Women's Health

Postpartum Haemorrhage

Postpartum haemorrhage is bleeding after birth that outruns the myometrial contraction meant to close the placental bed, usually from atony, retained tissue, trauma or failed clotting.

In a nutshell

Postpartum haemorrhage (PPH) is loss of 500 mL or more within 24 hours of birth, most often from uterine atony. Call for help, resuscitate, choose the uterotonic by what was given in the third stage, and give tranexamic acid 1 g intravenously over 10 minutes.

Classic presentation

Minutes after a long augmented labour the pad count looks modest, but the uterus feels soft and high, the pulse is climbing and the blood pressure is falling.

Key points

Primary PPH is 500 mL or more within 24 hours of birth: minor 500 to 1000 mL, major over 1000 mL.
The Royal College of Obstetricians and Gynaecologists (RCOG) splits major PPH into moderate, 1000 to 2000 mL, and severe, over 2000 mL.
Antepartum haemorrhage (APH) uses different numbers for the same words: Green-top 63 calls 50 to 1000 mL major and over 1000 mL massive. The terms are not interchangeable.
NICE table 12 first line: after physiological management, oxytocin plus ergometrine 1 mL intramuscularly; after oxytocin alone, ergometrine; after oxytocin plus ergometrine, carboprost; after carbetocin, ergometrine.
Carboprost 250 micrograms deep intramuscularly, repeatable no sooner than every 15 minutes, maximum 2 mg or 8 doses. Misoprostol 800 micrograms sublingually or rectally.
Severe atony: oxytocin 40 units in 500 mL by infusion, titrated to tone. Use an electrolyte-containing diluent rather than glucose and restrict oral fluids, because high-dose oxytocin causes hyponatraemia.
Intramuscular oxytocin acts in about 2.5 minutes and lasts 30 minutes to 1 hour; ergometrine acts in about 7 minutes and lasts about 3 hours.
Green-top 47: keep fibrinogen above 1.5 g/L with two 5-unit cryoprecipitate pools early, and platelets above 50 x 10⁹/L with a transfusion trigger of 75 x 10⁹/L.
Fresh frozen plasma (FFP) 12 to 15 mL/kg for every 6 units of red cells. Red cells are almost always needed below haemoglobin 60 g/L and rarely above 100 g/L.
A fibrinogen of 2.0 g/L or less during PPH is already abnormally low, because pregnancy normally raises it. An acutely bleeding woman can have a normal haemoglobin.
Balloon tamponade comes before laparotomy, then compression sutures, vessel ligation, embolisation and hysterectomy. NICE prefers no single operation. Never delay life-saving haemostasis to preserve fertility.
Secondary PPH is bleeding between 24 hours and 12 weeks, usually endometritis or retained products. No UK national guideline names an antibiotic regimen, so use the BNF.

First-line investigation

Quantified blood loss and uterine tone at the bedside, plus FBC, clotting with fibrinogen, and group and crossmatch.

Management

Call for help and resuscitate

Call obstetrics, anaesthetics, midwifery and haematology. Empty the bladder, massage the uterus, two large-bore cannulae, warmed intravenous fluids, and transfer to obstetric-led care.^1,2,3
Oxygen starting at 15 L/minute through a non-rebreathing mask with a reservoir bag, targeting saturations of 94% to 98%.^1,2
Over 1000 mL calls the major obstetric haemorrhage response; antepartum Green-top 63 adds clinical shock at any volume. Weigh swabs; do not eyeball the loss.^3,8

Find the four-T cause

Tone, Tissue, Trauma, Thrombin, all four at once. Check uterine tone, whether the placenta is complete, the cervix and vagina, and cannula-site oozing.^1,2,3
Send FBC, prothrombin time, activated partial thromboplastin time, fibrinogen and crossmatch, and repeat them while bleeding continues.⁴

