Postpartum haemorrhage

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.

References

1.FOGSI FOCUS Update — Factor VIIa in Severe PPH Management (2024); WHO Recommendations on the Management of Postpartum Haemorrhage; FIGO PPH guideline (2024)