Obstetric critical care

Postpartum haemorrhage

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Early detection (≥ 300-500 mL), the MOTIVE bundle with tranexamic acid, second-line uterotonics, balloon tamponade, surgery and massive transfusion.

Definition
PPH (WHO/FIGO/ICM 2025): blood loss ≥ 500 mL within 24 h of birth, or ≥ 300 mL with abnormal vital signs. Causes - 4 Ts: Tone (atony, ~70%), Trauma, Tissue (retained placenta), Thrombin (coagulopathy).

At the bedside

Timed steps
  1. 1

    Detect early

    0 min

    Measure blood loss objectively (calibrated drape, weighing); monitor vital signs and shock index (> 0.9-1 concerning).

  2. 2

    MOTIVE bundle immediately

    ≤ 15 min

    Massage of the uterus; Oxytocic (oxytocin 10 units IV/IM + infusion); Tranexamic acid 1 g IV; IV fluids (warmed crystalloid, blood); Vaginal and genital tract examination (tears, retained tissue); Escalation.

  3. 3

    Second-line uterotonics

    Carboprost 250 mcg IM every 15 min (not in asthma), methylergometrine 0.2 mg IM (not in hypertension), misoprostol 800 mcg SL.

  4. 4

    Call for help and blood

    Activate obstetric haemorrhage/massive transfusion protocol; group-specific/O-negative blood; FFP, platelets; keep fibrinogen > 200 mg/dL (cryoprecipitate/fibrinogen concentrate) - fibrinogen < 200 predicts severe PPH.

  5. 5

    Mechanical and surgical

    Bimanual compression, uterine balloon tamponade (Bakri or condom catheter), non-pneumatic anti-shock garment during transfer; laparotomy with compression sutures (B-Lynch), uterine/internal iliac artery ligation, interventional radiology embolisation, hysterectomy.

  6. 6

    Correct the lethal triad

    Warm fluids and patient, ionised Ca > 1.1 mmol/L, avoid acidosis; viscoelastic testing where available.

  7. 7

    After PPH

    HDU/ICU monitoring for re-bleeding, DIC, AKI, Sheehan's; IV iron for anaemia; VTE prophylaxis once bleeding controlled.

First-line uterotonic

Oxytocin

IV/IM
Dose
10 units slow IV/IM, then 40 units in 500 mL at 125 mL/h
Worked example
10 units/h = 125 mL/h of 40 units/500 mL

All PPH

Tranexamic acid

IV
Dose
1 g over 10 min; repeat 1 g after 30 min if bleeding continues
Worked example
1 g (10 mL of 100 mg/mL) in 100 mL NS over 10 min

Refractory atony

Carboprost (15-methyl PGF2α)

IM
Dose
250 mcg every 15 min (max 2 mg)

Adjunct uterotonic

Misoprostol

Sublingual
Dose
800 mcg once

Atony without hypertension

Methylergometrine (ergometrine)

IM
Dose
0.2 mg, may repeat after 15 min
Red flag · call your senior now
Shock index > 1 or blood loss > 1,500 mL: major obstetric haemorrhage - activate MTP, senior obstetrician and anaesthetist.
Pitfall
Visual estimation underestimates blood loss; young women compensate until late.
Pitfall
Giving TXA after 3 h from birth: benefit falls with delay (most effective early).
Pitfall
Ergometrine in pre-eclampsia (stroke risk).
Pearl
Concealed bleeding (broad ligament haematoma, uterine rupture, abruption) - look with ultrasound if shock is out of proportion to visible loss.

Calculators for this topic

Shock index

Heart rate ÷ systolic BP.

References

  1. 1

    World Health Organization, FIGO, ICM. Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. Geneva: WHO; 2025.

  2. 2

    Gallos I, Devall A, Martin J, et al. Randomized trial of early detection and treatment of postpartum hemorrhage (E-MOTIVE). N Engl J Med 2023;389:11-21.

  3. 3

    WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN). Lancet 2017;389:2105-16.

  4. 4

    Mavrides E, Allard S, Chandraharan E, et al.; Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage: Green-top Guideline No. 52. BJOG 2017;124:e106-49.

  5. 5

    Vlaar APJ, Dionne JC, de Bruin S, et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2021;47:1368-92.

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