Chart — Maternal-Newborn
Postpartum Hemorrhage — Four T’s Chart
The fundus sorts the differential in seconds: boggy means Tone, firm with bright bleeding means Trauma, bleeding that survives good tone means Tissue, and oozing from everywhere means Thrombin.
Educational use only. Hemorrhage management follows facility protocols and provider direction — this chart supports rapid cause-sorting at the bedside. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
The Four T’s Side by Side
| Cause | Share of PPH | Exam Findings | Management Ladder | Risk Factors |
|---|---|---|---|---|
| Tone — uterine atony | ≈70–80% of PPH | Boggy, soft fundus — often high and deviated (think full bladder); dark blood with clots pooling | Fundal massage immediately; empty the bladder; oxytocin then second-line uterotonics; bimanual compression → balloon tamponade → OR | Overdistension (macrosomia, twins, polyhydramnios), prolonged or precipitous labor, high parity, chorioamnionitis, magnesium |
| Trauma — lacerations, hematoma, rupture, inversion | ≈15–20% | Firm fundus with steady bright-red bleeding; or severe perineal/rectal pain with little visible blood (hematoma); inversion: fundus not palpable + shock | Provider exam and repair; hematoma evacuation per size; inversion and rupture are operative emergencies | Operative vaginal delivery, precipitous birth, macrosomia, episiotomy, prior uterine surgery |
| Tissue — retained placenta/fragments | ≈10% | Bleeding despite reasonable tone; placenta incomplete at inspection; boggy-then-firm-then-boggy cycling | Manual exploration/extraction, curettage per provider; anticipate accreta-spectrum escalation | Accreta spectrum, prior cesarean, preterm delivery, succenturiate lobe |
| Thrombin — coagulopathy | ≈1% | Oozing from IV sites and gums, blood that will not clot, bleeding out of proportion to exam | Labs (coags, fibrinogen, platelets), targeted products — FFP, cryoprecipitate, platelets — treat the underlying cause | Abruption, amniotic fluid embolism, HELLP, severe preeclampsia, sepsis, anticoagulants, massive transfusion dilution |
Universal Moves, Whatever the T
• Quantify the loss — weigh, don’t estimate (1 g = 1 mL); keep a running total
• Second large-bore IV, labs with type and crossmatch, warm fluids
• Vitals on a tight cycle — tachycardia and narrowing pulse pressure arrive before hypotension
• Activate the hemorrhage / massive-transfusion protocol at your facility’s trigger, not after
• One person owns the clock and the count
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with American College of Obstetricians and Gynecologists (ACOG) · AWHONN · American Academy of Pediatrics (AAP) — newborn. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →