Postpartum haemorrhage (PPH)
Call for help, rub up the uterus, give oxytocin and tranexamic acid, replace blood, and work through the 4 Ts. Act early: measure the blood, do not guess it.
Twenty minutes after a vaginal delivery of a 3.8 kg baby, a 29-year-old in her fourth pregnancy is bleeding steadily. The pad and sheet are soaked and there are clots on the floor. The uterus feels soft and above the umbilicus. Pulse 118, BP 98/60.
What do you do in the next 10 minutes?
- Call for helpSenior obstetrician, anaesthetist, midwives, blood bank. Say "postpartum haemorrhage".
- Rub up the uterusFundal massage to make it contract. Empty the bladder.
- OxytocinIM or slow IV now, then an infusion.
- Tranexamic acid1 g IV, within 3 hours of birth.
- Two wide-bore cannulasCBC, clotting, fibrinogen, cross-match 4 units. Warm fluids.
- Measure the blood lossWeigh pads and swabs, use a calibrated drape. Do not guess.
- Check the placenta and look for tearsIs it complete? Examine the vagina and cervix.
- More drugs if still bleedingErgometrine, carboprost, misoprostol. Then balloon or theatre.
- Blood loss over 500 mL (vaginal) or 1000 mL (caesarean), or ongoing
- Pulse above 100 or falling BP
- Placenta not delivered
- Uterus still soft after drugs
- Bleeding with a firm uterus
- Uterine atony
- Genital tract tears or uterine rupture
- Retained placenta or pieces
- Clotting failure (DIC)
- Uterine inversion
| PPH | Blood loss 500 mL or more after birth, or any loss with signs of shock |
| Major PPH | Over 1000 mL, or ongoing, or shock |
| Tranexamic acid | 1 g IV over 10 minutes within 3 hours of birth. Repeat once if bleeding continues after 30 minutes |
| Oxytocin | First drug. Doses in the drug section |
| Shock index | Pulse divided by systolic BP. 1 or more means significant blood loss |
Check every dose against a current drug reference and your hospital protocol.
On this page
Why it kills
PPH is a leading cause of maternal death in Pakistan and worldwide. Women can lose a large volume of blood in minutes. Young, fit women keep a normal BP until they have lost a great deal of blood, then collapse suddenly. Blood loss is almost always underestimated by eye.
Measure the blood. Weigh soaked pads and swabs (1 g of weight is about 1 mL of blood) or use a calibrated drape under the buttocks. Watch the shock index (pulse ÷ systolic BP): 1 or more means significant loss, even if the BP looks fine.
The 4 Ts
- Soft, boggy uterus
- Long labour, big baby, twins, many previous births, infection
- Massage and uterotonic drugs
- Bleeding with a firm uterus
- Tears of the vagina, cervix, perineum
- Uterine rupture (previous caesarean)
- Uterine inversion
- Repair
- Placenta not delivered or incomplete
- Pieces of placenta or membranes left inside
- Manual removal in theatre
- Clotting failure: blood not clotting, oozing from cannula sites
- After abruption, pre-eclampsia, sepsis, massive bleeding
- Blood products
First steps
- Call for helpShout. Pull the emergency bell. One person writes the times and drugs.
- Rub up the uterusFirm fundal massage. Bimanual compression if still bleeding.
- Empty the bladderCatheter. A full bladder stops the uterus contracting.
- Oxytocin10 IU IM or 5 IU slow IV, then an infusion.
- Tranexamic acid1 g IV over 10 minutes.
- IV access and bloodsTwo large cannulas. CBC, clotting, fibrinogen, cross-match 4 units.
- FluidsWarmed crystalloid while blood is coming. Blood early if shocked.
- Oxygen and keep her warmLie flat. Keep warm: cold blood does not clot.
- Check the placenta and look for traumaInspect the placenta. Examine the perineum, vagina, cervix.
