Postpartum Bleeding: Measure Blood Loss
Within 24 h of birth. Measure blood loss objectively (calibrated drape, weigh pads and swabs). Check pulse, BP and uterine tone. Be most alert in the first 2 h.
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Obstetrics & GynecologyEmergency
Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025)
Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025): Postpartum Bleeding: Measure Blood Loss → PPH? Blood loss 500 mL or more, or 300 mL or more with ...
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision PPH? Blood loss 500 mL or more, or 300 mL or more with an abnormal sign
Abnormal sign: pulse above 100/min, shock index above 1, SBP below 100 mmHg or DBP below 60 mmHg. Any bleeding with shock is PPH. Pre-eclampsia or a beta-blocker (for example labetalol) can hide shock: a normal pulse or BP can mislead. Use measured loss and the trend, and treat early.
- If Yes
03Warning PPH Confirmed: Uterotonic Contraindications and Uterine Inversion
Check these before any uterotonic drug.
- No ergometrine (US: methylergonovine): hypertension, pre-eclampsia, heart or vascular disease, severe sepsis, liver or kidney impairment, suspected retained placenta, or strong CYP3A4 inhibitors (for example ritonavir, clarithromycin, azole antifungals)
- No carboprost: asthma, or active heart, lung, kidney or liver disease
- Uterine inversion: stop uterotonics until the uterus is replaced
04Action PPH: First-Response Bundle (Start All Now)
Start together: massage, oxytocin, tranexamic acid (TXA) within 3 h of birth, IV fluids, genital tract check, escalation. No TXA after 3 h or after a thromboembolic event in this pregnancy. Pre-eclampsia or heart disease: small fluid boluses. Declines blood products: confirm her wishes and any advance directive now. Escalate to senior staff and surgery earlier.
- Call for help: senior obstetrician, midwife, anaesthetist. Start the PPH protocol
- Shock or heavy ongoing loss: activate the massive haemorrhage protocol. Give red cells early: group O RhD-negative until group-specific or crossmatched blood is ready
- Oxytocin 5 units slow IV, then infusion per local protocol (for example 40 units in 500 mL sodium chloride 0.9% over 4 h). No rapid high-dose IV bolus: it can cause severe hypotension
- Tranexamic acid 1 g IV (100 mg/mL) over 10 min, within 3 h of birth. Second 1 g if bleeding continues after 30 min or restarts within 24 h. Do not start after 3 h
- Uterine massage. Empty the bladder
- Two large-bore IV cannulas. FBC, coagulation screen with fibrinogen, group and crossmatch
- Warmed isotonic crystalloid (not colloid). Keep the woman warm. Pre-eclampsia or heart disease: give fluid in small boluses and reassess often (risk of pulmonary oedema)
- Examine the genital tract. Check that the placenta and membranes are complete
- Record pulse, BP, SpO2 and urine output. Oxygen if needed
05Action Find the Cause: Check All 4 Ts
More than one cause can be present. Treat every cause you find.
- Tone: soft, atonic uterus
- Trauma: tears, haematoma, uterine rupture or inversion
- Tissue: retained placenta or membranes
- Thrombin: coagulopathy
06Action If Atony (Soft Uterus): Second-Line Uterotonics, Then Tamponade
Give if bleeding does not respond to oxytocin. Check contraindications first.
- Bimanual uterine compression while drugs take effect
- Ergometrine 250 microgram (ampoule 500 microgram/mL) IM or slow IV over at least 1 min. Repeat every 5 min if needed, max 1 mg. US: methylergonovine 0.2 mg IM, repeat every 2 to 4 h if needed. Do not give either drug in hypertension or pre-eclampsia, or with strong CYP3A4 inhibitors (for example ritonavir)
- Carboprost 250 microgram deep IM. Repeat if needed, at least 15 min apart, max 2 mg (8 doses). Not in asthma
- Misoprostol 800 microgram sublingual, or up to 1000 microgram rectally
- Still bleeding and uterus empty: uterine balloon tamponade (fill per device instructions)
- Still bleeding: go to theatre
07Action If Genital Tract Trauma: Find and Repair
Inspect the perineum, vagina and cervix. Press on bleeding points.
- Repair tears in the birth room, or in theatre if access or analgesia is poor
- Expanding haematoma: evacuate and drain in theatre
- Shock out of proportion to visible bleeding: think of uterine rupture or intra-abdominal bleeding; urgent laparotomy
- Uterine inversion: stop uterotonics. Leave the placenta attached. Replace the uterus at once, under anaesthesia if needed. Give uterotonics after it is replaced
08Action If Retained Placenta or Tissue: Remove It
Explore the uterus in every persistent PPH, even if the placenta looks complete.
- Placenta not delivered and controlled cord traction fails: empty the bladder, then manual removal in theatre
- Placenta does not separate (suspected accreta): do not force it. Call a senior obstetrician. Be ready for hysterectomy
- Give prophylactic antibiotics for manual removal of the placenta
- Remove retained cotyledons, membranes or clots
- Do not give ergometrine while retained placenta is suspected
09Action If Coagulopathy (Thrombin): Correct It
Test early and repeat. Use ROTEM or TEG if available.
