Postpartum Haemorrhage (PPH)
RCOG Green Guideline No. 52 Prevention and Management of Postpartum Haemorrhage
NICE [NG235] Intrapartum care – Third Stage of Labour – Postpartum haemorrhage. Last updated: Jun 2025.
Background Information
Definition
Primary vs secondary:
- Primary PPH: bleeding from the genital tract within 24 hours of the birth of a baby
- Minor: 500-1000 mL of blood loss
- Major: >1000 mL of blood loss
- Secondary PPH: abnormal / excessive bleeding from the genital tract between 24 hours and 12 weeks (3 months)
Causes and Risk Factors
Primary PPH
Causes of primary PPH can be remembered using the ‘4 Ts‘:
| 4 Ts | Description | Risk factors |
|---|---|---|
| Tone (most common) | Uterine atony – failure of the uterus to contract effectively |
|
| Tissue | Retained placenta or membranes | Placenta accreta spectrum |
| Trauma | Lacerations or injury to the genital tract, uterus or surrounding tissue |
|
| Thrombin | Coagulopathy (pre-existing, or acquired) | Pre-existing: clotting disorder (e.g. von Willebrand disease)
Acquired: pre-eclampsia, placental abruption |
Secondary PPH
Main causes of secondary PPH are:
- Retained product of conception – most common
- Endometritis – 2nd most common
- Gestational trophoblastic disease
- Coaulopathy
Guidelines
Primary PPH Management
Since the most common cause of primary PPH is uterine atony, guidelines are based on the assumption of atony being the cause of primary PPH.
Prevention
Prophylactic uterotonics with oxytocin should be offered to ALL women in the management of the third stage labour.
If woman is at increased risk of PPH, consider:
- Ergometrine-oxytocin (e.g. Syntometrine)
- NB contraindicated in hypertension (ergometrine is a vasoconstrictor)
- More effective in reducing minor PPH than oxytocin alone, but carries higher risk of side effects
- IV tranexamic acid in addition to oxytocin
RCOG: Uterine massage is of no benefit in the prophylaxis of PPH
Resuscitation
Minor PPH without clinical shock:
- Gain IV access + give warm crystalloid infusion
- Urgent bloods for FBC, group and save, coagulation screen
- Pulse, respiratory rate, blood pressure every 15 min
Major PPH:
- Initial interventions/investigations
- 2 large-bore cannulae → urgent bloods for FBC, group and save, coagulation screen, renal and liver function
- Urinary catheterisation → monitor urine output + bladder decompression can aid/improve uterine contraction
- Consider arterial line monitoring
- Up to 3.5 L of warm clear fluids (up to 2 L of isotonic crystalloid and 1.5 L of colloid until blood arrives)
- Transfuse blood if clinically indicated
- Use O -ve initially, and switch to group-specific blood ASAP
Definitive Management
1st Line – Mechanical Measures
Aim: to stimulate uterine contractions:
- Uterine massage (fundal rub) – first line generally
- Bimanual uterine massage – typically if uterine massage failed but not explicitly mentioned in guidelines
2nd Line – Pharmacological Measures
Class of medication used: uterotonics (induce or augment uterine contraction)
- Most commonly used: Oxytocin IV
- Ergometrine 0.5mg IM or IV (contraindicated in hypertension)
- Carboprost 0.25 mg IM (caution in asthma)
- Misoprostol 800 micrograms sublingually
3rd line – Surgical Measures
- 1st line: intrauterine balloon tamponade
- 2nd line: haemostatic (B-Lynch) suturing
- 3rd line: internal iliac artery ligation / selective arterial occlusion by interventional radiology
- Last resort: hysterectomy
RROG recommends resorting to hysterectomy sooner rather than later, especially in cases of placenta accreta or uterine rupture.
Secondary PPH
Assessment and Management
- If retained products of conception suspected
- Pelvic ultrasound
- Consider surgical evacuation if confirmed
- If endometritis suspected → high vaginal and endocervical swabs for microbiology
- Not specified by NICE / RCOG guidelines but a commonly accepted 1st line regimen is IV ceftriaxone + metronidazole
References
Original Guideline