Surgical management of postpartum hemorrhage illustration

Postpartum Hemorrhage: A Comprehensive Guide to Surgical Management

Samir D’Costa in Health & Wellness November 2025 • 3 min read.

"When medical interventions aren't enough: Exploring surgical options to manage and treat postpartum hemorrhage."

Postpartum hemorrhage (PPH), or excessive bleeding after childbirth, is a serious complication that can lead to significant maternal morbidity and mortality. While prevention and initial medical management are crucial, surgical intervention becomes necessary when these measures fail to control the bleeding effectively.

This article aims to provide a comprehensive overview of the surgical management of PPH, outlining the essential steps for preparation, resource mobilization, and a systematic approach to evaluation and treatment. We'll explore various fertility-preserving surgical techniques and discuss the critical decision-making process for when a hysterectomy is the only life-saving option.

Understanding the different surgical approaches and knowing when to implement them can significantly improve outcomes for women experiencing PPH. This guide will equip healthcare providers and expectant parents with valuable knowledge to navigate this challenging situation.

Understanding the '4 Ts' of Postpartum Hemorrhage: A Surgical Perspective

Surgical management of postpartum hemorrhage illustration

The approach to managing PPH surgically often revolves around addressing the "4 Ts": Tone (uterine atony), Trauma (lacerations), Tissue (retained placental fragments), and Thrombin (coagulation disorders). Surgical interventions are designed to improve uterine tone, remove retained tissue, repair trauma, and control blood loss.

These surgical techniques generally fall into three categories:

Restoring uterine contractility by removing tissue and repairing trauma.
Decreasing blood loss, allowing uterotonic medications to take effect.
Providing tone through internal or external tamponade.

It's important to note that there's no definitive order in which these techniques should be used, and the approach must be tailored to the individual patient's condition, the severity of the hemorrhage, and the available resources. The "STASIS" algorithm (Shift, Tissue, Apply Compression, Systematic devascularization, Interventional Radiology, Subtotal/Total hysterectomy) provides a useful framework for decision-making.

The Importance of Readiness: When Hysterectomy is the Definitive Solution

While conservative, fertility-sparing surgical approaches are valuable tools in managing PPH, it is crucial to recognize when a hysterectomy becomes necessary. In a hemodynamically unstable patient, team readiness for definitive management with a hysterectomy is essential to reduce the risk of maternal mortality. This decision should be made promptly and decisively, based on the patient's overall condition and response to other interventions.

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Everything You Need To Know

What are the main surgical goals when managing Postpartum Hemorrhage (PPH)?

The primary surgical goals in managing Postpartum Hemorrhage (PPH) include restoring uterine contractility by removing tissue and repairing trauma, decreasing blood loss to allow uterotonic medications to take effect, and providing tone through internal or external tamponade. These techniques align with addressing the '4 Ts': Tone, Trauma, Tissue, and Thrombin.

How do the '4 Ts' relate to surgical management of Postpartum Hemorrhage (PPH)?

The '4 Ts'—Tone (uterine atony), Trauma (lacerations), Tissue (retained placental fragments), and Thrombin (coagulation disorders)—directly guide the surgical approach to Postpartum Hemorrhage (PPH). Surgical interventions aim to improve uterine tone, remove retained tissue, repair trauma, and control blood loss, thereby addressing each of the '4 Ts'.

What is the 'STASIS' algorithm, and how does it guide decisions in surgical management of Postpartum Hemorrhage (PPH)?

The 'STASIS' algorithm (Shift, Tissue, Apply Compression, Systematic devascularization, Interventional Radiology, Subtotal/Total hysterectomy) provides a structured framework for decision-making in the surgical management of Postpartum Hemorrhage (PPH). It helps guide healthcare providers through a systematic approach, starting with shifting resources and addressing tissue issues, and escalating interventions as needed, potentially leading to a hysterectomy if other measures fail. The algorithm emphasizes a progressive approach based on the patient's condition and response to treatment.

When is a hysterectomy considered the definitive solution for Postpartum Hemorrhage (PPH), and what factors influence this decision?

A hysterectomy is considered the definitive solution for Postpartum Hemorrhage (PPH) when the patient is hemodynamically unstable and other conservative, fertility-sparing surgical approaches have failed to control the bleeding. The decision to perform a hysterectomy is influenced by the patient's overall condition, the severity of the hemorrhage, and their response to previous interventions. Prompt and decisive action is essential to reduce the risk of maternal mortality in these situations.

What is the importance of readiness for a hysterectomy in the context of managing Postpartum Hemorrhage (PPH), and what are its implications?

Readiness for a hysterectomy is crucial in managing Postpartum Hemorrhage (PPH) because it represents the definitive surgical solution when other interventions are insufficient. The implications of being prepared include having a trained surgical team, necessary resources, and a clear understanding of the patient's condition. Delaying or being unprepared for a hysterectomy in a critical situation can increase the risk of maternal mortality. This readiness ensures that if a hysterectomy becomes necessary, it can be performed promptly to save the patient's life.