助產師閒聊出現PPH 4Ts’ causes也是很自然的， tone, trauma, tissue, thrombin很重要，要念三次。 “When evaluating a patient who is bleeding, it may be helpful to consider “the 4Ts” mnemonic device—tone, trauma, tissue, and thrombin” *Tone-70-80%的產後大出血是因子宮無法有效收縮導致，是產後出血最主要原因，需要做的處置包含子宮按摩、加壓止血(其他Foley水球等細項就不多說）、宮縮藥 Abnormal uterine tone (uterine atony) is estimated to cause 70–80% of postpartum hemorrhage and usually should be suspected first as the etiology of postpartum hemorrhage . *Trauma-如字面所譯 外傷性的如可見的會陰撕裂傷、或外表不一定可見的血腫，子宮破裂等。 Maternal trauma is indicated by lacerations, expanding hematomas, or uterine rupture. *Tissue-胎盤殘留導致的收縮不佳引起，可透過超音波診斷即時刮除 Retention of placental tissue can be readily diagnosed with manual examination or bedside ultrasonography of the uterine cavity and is addressed with manual removal or uterine curettage. *Thrombin-撇除前述的原因，勿忘檢視凝血功能（在子癲前症或子癲症，疑似HELLP syndrome的個案身上，也須特別注意） Thrombin is a reminder to evaluate the patient’s coagulation status and if abnormal to correct w