Uterotonic drugs
Ergometrine 0.5 mg IM or slow IV
- Not ergometrine
- Carboprost (if no asthma) or misoprostol
- Not carboprost
- Ergometrine (if BP normal) or misoprostol
Blood and clotting
- Major PPH: activate the major haemorrhage protocol. Red cells early. FFP, platelets and cryoprecipitate guided by bloods or by protocol.
- Fibrinogen below 2 g/L in an ongoing bleed: cryoprecipitate or fibrinogen concentrate. Fibrinogen falls early in PPH.
- Keep her warm, correct calcium.
- Pakistan: blood can take time. Ask relatives to arrange donors early, while you treat.
If drugs are not enough
- Bimanual uterine compressionWhile preparing for the next step.
- Intrauterine balloon tamponadeA Bakri balloon, or a condom catheter (a condom tied over a Foley catheter, filled with saline) where balloons are not available.
- Non-pneumatic anti-shock garmentWhere available, as a bridge during transfer.
- TheatreExamination under anaesthesia, repair of tears, removal of retained tissue.
- SurgeryCompression sutures (B-Lynch), uterine artery ligation, interventional radiology if available, and hysterectomy as a life-saving last step.
Retained placenta
- Placenta not delivered 30 minutes after birth with active management (or 60 minutes with physiological management).
- If bleeding: manual removal in theatre urgently.
- Antibiotics for manual removal per protocol.
Prevention
- Every birth: oxytocin 10 IU IM after delivery of the baby (active management of the third stage).
- Identify high-risk women: previous PPH, anaemia, many previous births, twins, big baby, previous caesarean (placenta accreta risk), pre-eclampsia, long labour.
- Treat anaemia during pregnancy.
Common mistakes
- Estimating blood loss by eye and calling it "normal lochia".
- Waiting for the BP to drop before acting.
- Forgetting to empty the bladder.
- Giving ergometrine to a woman with pre-eclampsia.
- Giving carboprost to an asthmatic.
- Giving tranexamic acid late, or not at all.
- Missing a tear because the uterus is "firm".
Frequently asked questions
What are the 4 Ts of postpartum haemorrhage?
Tone (uterine atony), Trauma (tears, rupture, inversion), Tissue (retained placenta or pieces) and Thrombin (clotting problems).
What is the dose of oxytocin in PPH?
10 IU IM or 5 IU slow IV, followed by an infusion of 40 IU in 500 mL over 4 hours.
When is tranexamic acid given in PPH?
1 g IV over 10 minutes as soon as possible and within 3 hours of birth, with a second 1 g if bleeding continues after 30 minutes.
Which uterotonic is avoided in pre-eclampsia?
Ergometrine, because it raises the BP. Carboprost is avoided in asthma.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. After delivery a woman has pulse 120 and systolic BP 100. What is her shock index and what does it suggest?
Answer: 1.2: significant blood loss. Shock index = pulse ÷ systolic BP. Above 1 in the postpartum woman suggests major haemorrhage before BP falls.
- Cannot be calculated: It is pulse divided by systolic BP.
- 1.2: normal after delivery: 1 or more suggests significant blood loss.
- 0.5: mild: Wrong.
- 0.8: normal: Wrong calculation.
2. Postpartum haemorrhage continues after oxytocin. BP is 160/105. Which drug should be avoided?
Answer: Ergometrine. Ergometrine raises BP and is avoided in hypertension and pre-eclampsia.
- Misoprostol: Can be used.
- Tranexamic acid: Should be given.
- Carboprost: Can be used if no asthma.
- Oxytocin infusion: Can be used.
3. Two hours after birth, postpartum haemorrhage continues. Is it too late for tranexamic acid?
Answer: No: give it now; it works within 3 hours of birth. Tranexamic acid 1 g IV reduces death from bleeding when given within 3 hours of birth; the earlier the better.
- Yes, never in PPH: It reduces death from bleeding.
- Yes, it only works in the first hour: WOMAN trial showed benefit up to 3 hours.
