The Four T’s of PostPartum Hemorrhage: What Labor Nurses Need to Know


Postpartum hemorrhage is one of the three leading causes of maternal mortality worldwide.  It is estimated that one maternal death occurs every 4 minutes secondary to postpartum hemorrhage.  The Four T's of postpartum hemorrhage: tone, tissue, trauma, & thrombin, classify the most common causes of abnormal bleeding.

Postpartum hemorrhage according to ACOG (American College of Obstetrics and Gynecology) is defined as:

Cumulative blood loss ≥ 1000cc within 24 hours of delivery (cesarean or vaginal)


Blood loss that is partnered with associated signs & symptoms of hypovolemia within 24 hours of delivery

          As a labor nurse, knowing the risk factors of postpartum hemorrhage prior to a vaginal or cesarean delivery is paramount.  Understand what causes PPH to prevent, identify, and respond quickly to abnormal bleeding and improve outcomes to save lives.

A simple way to remember the causes of postpartum hemorrhage are to remember the FOUR T's:

incidence_pph_nurse_forward (1)
  1.  Tone (uterine atony)
  2.  Tissue (retained placenta and/or placental pieces, clots, retained products of delivery)
  3.  Trauma (vaginal or cervical lacerations, hematomas, uterine rupture or inversion)
  4.  Thrombin (missing clotting factors, bleeding disorders)

Let's explore each of the FOUR T's of POSTPARTUM HEMORRHAGE :


"Tone" refers to uterine atony.  Uterine atony is defined as lack of tone of the uterus after a vaginal or cesarean delivery.  A uterus that has sufficient tone "clamps down" on itself to constrict the uterine blood vessels.  This causes restriction of blood flow through the vessels and allows them to clot off thus stopping any abnormal bleeding.  Uterine Atony is responsible for 70-80% of postpartum hemorrhages.

Causes of Uterine Atony

⇒ Over-distention of Uterus
  • Multiple gestations (twins, triplets)
  • Macrosomia (large baby ≥ 9lbs)
  • Polyhydramnios (amniotic fluid index ≥ 24cm measured via ultrasound)
⇒ Chorioamnionitis
  • bacteria which has infected the membranes that surround the fetus (chorion) and the amniotic fluid in which the fetus is immersed (amnion)
⇒ Prolonged Labor or Labor Augmented with Oxytocin
  • labor lasting > 20 hours in primiparas or > 14 hours in multiparas
  • extended use of intravenous oxytocin to induce or augment labor
⇒ Precipitous Delivery/"Fast" Labor
  • labor and delivery from start to finish < 3 hours
⇒ Full bladder
  • A distended bladder presses on the uterus and prevents it from clamping down effectively

Prevention of Uterine Atony

Most cases of postpartum hemorrhage are preventable with appropriate response to risk factors.  Practitioners can also actively manage the third stage of labor to decrease maternal risk of hemorrhage.

Active Management of the Third Stage of Labor to prevent PPH:
⇒ Perform Fundal massage
⇒ Gentle cord traction
⇒ Administer Uterotonic agents:
  1. Oxytocin administration → 10 units IM or 10-40 units IV in NS (give first upon delivery of the anterior shoulder)
  2. Methergine → 0.2mg IM
  3. Cytotec → 1000mcg PR
  4. Hemabate → 0.25mg IM

Nursing Practice Tip:  Ensure adequate bladder emptying via patient void or straight cathetarization post delivery to prevent abnormal bleeding.


"Tissue" refers to having retained placenta (undelivered placenta within 30 minutes of delivery) or retained placental fragments, membranes, and/or clots.  Retained products are responsible for approximately 10% of postpartum hemorrhage.

Prevention of Retained Products

  • Examine placenta for missing pieces after delivery
  • If retained parts are suspected, do sterile manual sweep of uterus to remove adherent or missing placental parts
  • Bi-manual uterine massage
  • Perform ultrasound to confirm presence of retained fragments/clots/blood
  • Rule out Placenta Accreta (partial or whole implantation of placenta into uterine wall)
  • Consider D&C (dilation & curettage) in operating room

Nursing Practice Tip:  Inspect all delivered placentas, labor nurses should be inept in identifying abnormal findings and able to report them to the physician.