- Tests: FBC, PT/INR, APTT, fibrinogen, ionised calcium, blood gas with lactate
- On heparin or LMWH: stop it. Protamine fully reverses unfractionated heparin but only partly reverses LMWH. Get haematology advice
- Fibrinogen below 2 g/L with ongoing bleeding: cryoprecipitate or fibrinogen concentrate, 3 to 4 g fibrinogen (AU: 10 units whole-blood or 4 units apheresis cryoprecipitate)
- FFP guided by tests. Massive bleeding: RBC:FFP:platelets at least 2:1:1
- Platelets if below 50 x 10^9/L with ongoing bleeding
- Correct temperature below 35 degrees C, pH below 7.2 and ionised calcium below 1 mmol/L
- Recombinant factor VIIa: off-label and associated with harm. Only when all other measures have failed, with haematology advice
10Decision Bleeding Controlled?
Reassess blood loss, uterine tone, pulse, BP and urine output.
- If Yes
11Outcome Bleeding Controlled: Monitor and Recover
Close observation. HDU or ICU after severe PPH or if unstable.
- Observe pulse, BP, uterine tone, blood loss and urine output
- HDU or ICU care after severe PPH (1000 mL or more) or ongoing instability
- Repeat FBC and coagulation tests
- VTE prophylaxis once bleeding is controlled
- Iron: IV iron for severe iron-deficiency anaemia or if oral iron is not tolerated
- Debrief the woman, her family and the team
If No12Action Bleeding Continues: Escalate in Theatre
Do not delay surgery. Start the massive haemorrhage protocol. Uterine rupture or placenta accreta: early hysterectomy. Small hospital: arrange transfer early.
- Massive haemorrhage protocol. Senior obstetrician, anaesthetist and haematology
- Transfuse RBC: group O RhD-negative or group-specific until crossmatched. RBC:FFP:platelets at least 2:1:1
- Bimanual or aortic compression as a bridge
- Balloon tamponade if not yet tried (atony, uterus empty)
- Compression (brace) sutures, for example B-Lynch
- Uterine artery ligation. Internal iliac artery ligation only by an experienced surgeon
- Uterine artery embolisation only if available without delay
- Hysterectomy early for uterine rupture, placenta accreta or uncontrolled bleeding
- Small hospital: arrange transfer early and keep resuscitating
13Decision Bleeding Controlled After Escalation?
Reassess blood loss and haemodynamic response.
- If Yes
- Path rejoins step 11Shared downstream outcome
If No14Warning Bleeding Not Controlled: Peripartum Hysterectomy
Definitive surgery for uncontrolled haemorrhage. Do not delay.
- Peripartum hysterectomy by an experienced surgeon
- Subtotal for atony (faster). Total if placenta accreta, or bleeding or injury at the lower segment or cervix
- Coagulopathic or unstable: damage-control surgery (abdominal packing, planned return to theatre)
15Outcome After Hysterectomy: Critical Care
ICU or HDU care and continued resuscitation.
- ICU or HDU care
- Continue the massive haemorrhage protocol as needed
- Monitor for coagulopathy, re-bleeding and kidney injury
- VTE prophylaxis once bleeding is controlled
- Debrief and support for the woman and her family
If No16Outcome Not PPH Yet: Keep Measuring
Below the PPH threshold and no abnormal sign. Do not stop checking while bleeding continues.
- Keep measuring blood loss and checking pulse, BP and uterine tone
- Start PPH treatment as soon as a PPH criterion is met
- Shock with little visible bleeding: think of concealed bleeding (uterine rupture, broad ligament or intra-abdominal)
Guideline Source
WHO/FIGO/ICM Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage (2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Primary PPH only (first 24 h after birth). Not for antepartum or secondary PPH, or prevention.
- Follow the local PPH and massive haemorrhage protocols; drug stock and blood products vary.
- Uterine inversion, placenta accreta and amniotic fluid embolism need specialist protocols.
- Does not replace clinical judgement.
Contraindicated Populations
Antepartum haemorrhageSecondary PPH (more than 24 hours after birth)Non-pregnancy-related bleeding
Applicable Regions
AUUSEUGlobal
AU: RANZCOG C-Obs 43 (2021) doses. Ergometrine ampoule 500 microgram/mL. Carboprost is on the ARTG (250 microgram/mL). Misoprostol for PPH is off-label. Blood products per NBA critical bleeding guideline.
US: ACOG Practice Bulletin 183 (2017). Methylergonovine 0.2 mg IM is used in place of ergometrine; same contraindications.
Global: WHO/FIGO/ICM 2025: first-response bundle (E-MOTIVE) with objective blood loss measurement.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025)?
The Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025) is a emergency clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on WHO/FIGO/ICM Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage (2025).
What guideline is the Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025) based on?
This algorithm is based on WHO/FIGO/ICM Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage (2025).
What are the limitations of the Postpartum Haemorrhage Management (WHO/FIGO/ICM 2025)?
Known limitations include: Primary PPH only (first 24 h after birth). Not for antepartum or secondary PPH, or prevention.; Follow the local PPH and massive haemorrhage protocols; drug stock and blood products vary.; Uterine inversion, placenta accreta and amniotic fluid embolism need specialist protocols.; Does not replace clinical judgement.. Individual patient factors may require deviation from these recommendations.
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