- Only orally: IV is used.
- Only if fibrinogen is low: Not required.
4. Despite oxytocin, ergometrine, misoprostol, tranexamic acid and bimanual compression, a woman with uterine atony continues to bleed heavily. What is the next step while preparing theatre?
Answer: Intrauterine balloon tamponade. PPH management (4 Ts: tone, trauma, tissue, thrombin): call for help, resuscitate, uterine massage, uterotonics (oxytocin, ergometrine if no hypertension, carboprost, misoprostol), IV tranexamic acid within 3 hours. Refractory atony: intrauterine balloon tamponade (condom catheter is a low-cost option used in Pakistan), non-pneumatic anti-shock garment for transfer, then surgery — B-Lynch compression suture, uterine/internal iliac artery ligation, interventional radiology, and hysterectomy as a life-saving last step.
- Further oxytocin bolus only: Uterotonics are already maximal.
- Wait for spontaneous contraction: Waiting allows ongoing haemorrhage.
- Hysterectomy as first step in all: Hysterectomy comes after conservative measures.
5. Forty minutes after a vaginal delivery with active management, the placenta has not delivered. Bleeding is minimal and she is stable. What is the next step?
Answer: Manual removal under anaesthesia. Retained placenta: not delivered within 30 minutes with active management (60 minutes physiological). Empty the bladder, try controlled cord traction, give oxytocin if not already; then manual removal of placenta in theatre under regional/general anaesthesia with antibiotic prophylaxis. Excessive traction risks uterine inversion; placenta accreta may be found. Bleeding with retained placenta is a cause of PPH (tissue).
- Fundal pressure and cord traction harder: Pulling harder risks uterine inversion.
- Wait 24 hours: Waiting 24 hours risks haemorrhage.
- Hysterectomy: Hysterectomy is not indicated.
6. After a massive postpartum haemorrhage, a woman cannot breastfeed and her periods do not return. What is the diagnosis?
Answer: Sheehan syndrome. The pituitary enlarges in pregnancy and is vulnerable to ischaemia. Severe postpartum haemorrhage and hypotension cause necrosis of the anterior pituitary. Failure to lactate (low prolactin) is often the first sign, followed by amenorrhoea, hypothyroidism and adrenal insufficiency. Hormone replacement is needed.
- Prolactinoma: Causes galactorrhoea, not failure to lactate.
- Asherman syndrome only: Intrauterine adhesions after curettage; lactation normal.
- Premature ovarian failure: Lactation would be normal.
- Turner syndrome: Congenital; not after delivery.
7. A prolonged high-dose oxytocin infusion in large volumes of dextrose may cause which complication?
Answer: Water intoxication with hyponatraemia. Oxytocin is structurally similar to ADH and has an antidiuretic effect at high doses, especially with large volumes of hypotonic fluid, causing water intoxication, hyponatraemia and seizures. Other risks: uterine hyperstimulation, fetal distress and uterine rupture; bolus doses can cause hypotension.
- Hyperkalaemia: Not a feature.
- Hypertension crisis from α stimulation: Bolus may cause hypotension, not crisis.
- Malignant hyperthermia: Not linked.
- Hypercalcaemia: Not linked.
References and dose sources
- RCOG Green-top Guideline 52: Postpartum haemorrhage
- WOMAN trial: tranexamic acid in PPH
- Oxytocin dosing: Drugs.com: Oxytocin dosage (see also our oxytocin dose page)
- Ergometrine dosing: Drugs.com: Ergonovine and methylergonovine monograph (see also our ergometrine dose page)
- Carboprost dosing: Drugs.com: Hemabate (carboprost) dosage (see also our carboprost dose page)
- Misoprostol dosing: Drugs.com: Misoprostol dosage (see also our misoprostol dose page)
- Tranexamic acid dosing: Drugs.com: Tranexamic acid dosage (see also our tranexamic acid dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.