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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

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 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
  • Multiple pregnancy
  • Polyhydramnios
  • Fetal macrosomia
  • Prolonged labour
  • General anaesthesia
Tissue Retained placenta or membranes Placenta accreta spectrum
Trauma Lacerations or injury to the genital tract, uterus or surrounding tissue
  • Episiotomy
  • Vaginal tears
  • Perineal laceration
Thrombin Coagulopathy (pre-existing, or acquired) Pre-existing: clotting disorder (e.g. von Willebrand disease)

Acquired: pre-eclampsia, placental abruption

Main causes of secondary PPH are:
  • Retained product of conception - most common 
  • Endometritis - 2nd most common 
  • Gestational trophoblastic disease
  • Coaulopathy 

Guidelines

Since the most common cause of primary PPH is uterine atony, most of the guidelines based on the assumption of atony being the cause of primary PPH.
 

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
    • 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

Minor PPH without clinical shock:
  • Gain IV access + give warm crystalloid infusion
  • Urgent bloods for FBC, G&S, coagulation screen
  • Pulse, respiratory rate, blood pressure every 15 min

Major PPH:
  • A to E approach
  • Investigations
    • 2 large-bore cannulae
    • Urgent bloods for FBC, G&S, coagulation screen, renal and liver function
    • Foley catheter
    • 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

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

Class of medication used: uterotonics (induce or augment uterine contraction)
  • Most commonly used: Oxytocin slow IV or infusion 
  • Ergometrine 0.5mg IM or slow IV (contraindicated in hypertension)
  • Carboprost 0.25 mg IM (caution in asthma)
  • Misoprostol 800 mcg sublingually
 

Enrichment information: NICE provided recommendations in terms of the choice of uterotonics for PPH depending on what uterotonic has already been given for routine prophylaxis.
 
Uterotonic used in 3rd stage 1st line 2nd line 3rd line
None (physiological management)
  • Oxytocin + ergometrine IM, or
  • Oxytocin infusion once IV access available
 Carboprost IM Misoprostol
Oxytocin
  • Ergometrine IM, or
  • Oxytocin infusion once IV access available
Oxytocin + ergometrine
  • Carboprost IM, or
  • Oxytocin infusion once IV access available
Carbetocin
  • Ergometrine IM
 

  • 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. 

  • 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

Author: Adams Lau
Reviewer:
Last edited: 08/07/25