Synopsis
Recognise significant postpartum bleeding early, coordinate resuscitation with cause-directed haemostasis, and use uterotonics and blood components safely.
- Measure cumulative blood loss and interpret it alongside the woman's physiology.
- Primary PPH occurs within twenty-four hours of birth; later abnormal bleeding follows a secondary-PPH assessment.
- Use the four Ts to organise causes: tone, trauma, tissue and thrombin.
- Massage an atonic uterus, empty the bladder and give an appropriate uterotonic.
- Choose uterotonics according to what was already given, contraindications and current NICE guidance.
- Give intravenous tranexamic acid early for PPH alongside uterotonics and other treatment.
- Do not wait for a haemoglobin threshold or a completed transfusion count to activate major haemorrhage care.
- Escalate to mechanical or surgical control promptly when bleeding persists.
Key red flags
Continuing brisk bleeding, rising pulse, falling pressure, confusion or poor perfusion requires emergency escalation regardless of measured volume.
A poorly contracted uterus suggests atony, but a firm uterus with ongoing loss requires examination for trauma or retained tissue.
Early severe coagulopathy or low fibrinogen should raise concern for abruption, AFE or other consumptive processes.
Investigation priorities
Prepare transfusion and assess haemoglobin and platelet trends.
Management branches
Bleeding is excessive, continuing or accompanied by physiological deterioration.
- Call senior maternity and anaesthetic help, allocate leadership and a recorder, and alert the laboratory early when substantial replacement may be needed.
- Assess ABC, lie the woman appropriately, give oxygen for significant shock or hypoxaemia, and obtain two large-bore intravenous lines with urgent samples.
- Quantify ongoing loss, keep the woman warm and use warmed fluid judiciously while arranging blood components when indicated.
- Massage an atonic uterus, empty the bladder, give suitable uterotonics and early tranexamic acid while inspecting for trauma or retained tissue.
- Activate the major haemorrhage protocol according to ongoing bleeding, physiology and expected need; do not wait to satisfy a retrospective massive-transfusion definition.
Key medicines
Oxytocin: product-specific treatment exampleFor the 10 IU/mL concentrate cited, give 5 IU diluted in physiological electrolyte solution by intravenous infusion over 5 minutes; severe cases may need 5–20 IU in 500 mL electrolyte diluent, titrated to control atony.This is the cited product's regimen, not a universal instruction for every formulation or local infusion. Avoid rapid undiluted intravenous bolus dosing; monitor hypotension, tachycardia, fluid balance and hyponatraemia risk, and stop or review once control is achieved.
Ergometrine injectionA commonly used acute PPH dose is 500 micrograms intramuscularly; the cited SmPC permits 200–500 micrograms IM or 250–500 micrograms by slow IV injection for severe atonic haemorrhage.Avoid in severe hypertension, pre-eclampsia or eclampsia, severe cardiac, hepatic or renal disease, occlusive vascular disease and sepsis. Check non-atonic causes before repeating; NICE allows selected repeat ergot treatment if other medicines are unavailable, rather than routine repeated dosing.