⚡ Postpartum Haemorrhage
1 RECOGNIZE
- Start the PPH bundle for measured blood loss ≥500 mL, or ≥300 mL with abnormal haemodynamics (WHO 2025); treat concerning ongoing bleeding/shock immediately without waiting for a volume threshold.
- Assess pulse, BP, shock index, perfusion and consciousness repeatedly; concealed loss and baseline anaemia can mask severity.
- A soft enlarged uterus suggests atony. Persistent bleeding with a firm uterus requires urgent assessment for trauma, retained tissue, inversion/rupture or coagulopathy.
2 CALL FOR HELP
- Declare PPH, state time of birth and blood loss, and allocate a team leader, resuscitation/drug clinician and recorder.
- Call senior obstetrician, anaesthetist, midwifery lead and blood bank together; activate the major-haemorrhage protocol early if bleeding/shock is substantial.
- Prepare theatre, blood products and neonatal support; explain events to the patient/companion through a designated team member.
3 IMMEDIATE ACTION
- Resuscitate and identify the cause IN PARALLEL: two large-bore IV cannulae, bloods/crossmatch and quantified cumulative loss; oxygen for hypoxia/shock, active warming and monitored fluid/blood replacement.
- Massage the uterus and use bimanual compression for atony; empty the bladder with a Foley catheter and measure urine output.
- Give oxytocin loading plus infusion and TXA using the complete cards below. Record previous prophylactic uterotonics: their identity changes the next uterotonic choice.
- For ongoing ATONIC bleeding, choose an appropriate additional uterotonic now: avoid ergometrine/methylergometrine with hypertension or pre-eclampsia, and avoid carboprost with asthma/significant pulmonary disease. Do not give both ergot preparations as though they are interchangeable.
- Keep examining the 4Ts while drugs are administered. Do not wait to finish eight carboprost doses before preparing tamponade or surgery in ongoing haemorrhage.
Drug doses & preparation
Choose the regimen for the stated indication. Alternatives are not instructions to give every medicine. Check prior doses, contraindications, concentration and the response before repeating.
Oxytocin — treatment of atonic PPHMSFchecked
Dose5–10 IU slowly IV, then 20 IU in 1 L isotonic crystalloid over 2 hours (MSF regimen)
RouteSlow IV loading + IV infusion
FrequencyLoading followed immediately by infusion
DurationInitial infusion over 2 h; reassess continuously and prescribe further treatment according to response
PreparationWith 10 IU/mL stock, 20 IU = 2 mL added to 1 L sodium chloride 0.9% or Ringer lactate. Pump 500 mL/hour = 10 IU/hour. Include this litre in total resuscitation fluid
Max doseMSF maximum total oxytocin 60 IU; avoid rapid boluses and excessive fluid
- Indication: Atonic bleeding after delivery; treatment continues alongside the PPH bundle
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- Fluid balance, sodium if prolonged/high-volume treatment; cardiac disease needs a separately prescribed concentrated infusion
Contraindications: Rapid IV injection can cause hypotension/tachycardia · Monitor fluid overload, especially pre-eclampsia or cardiac disease
Tranexamic acid — PPHWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checked
Dose1 g IV over 10 min; repeat 1 g if bleeding continues after 30 min OR restarts within 24 h
RouteIV only
FrequencyOne initial dose; at most one additional 1 g dose under those criteria
DurationAcute PPH treatment, maximum 2 doses in this regimen
Preparation100 mg/mL: 1 g = 10 mL. Give no faster than 1 mL/min, or dilute in compatible sodium chloride 0.9% and infuse over 10 min. Clearly label IV ONLY; never intrathecal
Max dose2 g total. The 24 h repeat rule does NOT permit a first dose after the 3 h window
- Indication: PPH of any cause; first dose as soon as possible and WITHIN 3 h of birth
- Renal / hepatic: Renal clearance: assess renal function and seek dose advice with impairment; do not repeatedly dose without review
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
Contraindications: Clear contraindication to antifibrinolysis, such as a known thromboembolic event during pregnancy; renal dysfunction needs dose review
Methylergometrine (methylergonovine)Manufacturer prescribing information / DailyMedchecked
Dose0.2 mg (200 micrograms)
RouteIM
FrequencyMay repeat after 2–4 h if necessary, following reassessment
DurationAcute treatment after birth; do not prescribe repeated doses while delaying haemorrhage control
Preparation0.2 mg/mL: 1 mL IM. Check the ampoule for the actual drug name. Routine IV use is avoided because of sudden hypertension/stroke risk
Max dose0.2 mg per injection; further doses require documented reassessment. No invented 15-minute repeat course
- Indication: Atonic PPH after delivery; this is NOT the same formulation/dose as ergometrine
- The product label advises no breastfeeding during treatment and for at least 12 h after the last dose; express/discard milk during that interval.