Bleeding that results from trauma is responsible for approximately 20% of abnormal postpartum bleeding and is the second most common cause of PPH.  Trauma secondary to vaginal delivery of the maternal patient may indicate a need for surgical repair/active management due to several possible causes.

Examples of Trauma s/p Vaginal Delivery

  • Vaginal laceration (common in primipara's)
  • Cervical laceration
  • Hematoma
  • Uterine rupture
  • Uterine inversion

Identify Risk Factors for Trauma s/p Vaginal Delivery

⇒ Vaginal Lacerations
  • Primparity
  • Macrosomia
  • Operative vaginal delivery (forceps, vacuum-assisted)
  • Occiput posterior position (sunny-side up)
  • Prolonged second stage of labor (prolonged pushing)
⇒ Cervical Lacerations
  • Cerclage
  • Pushing before 10cm ("fully dilated" or "complete")
⇒ Hematomas
  • present as increased pain or change in vital signs (↓BP,↑HR)
  • managed via observation or incision and evacuation depending on volume of blood loss/size of hematoma
⇒ Uterine Rupture
  • history of cesarean section delivery
  • uterine abnormalities (i.e.bicorniate uterus)
  • macrosomia
  • prolonged use of oxytocin for induction & augmentation of labor
⇒ Uterine Inversion
  • Applying excessive tension on the umbilical cord
  • fundal implantation of placenta
  • excessive fundal pressure
  • placenta accreta
  • short umbilical cord

Nursing Practice Tip:  Good visualization is important when suspected trauma is being ruled out as the cause of abnormal bleeding.  Ensure a spot light is available and/or consider repair of lacerations in the operating room where visualization is optimal.


Thrombin represents bleeding disorders and lack of coagulating factors.  Less than 1% of all postpartum hemorrhages are caused by coagulopathy.  Taking a full history and physical as part of routine prenatal care is critical to identifying risk factors for PPH due to coagulopathy.

Preventing PPH from Coagulopathy

  • Assess history of hemophilia, Von Willebrands,  idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), or other bleeding disorders
  • Obtain CBC, PT/PTT/INR, fibrinogen levels
  • Consider TXA (tranexamic acid) to promote clotting
  • Rule out HELLP syndrome (hemolysis, elevated liver enzyme levels, and low platelet levels)
  • Replace factors, FFP, factor VIIa or PLT infusion to avoid DIC (disseminated intravascular coagulation)

Read this post to learn about Nursing Care during Blood or Blood Product Transfusion

Early Resuscitation in PPH

If a postpartum hemorrhage is suspected or anticipated, early resuscitation is key.  Labor nurses should ensure a patient with a high hemorrhage risk or with signs of abnormal bleeding postpartum be prepared for an emergency.  Nursing prep for the at risk patient includes, but is not limited to:

  • 2 large bore (18G or higher) IV sites
  • Active type & screen in the blood bank
  • Request 2 units of pRBC's be placed on hold
  • Monitor Vital signs and patient status closely
  • Have Obstetrics doctor at bedside for immediate assessment
  • Ensure uterotonic medications and hemorrhage supplies (bakri, instruments, or ultrasound, etc.) are available
  • Replace any repleted volume with Lactated Ringers intravenous fluid
  • Apply oxygen as needed
  • Acquire additional nursing support to assist with medical management of the hemorrhage
  • Patient education

Nurses Practice Guide:


In many cases, the risk of postpartum hemorrhage can be detected early and often prevented.  Through education, taking a thorough maternal history, and being prepared as health care providers, we can protect patients from the dangers of hemorrhage.

ACOG recommends that every birthing facility have specific protocols and procedures in place to train healthcare professionals in the event of postpartum hemorrhage.  Does your hospital or facility have protocols and procedures in place for the prevention and management of a PPH?   Would you feel confident in your ability to identify and manage the care of a woman during a hemorrhage?

Let me know in the comments at the bottom of  this post or ask a question on my facebook page.

Thank you for reading!  

4 thoughts on “The Four T’s of PostPartum Hemorrhage: What Labor Nurses Need to Know”

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