CLINICAL GUIDELINE

Postpartum Haemorrhage (PPH),

Management

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient
characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased
susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good
practice to record these and communicate them to others involved in the care of the patient.

Version Number: 3
Does this version include
Yes
changes to clinical advice:
Date Approved: 31st August 2022

Date of Next Review: 31st August 2027

Lead Author: Julie Murphy

Approval Group: Gynaecology, Obstetrics & Neonatology Effectiveness Committee (GONEC)

Important Note:

The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain the
latest updates and amendments.
Management of Postpartum Haemorrhage (PPH)

Primary Postpartum Haemorrhage (PPH) is the most common form of major obstetric haemorrhage.
The most recent Confidential enquiry reported 6% of all maternal deaths were as a result of
bleeding. Obstetric haemorrhage is common but with prompt recognition and management
maternal morbidity and mortality can be avoided. Recognition of risk factors, multi-disciplinary team
working and good communication are all recognised factors which improve outcomes in cases of
major obstetric haemorrhage. The following recommendations reduce morbidity and mortality;

• Identification of high risk groups and instituting measures to prevent/minimise post partum
haemorrhage.
• Appropriate counselling about place of delivery of there are any risk factors identified for
PPH

• Clear and timely communication between surgical, anaesthetic and haematology/blood

transfusion services.

• Prompt resuscitation and supportive measures including replacing the blood loss.

• Investigating the cause for and arresting the haemorrhage.

• Instituting appropriate monitoring.

Definitions

Primary Postpartum Haemorrhage – blood loss from the vagina of over 500ml blood within 24
hours of delivery.

Major Postpartum Haemorrhage – Blood loss of over 1000ml and can be divided further into
moderate (1000-2000ml) or severe (more than 2000ml)

A smaller blood loss associated with clinical signs of shock, hypotension (systolic BP drop of
30mmHg), tachycardia (pulse rate rise of more than 30bpm), tachypnoea (respiratory rate
greater than 30breaths per minute) or oliguria can also be managed following this protocol.

Secondary Postpartum Haemorrhage – Abnormal or excessive bleeding from the vagina

between 24 hours and 12 weeks postpartum.

Causes of Postpartum Haemorrhage

• Tone (70%) – most common cause

• Tissue (9%) – Retained placenta, placenta accreta.

• Trauma (20%) – Genital trauma i.e. vulva, vaginal, cervix, uterus or broad ligament.

• Thrombin (1%) – Disseminated intravascular coagulation (DIC), pre-existing bleeding disorders

such a haemophilia or women taking therapeutic anticoagulants.
 Blood loss can be easy to underestimate and difficult to accurately estimate. Cumulative blood
loss should be recorded contemporaneously. Swabs and clots should be weighed to gain a more
accurate estimate.

Small women have small blood volumes

Weight (kg) Total Blood Vol 15% loss 30% loss 40% loss
(ml)
(ml) (ml) (ml)

50 5000 750 1500 2000

55 5500 825 1650 2200

60 6000 900 1800 2400

65 6500 975 1950 2600

70 7000 1050 2100 2800

*Based on 100mls/kg blood volume in pregnancy (RCOG 2011) but may overestimate blood
volume in obese women

Prediction and Prevention of PPH

Identify risk factors in antenatal and intrapartum period and modify care plans accordingly
including place of delivery.

Badgernet PPH Prevention Risk Assessment tool should be completed at the following
appointments:

• Booking appointment

• 34/36 week appointment

• On admission in labour or for induction of labour

• During intrapartum care

The PPH Prevention Risk Assessment tool should be updated every 4 hours during intrapartum
care and it should be reviewed in second stage to ensure an appropriate management plan for
the prevention of PPH is followed.

Women who have a PPH score on Badgernet of ≥3 are at high risk of PPH and should have the
following management to prevent PPH:

• IV access and FBC Group & Save (Cross Match if Hb <90g/L)

• Syntocinon 5 units IV and 1ml Syntometrine IM (unless contraindicated due to hypertension

or maternal cardiac history) after delivery of anterior shoulder.
 • If Syntometrine is contraindicated then Syntocinon 5units IV and Syntocinon 10 units IM
with delivery of the anterior shoulder

• Consider prophylactic Syntocinon infusion (40 units of Syntocinon in 500ml Sodium Chloride
0.9% at 125 ml/hour).

