Red Flags
- Severe primary PPH (>1000 mL or signs of haemodynamic compromise) — major obstetric haemorrhage protocol; cross-match 4 units; multidisciplinary team[1]
- Suspected uterine inversion — emergency replacement under anaesthesia; stop oxytocics; tocolysis (terbutaline, GTN) if rigid[1]
- Persistent bleeding despite uterotonics and tranexamic acid — proceed to surgical haemostasis (intra-uterine balloon, B-Lynch, internal iliac ligation, hysterectomy)[1]
- Disseminated intravascular coagulation with persistent bleeding — replace clotting factors (FFP, cryoprecipitate, platelets); consider rFVIIa as last-resort adjunct[1]
First-line treatment
Interventions
- Active management of third stage of labour (prevention)[1]Oxytocin 10 IU IM (or 5 IU slow IV) within 1 minute of delivery; controlled cord traction with delivery of placenta; uterine massage after placenta. Reduces PPH by 50%
- Stepwise PPH protocol[1]Call for help → A-B-C with O2 + 2 large-bore IV → bimanual uterine compression → uterotonics → tranexamic acid → uterine tamponade balloon → surgical haemostasis (B-Lynch, vessel ligation, hysterectomy as ultimate measure)
- Resuscitation with balanced ratios[1]Massive haemorrhage protocol with packed cells:FFP:platelets ~1:1:1; cryoprecipitate when fibrinogen <2 g/L; warm fluids; correct hypothermia, acidosis, hypocalcaemia (lethal triad)
- Uterine balloon tamponade[1]Bakri or condom-catheter tamponade for atonic PPH refractory to uterotonics; bridge to surgical management or transfer; effective in 80–90% when first-line drug therapy fails
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Oxytocin[1] | Synthetic oxytocin | 10 IU IM or 5 IU slow IV (over 1 min) followed by 40 IU in 500 mL crystalloid IV at 125 mL/h | — | First-line uterotonic for prevention and treatment of PPH; thermolabile — store cold; no hypertension contraindication |
| Tranexamic acid[1] | Antifibrinolytic | 1 g IV over 10 min within 3 hours of PPH onset; repeat 1 g IV after 30 min if bleeding continues | — | WOMAN trial showed mortality reduction in PPH; second-line after oxytocin; can be combined with uterotonics |
| Carboprost (15-methyl PGF2α)[1] | Prostaglandin F2α analogue | 250 µg IM (or intramyometrial); repeat every 15 min, max 2 mg total | — | Refractory atonic PPH; contraindicated in asthma, hypertension, severe cardiac disease; bronchospasm and diarrhoea common |
| Misoprostol[1] | Synthetic prostaglandin E1 | 800 µg sublingual or rectal | — | Adjunct to or substitute for oxytocin where unavailable; pyrexia, shivering common; useful in primary care or low-resource settings |
| Ergometrine (methylergometrine)[1] | Ergot alkaloid | 0.2 mg IM or slow IV, repeat every 2–4 h, max 5 doses | — | Second-line uterotonic; CONTRAINDICATED in hypertension, pre-eclampsia, severe cardiac disease; hypertensive crisis risk |
| Recombinant factor VIIa (rFVIIa) — last-resort adjunct[1] | Recombinant coagulation factor VIIa | 60–90 µg/kg IV bolus; may repeat after 15–30 min if needed | — | Adjunct in life-threatening PPH refractory to standard surgical and pharmacological measures, with corrected acidosis, hypothermia, and platelets/fibrinogen replenished; thrombotic risk; specialist decision |
Oxytocin[1]
Synthetic oxytocin
- Adult
- 10 IU IM or 5 IU slow IV (over 1 min) followed by 40 IU in 500 mL crystalloid IV at 125 mL/h
- Paediatric
- —
First-line uterotonic for prevention and treatment of PPH; thermolabile — store cold; no hypertension contraindication
Tranexamic acid[1]
Antifibrinolytic
- Adult
- 1 g IV over 10 min within 3 hours of PPH onset; repeat 1 g IV after 30 min if bleeding continues
- Paediatric
- —
WOMAN trial showed mortality reduction in PPH; second-line after oxytocin; can be combined with uterotonics
Carboprost (15-methyl PGF2α)[1]
Prostaglandin F2α analogue
- Adult
- 250 µg IM (or intramyometrial); repeat every 15 min, max 2 mg total
- Paediatric
- —
Refractory atonic PPH; contraindicated in asthma, hypertension, severe cardiac disease; bronchospasm and diarrhoea common
Misoprostol[1]
Synthetic prostaglandin E1
- Adult
- 800 µg sublingual or rectal
- Paediatric
- —
Adjunct to or substitute for oxytocin where unavailable; pyrexia, shivering common; useful in primary care or low-resource settings
Ergometrine (methylergometrine)[1]
Ergot alkaloid
- Adult
- 0.2 mg IM or slow IV, repeat every 2–4 h, max 5 doses
- Paediatric
- —
Second-line uterotonic; CONTRAINDICATED in hypertension, pre-eclampsia, severe cardiac disease; hypertensive crisis risk
Recombinant factor VIIa (rFVIIa) — last-resort adjunct[1]
Recombinant coagulation factor VIIa
- Adult
- 60–90 µg/kg IV bolus; may repeat after 15–30 min if needed
- Paediatric
- —
Adjunct in life-threatening PPH refractory to standard surgical and pharmacological measures, with corrected acidosis, hypothermia, and platelets/fibrinogen replenished; thrombotic risk; specialist decision
Safety-net
- Continued vigilance for ≥24 hours postpartum — secondary PPH can occur up to 12 weeks; report heavy bleeding, foul-smelling discharge, or fever[1]
- Ensure iron repletion postpartum — IV iron preferred for severe blood loss anaemia to enable breastfeeding and rapid recovery[1]
- Counsel about future pregnancy planning — recurrence risk increases with prior PPH; planned delivery in well-equipped unit[1]
Referral criteria
- Active PPH refractory to uterotonics and tranexamic acidSenior obstetrician, anaesthetic team, blood bank; theatre[1]
- Need for surgical haemostasis (B-Lynch, internal iliac ligation, hysterectomy)Theatre with experienced operator; involve interventional radiology where available[1]
- Suspected coagulopathy (DIC, prior bleeding disorder)Haematology / massive transfusion protocol[1]
- Antenatal high-risk (prior PPH, accreta, multiple pregnancy, severe anaemia)Plan delivery in unit with blood bank, theatre, anaesthetic, and IR access[1]
Clinical summary
Recognition, resuscitation, and stepwise pharmacological and surgical management of primary postpartum haemorrhage and the role of rFVIIa.