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- BP before each dose; chest pain, vasospasm, headache and neurological symptoms
Contraindications: Hypertension/pre-eclampsia/eclampsia; vascular or significant cardiac disease; before delivery of the last baby · Avoid strong CYP3A4 inhibitors; do not combine ergot preparations
Ergometrine maleateManufacturer / emcchecked
Dose200–500 micrograms IM; severe haemorrhage option 250–500 micrograms slow IV by a senior clinician
RouteIM; slow IV only for severe haemorrhage
FrequencyInitial dose followed by reassessment; select another indicated intervention for continuing bleeding
DurationAcute post-birth treatment; no routine multi-day course in this emergency row
Preparation500 micrograms/mL formulation: 500 micrograms = 1 mL. For IV use the cited label permits dilution to 5 mL with sodium chloride 0.9%; administer slowly with BP monitoring
Max dose500 micrograms per dose in this label; do not substitute the methylergometrine schedule or invent a cumulative ceiling
- Indication: Alternative uterotonic for atonic PPH; use this row only when the ampoule is ERGOMETRINE
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- BP before and after injection; chest pain, severe headache, peripheral ischaemia
Contraindications: Hypertension/pre-eclampsia/eclampsia, severe cardiac/vascular disease, severe renal/hepatic impairment · Never use before delivery of the last baby
Dose250 micrograms (0.25 mg) deep IM
RouteIM only
FrequencyRepeat according to response at intervals of 15–90 min; NEVER sooner than 15 min
DurationAcute rescue; ongoing bleeding requires parallel tamponade/surgery
Preparation250 micrograms/mL: draw 1 mL undiluted. Verify units carefully: micrograms, not milligrams. Do not administer IV
Max dose2 mg total = 8 doses of 250 micrograms
- Indication: Refractory atonic PPH after first-line uterotonic; do not use for trauma or retained tissue alone
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- Respiratory status/bronchospasm, BP, vomiting/diarrhoea
Contraindications: Asthma or significant active pulmonary disease; active cardiac, renal or hepatic disease · Do not persist with repeated injections in a deteriorating patient
Misoprostol — PPHMSFchecked
Dose800 micrograms
RouteSublingual; rectal if sublingual administration is not feasible
FrequencySingle rescue dose
DurationOne acute dose; arrange further haemorrhage control if bleeding continues
PreparationFour 200-microgram tablets = 800 micrograms; place under the tongue. Do not confuse this with the 25-microgram labour-induction dose
Max dose800 micrograms in this rescue regimen; do not automatically repeat
- Indication: Atonic PPH when IV oxytocin is unavailable or bleeding does not respond; additional uterotonic selection depends on drugs already given
Monitoring
- Quantified blood loss, uterine tone, BP/pulse, perfusion and urine output; record every dose and time
- Persistent shock or bleeding needs source control and blood products in parallel; do not wait for all drug doses
- Temperature, shivering, gastrointestinal effects; distinguish drug fever from ongoing sepsis
Contraindications: Do not use PPH dosing before birth of the baby
4 INVESTIGATIONS (never delaying treatment)
- CBC/platelets, group and crossmatch, PT/APTT and fibrinogen; repeat during ongoing major loss and after replacement.
- Blood gas/lactate, ionised calcium, potassium, temperature and renal function; results guide resuscitation but never postpone haemorrhage control.
- Examine placenta/membranes and inspect cervix/vagina/perineum with adequate exposure/analgesia. Ultrasound can support assessment of retained tissue but must not delay treatment.
5 DEFINITIVE MANAGEMENT
- TONE: continue bimanual compression and the selected uterotonics. TRAUMA: inspect and repair tears/haematoma; assess rupture/inversion. TISSUE: arrange skilled manual removal/evacuation when indicated; do not forcibly detach a suspected accreta placenta. THROMBIN: correct coagulopathy with the blood bank while obtaining source control.
- If atony continues despite initial treatment, consider intrauterine balloon tamponade only after assessing trauma/retained tissue and where monitoring, blood and immediate surgical rescue are available. Use sterile technique, the specific balloon’s recommended filling fluid/volume and a drainage channel; record fill volume and continuing blood loss.
- Bakri-type devices have a manufacturer-specific maximum volume (commonly 500 mL); do not inflate repeatedly beyond the device limit to compensate for persistent bleeding. Continue observations, uterotonic support and an explicitly prescribed antibiotic/removal plan.
- Persistent bleeding, deteriorating physiology or a failed tamponade test means immediate senior operative control. Compression sutures/devascularisation, embolisation in a stable suitable patient, or hysterectomy are selected by cause and expertise; this is not a mandatory ladder requiring every step before hysterectomy.
6 ESCALATION
- Continuing loss or shock despite initial treatment: theatre and major-haemorrhage support immediately, without an arbitrary waiting period.
- HDU/ICU for ongoing shock, vasopressor/ventilation need, coagulopathy, organ dysfunction or large transfusion; a unit count is not the sole admission criterion.
- During transfer, continue uterine/aortic compression as appropriate, warming and blood/fluid support with skilled escort; contact the receiving team first. Compression/tamponade must not delay transfer or definitive rescue.
7 POST-EVENT CARE
- Continue close uterine-tone, bleeding, perfusion, urine-output and laboratory review until stable; document every product, drug and operative decision.
