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 with replacement of clotting factors, fibrinogen, or other factor replacement sources.
最後，提到“living ligatures"，子宮是由三種不同走向的肌肉層組合，而供給子宮血液的血管，就如同編織一樣貫穿在子宮肌肉當中，在產後的瞬間，止血的第一要務，就是使子宮肌肉收縮，可以透過肌膚接觸、寶寶吸吮乳頭、天然的催產素釋放、或是子宮按摩，讓血管們自然的被束緊閉合，正是“living ligatures"的機轉，何其重要！
講一講不知道會不會太嚇人，不過身為助產師，不就是把各種可能的蛛絲馬跡收在眼裡，一時一刻承擔也祈願生產時一切靜好，見微知著。
參考資料
ACOG
Practice Bulletin No. 183: Postpartum Hemorrhage. (2017). Obstetrics & Gynecology, 130(4), e168-e186. doi:10.1097/aog.0000000000002351
FIGO
Lalonde, A. and , (2012), Prevention and treatment of postpartum hemorrhage in low‐resource settings. International Journal of Gynecology & Obstetrics, 117: 108-118.
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