Uterotonics by NICE table 12

After physiological management: oxytocin plus ergometrine 1 mL intramuscularly, or carboprost if ergometrine is contraindicated. After oxytocin alone: ergometrine intramuscularly. After both, or after carbetocin: carboprost or ergometrine respectively.^1,2,5,9
Oxytocin 5 units by slow intravenous injection, repeated if needed, then 40 units in 500 mL by infusion for severe haemorrhage, titrated to uterine tone.¹⁰
Carboprost 250 micrograms deep intramuscularly, repeatable at not less than 15-minute intervals, maximum 2 mg or 8 doses. Misoprostol 800 micrograms sublingually or rectally.^11,12,1,2
No carboprost in asthma: use prostaglandin E1, which is misoprostol. No ergometrine in hypertension, pre-eclampsia, eclampsia or severe cardiac disease; use carboprost.^13,14,11,12

Tranexamic acid and blood products

Tranexamic acid 1 g by slow intravenous injection over 10 minutes at diagnosis, repeated once after at least 30 minutes if bleeding continues.^1,2,6
Group O RhD-negative, K-negative red cells in extremis, switching to group-specific as soon as feasible. Fresh frozen plasma (FFP) 12 to 15 mL/kg per 6 units of red cells.⁴
Cryoprecipitate two 5-unit pools early, keeping fibrinogen above 1.5 g/L. Platelets above 50 x 10⁹/L, trigger 75 x 10⁹/L. Fibrinogen concentrate is unlicensed in the UK here.⁴

Theatre, examination and tamponade

Examination under anaesthesia: confirm an empty uterus, remove retained tissue, repair tears. Manual removal of the placenta needs anaesthesia.^1,2,3
Intrauterine balloon tamponade before laparotomy, while major haemorrhage resuscitation continues.³

Surgery and embolisation

Compression sutures, stepwise vessel ligation, uterine artery embolisation where interventional radiology exists, and hysterectomy. NICE prefers no single procedure.³
The consultant obstetrician chooses. Recombinant factor VIIa is a haematology decision and must not delay surgery, embolisation or transfer.⁴

Secondary PPH and recovery

Secondary PPH, 24 hours to 12 weeks: usually endometritis or retained products. Swabs, cultures, ultrasound, and antibiotics taken from the BNF because no UK guideline names a regimen.^3,7
Check haemoglobin and treat iron deficiency; red cells almost always below 60 g/L, rarely above 100 g/L. Offer thromboprophylaxis, a debrief and a plan for the next pregnancy.^4,7
Never pre-prepare oxytocin infusions at ward level. Prepare at the time of birth, keep PPH kits immediately available, and use a second midwife for high-risk women.^15,10

Exam traps

A firm, well-contracted uterus that keeps bleeding is not atony. Look for a cervical or vaginal tear, or for coagulopathy, before reaching for another uterotonic.
Do not give carboprost in asthma: NICE NG121 says use prostaglandin E1, which is misoprostol, instead. Avoid ergometrine in hypertension, pre-eclampsia and eclampsia.
Carbetocin prevents haemorrhage after caesarean birth but was removed from NICE table 12 as a treatment in December 2024, being unlicensed for treatment and more expensive.
Misoprostol 800 micrograms is an off-label use in PPH. NICE prints that dose inside table 12 for exactly that reason and sends you to the BNF for the rest.
Tranexamic acid goes in at diagnosis, alongside the uterotonics, not after they fail. The repeat waits at least 30 minutes; it is not given sooner.
Oxytocin's third-stage prophylactic dose, 10 units intramuscularly, is not its treatment dose, 5 units by slow intravenous injection. Giving the postpartum regimen during labour caused the 2024 national alert.
Collapse with little visible blood means inversion, rupture or concealed loss, not a mild bleed. An absent fundus with a mass at the introitus gives inversion away.
Green-top 52 dates from 2016 and is still the standing UK guideline, with the third edition in development. Old is not the same as superseded.

Illustrations

Myometrial compression of the placental bedDiagram showing the postpartum uterus contracting around the placental bed and compressing its vessels, with a contrasting atonic uterus in which the bed continues to bleed.PassFinals · original

The four Ts of postpartum haemorrhageSummary diagram of Tone, Tissue, Trauma and Thrombin linked to examination findings and the immediate cause-directed action.PassFinals · original

Intrauterine balloon tamponadeIllustration of an intrauterine balloon applying pressure to the placental bed after uterotonics and tranexamic acid have not controlled atonic bleeding.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.