- Correct iron deficiency/anaemia using the measured deficit and clinical status. Reassess VTE prophylaxis only after haemostasis and an anaesthetic/bleeding-risk review.
- Explain the cause and treatment, offer psychological/lactation support, arrange Hb/clinical follow-up and a future-pregnancy delivery plan.
Admission & discharge after the acute event
Care setting: Emergency admission; major bleeding may need theatre/critical care
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit and treat ongoing heavy bleeding, abnormal haemodynamics, suspected retained tissue/infection or coagulopathy. Transfer to theatre/critical care according to bleeding and organ-support requirements.
When clinic, day care or home care may be suitable
- Active PPH, shock or suspected secondary PPH with systemic illness is not suitable for routine outpatient management.
Before going home
- The bleeding source is controlled; uterine/perineal/wound assessment is satisfactory and there is no recurrent concerning loss.
- Haemodynamics, consciousness, urine output, oral intake, mobility and pain control support home care. Review anaemia symptoms, Hb trend and any coagulopathy/organ injury; there is no single Hb value that alone certifies safe discharge.
Discharge medicines and treatment changes
- Prescribe iron replacement when iron deficiency/anaemia is present, using a documented formulation, dose and response plan; assess whether IV treatment or transfusion is needed before discharge.
- Uterotonics and TXA used for the acute event are not automatically continued at home. Reassess VTE prophylaxis after bleeding risk has fallen.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
Only for diagnosed postpartum iron-deficiency anaemia after bleeding is controlled.
Oral iron and folic acid — postpartum anaemia treatmentWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checked
Dose120 mg ELEMENTAL iron plus 400 micrograms folic acid per day
RouteOral
FrequencyDaily; tailor administration for tolerance without accidentally changing the prescribed total
DurationWHO postpartum anaemia treatment: until Hb normalises. Then document any continuing preventive/repletion course and review; the preventive 6–12-week recommendation is a different indication.
PreparationUse the product’s ELEMENTAL iron content, not salt weight: two tablets each containing 60 mg elemental iron provide 120 mg. Check the combined-tablet folate separately. Separate iron from calcium by several hours and levothyroxine by 4–5 hours.
Max dose120 mg/day elemental iron in this WHO treatment schedule; do not add duplicate antenatal/OTC iron or overlap oral and IV courses without an explicit plan.
- Indication: Diagnosed postpartum iron-deficiency anaemia after haemorrhage is controlled and outpatient oral treatment is suitable
- The WHO 2025 supportive-care recommendation supplies the postpartum dose/endpoint. Preparation and response monitoring reuse the checked oral-iron reference; breastfeeding is compatible with indicated maternal supplementation.
Monitoring
- Arrange Hb response review after 2–4 weeks, tolerance and adherence; investigate non-response or ongoing bleeding and reassess the replacement route.
- Review the cause of anaemia and any coexisting B12/folate deficiency or haemoglobinopathy.
Contraindications: Iron overload or anaemia without iron deficiency; oral iron alone is inadequate for unstable bleeding or cardiovascular compromise.
Tests, pending results and their reviewer
- Record quantified loss, procedures, transfusion and latest relevant CBC/coagulation/renal results; assign a reviewer/date for outstanding investigations.
Home care and counselling
- Explain the cause and treatment, expected lochia, worsening-bleeding warnings, fatigue/feeding support and the future-birth haemorrhage plan. Offer a debrief and emotional support.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
Before leaving | Book anaemia/Hb response review and communicate any organ-injury or transfusion follow-up to the responsible team. |
Early postnatal contacts and 6-week review | Review bleeding, recovery, mental health and the future-pregnancy plan; review sooner for symptoms or major anaemia. |
Return urgently
- Sudden/heavy or increasing bleeding, fainting, breathlessness, fever, offensive discharge or worsening abdominal pain require immediate assessment.
Sources
WHO / FIGO / ICM · Consolidated edition (supersedes fragmented prior guidance incl. 2012 PPH recs; incorporates 2017 TXA recs, 2018 uterotonics, 2023 blood-loss assessment/treatment bundle)summary checkedWHOcheckedMSFcheckedNICE · NG235 (replaces CG190); updates Nov 2025 water birth, Jun 2025 fluid balance/bladder care/hyponatraemia, Jun 2026 vitamin K deficiency bleeding prevention reintroducedcheckedMSFcheckedWHO · Supersedes 2012 TXA recommendation; now folded into Consolidated PPH 2025 Recs 27/29checkedManufacturer prescribing information / DailyMedcheckedManufacturer / emccheckedManufacturer prescribing information / DailyMedcheckedMSFcheckedNICE · NG194, recommendationscheckedIndia MoHFW / NHM · LaQshya district-hospital SOP, linked editioncheckedWHO · 2022 official recommendation summarycheckedWHOsummary checkedWHO / FIGO / ICM · 2025 consolidated recommendations, supportive care tablesummary checkedRCOG · Current public recovery informationcheckedNICE · CG50, recommendationschecked