real-time post-administration. Conduct root cause analysis for ineffective treatment or adverse events, incorporating findings into continuous QC improvement to form a closed loop of "monitoring-review-optimization."
B. Key Points from the Critical Rescue Management Dimension
1. Prioritize Rapid Access to Uterotonics
Since uterine atony is the primary cause of PPH, the top priority in rescue is the rapid initiation of uterotonics. Ensure drugs are prepared and administration routes (IV, IM, intrauterine injection) are confirmed before delivery.
2. Synergy in Combination Therapy, Avoid Redundancy
For refractory PPH, combine uterotonics with hemostatics (initiate Tranexamic Acid early). The core is mechanistic complementarity rather than simple stacking to reduce adverse reaction risks and buy time for subsequent surgical intervention.
3. Rapid Efficacy Assessment and Timely Escalation
Immediately assess uterine tone and vaginal bleeding after drug administration. If ineffective, immediately escalate to second-line drugs or transition to compression, interventional, or surgical treatments. Avoid delaying rescue by repeatedly switching drugs.
4. Synchronized Rescue Records for Full Traceability
Fully document medication time, dosage, route, efficacy, adverse reactions, and drug changes. This provides a basis for QC verification, medical safety tracing, and case review.
Part 2: Methods to Help Frontline Doctors Establish Standardized Medication Thinking
The core shift is moving from experience-driven to process-, evidence-, and stratification-driven approaches, promoted through four dimensions: training, tools, QC, and practice.
1. Construct a Three-Tiered Medication Logic Model
Establish a layered logic of "Prevention – First-line Rescue – Refractory Rescue" to form conditioned reflexes:
◦ Prevention: Use first-line drugs.
◦ First-line Failure: Escalate to second-line drugs.
◦ Second-line Failure: Activate multidisciplinary consultation and surgical intervention.
2. Equip Teams with Visualized, Portable Standardized Tools
Create quick-reference drug cards posted visibly in delivery rooms. Set up fixed electronic order sets for scenarios like prevention, mild bleeding, and severe bleeding to prevent manual entry errors.
3. Conduct Scenario-Based Simulation and Routine Review
Simulate PPH scenarios based on real high-risk cases, requiring doctors to complete medication selection, administration, and efficacy assessment within time limits, with corrections by senior physicians. Conduct routine reviews post-rescue to discuss rationality and optimization.
4. Strengthen Targeted Training on Weak Links
Conduct specialized training on high-frequency error points such as the timing of Tranexamic Acid use, contraindications of second-line drugs, and dosing frequency to reinforce memory.
5. Implement Standards Through QC Assessments
Incorporate medication standardization, dosage accuracy, and record completeness into frontline doctor evaluations. Establish an adverse reaction warning mechanism; conduct targeted retraining when issues arise. Departmental QC teams should regularly audit cases to supervise junior doctors and standardize medication thinking at the source.
Q: In rescuing critical PPH with multiple overlapping high-risk factors, how should potent uterotonics, hemostatic drugs, mechanical compression, and surgical intervention be sequentially coordinated to maximize success rates and protect maternal safety?
Professor Xu Qian:
Part 1: Core Principles of Rescue
Critical PPH with overlapping high-risk factors (placenta previa, accreta, scarred uterus, multiple gestations, macrosomia, comorbidities, etc.) often presents acutely, progresses rapidly, and involves complex etiologies, easily leading to hemorrhagic shock, DIC, and multi-organ failure.
The core strategy is: Active Prevention, Layered Sequencing, and Multi-Modal Synchronization.
• Uterotonics run throughout the process.
• Hemostatics are used early.
• Mechanical compression is connected rapidly.
• Surgical intervention is never delayed.
The goal is closed-loop management to achieve rapid hemostasis, block DIC, reduce organ damage, and lower maternal mortality.
Part 2: Sequential Coordination Process
A. Antepartum: Front-loaded Prevention, Building the First Line of Defense
• Prophylactic Uterotonics: Administer first-line uterotonics (Oxytocin IV maintenance, Carbetocin) before fetal delivery. Prepare second-line uterotonics (prostaglandins) preoperatively for high-risk patients.
• Front-loaded Hemostatics: Initiate Tranexamic Acid early after fetal delivery for patients with placenta previa, accreta, history of massive hemorrhage, or hypercoagulable/bleeding tendencies—do not wait for increased blood loss.
• Mechanical Preparation: Have intrauterine balloons and B-Lynch suture instruments ready.
• Surgical Planning: Conduct multidisciplinary consultations preoperatively to clarify timing for embolization, uterine sutures, or hysterectomy.
B. Intrapartum: Bleeding Onset, Layered Escalation
• Trigger Threshold: Initiate medical therapy when blood loss ≥ 500 ml, and rapidly add mechanical methods.
• First-tier Intervention: Uterotonics + Hemostatics. Uterotonics are maintained throughout. Escalate to second-line if first-line fails (excluding contraindications). Initiate Tranexamic Acid early to block hyperfibrinolysis.
• Second-tier Intervention: Seamless connection to mechanical compression. During the gap before drugs take effect, implement mechanical compression immediately: start with manual uterine massage; if ineffective, rapidly perform intrauterine packing, intraoperative B-Lynch suture, or uterine artery ligation to buy time.
• Third-tier Intervention: Timely transition to surgery for refractory bleeding. If drugs + compression fail, blood loss continues to increase, or vitals become unstable, escalate to surgery immediately.
◦ Rule: Do not blindly increase drug dosages or change drugs ("No lingering").
◦ Compression: Must be standardized and到位 (properly positioned) to ensure efficacy.
◦ Surgery: Prioritize Damage Control principles: first compression/suturing/vessel ligation; perform hysterectomy if necessary, shifting focus from "saving the uterus" to "saving the life."
◦ Support: Maintain uterotonics and Tranexamic Acid intraoperatively; correct coagulopathy. Use mechanical compression post-op to prevent delayed bleeding.
Part 3: Key Considerations
1. Eliminate procrastination ("wait and see"). Set time limits for every intervention.
2. In refractory PPH, hysterectomy is a vital life-saving measure; do not hesitate.
3. Departments must post sequential rescue flowcharts for critical PPH, clarifying trigger conditions for interventions.
4. Conduct regular scenario simulations focusing on timed escalation and multidisciplinary collaboration.
Conclusion
This interview focused on the precise prevention and standardized treatment of postpartum hemorrhage. Professor Xu Qian clarified the principles of medication safety, stratification, and sequencing from the dual perspectives of obstetric QC and critical rescue. She proposed methods for constructing standardized medication thinking and outlined联动 (linkage) rescue pathways for high-risk, overlapping bleeding scenarios, emphasizing active prevention, timed escalation, and multidisciplinary collaboration. Addressing key clinical pain points and integrating QC standards with practical experience, this interview provides authoritative, actionable guidance for the precise medication, stratified treatment, and critical management of PPH, thereby enhancing the rescue capabilities of obstetric staff and ensuring maternal and infant safety.
Editor：Lily