Minimising risk – treat antenatal anaemia

https://obsgynhandbook.nhsggc.org.uk/nhsggc-obstetrics-gynaecology-guidelines/guidelines-
library/antenatal-general/cg-management-of-iron-deficiency-during-pregnancy-and-the-
puerperium/

Minimising risk – measure all blood loss at delivery.

Active management of third stage

Active management of third stage should be recommended as it shortens the third stage and
reduces the risk of postpartum haemorrhage and blood transfusion. It involves the following
components:

Uterotonics

Vaginal delivery: oxytocin 10 units IM with the birth of the anterior shoulder.

Caesarean section: oxytocin 5 units slow IV injection AFTER the cord has been clamped and cut.
Tranexamic Acid 1g IV (over 10mins) should be considered if ongoing blood loss is ≥ 500mls

Delayed cord clamping

Delayed cord clamping is not thought to increase the risk of postpartum haemorrhage and
should be recommended unless there are concerns over fetal wellbeing or the integrity of the
cord. It is safe to administer IM oxytocin with delivery of the anterior shoulder even with the
recommendation of delayed cord clamping. Do not clamp and cut the cord earlier than 1 min
from birth unless there are concerns over fetal wellbeing (baby’s heart rate is <60 beats/minute
and not increasing) or the integrity of the cord or signs of placental abruption. Clamp and cut the
cord before 5 minutes to allow controlled cord traction to be performed.

Controlled Cord Traction

Controlled Cord Traction after signs of separation of the placenta and after administration of
uterotonic drugs.
 Physiological Management of Third Stage

Physiological management of third stage involves the following components;

No routine use of uterotonic drugs

No clamping of the cord until pulsations have stopped

Delivery of the placenta by maternal effort

Women should be advised that physiological management of third stage is associated with an
increased risk of primary postpartum haemorrhage and blood transfusion.

Advise that the women should change from physiological management of third stage to active
management of third stage in the following situations;

• Haemorrhage
• Placenta not delivered within 1 hour of the birth of the baby

1st Line Management of PPH (Appendix 1)

Minor PPH blood loss 500 – 1000ml without clinical shock

Alert labour ward coordinator, middle grade obstetric and anaesthetic staff

Intravenous access one grey cannula

Urgent venepuncture: FBC, Group and Save, Coagulation screen including fibrinogen

Pulse, respiratory rate, blood pressure every 15 minutes

Commence warmed crystalloid infusion.

Major PPH blood loss more than 1000ml and ongoing bleeding or clinical shock (Appendix 2)

• ABC: assess airway and breathing; Oxygen 15L/min via facemask

• Evaluate circulation

• Position the patient flat

• Call for help – emergency buzzer – request Labour Ward Coordinator, Obstetric Registrar and
Anaesthetist. Call 2222 for Obstetric emergency call to be put out – Alert Consultant Obstetrician
and Consultant Anaesthetist.

• Assign a scribe to document events on Badgernet using the PPH management tool

• Give immediate clinical treatment:

o Uterine massage/bimanual compression if required

o Empty bladder – leave catheter in place and commence fluid balance chart

o Uterotonic drugs – see below for options

o Ensure there are two Grey cannulas in place, take bloods for full blood count, coagulation
screen, U&Es & LFTs as a baseline and cross match packed red cells (PRC) minimum of 2 units. If
blood loss is ongoing at 1500mls request Pack A which will contain 6 units PRC

o Controlled cord traction if placenta has not yet been delivered – remove any clots or remaining
tissue

o Continuously assess blood loss – weigh swabs and clots and keep a contemporaneous estimate
of blood loss and ensure this is clearly communicated to the obstetric team managing the case

o Continuously assess the woman’s condition – blood pressure, pulse, oxygen saturations,
temperature every 15 minutes initially then as required by early warning score, hourly urine
output minimum 0.5ml / Kg/ hour

o Identify the source of the bleeding – consider the 4 T’s as above.

o Volume replacement: involves restoration of both blood volume and oxygen carrying capacity.
As rapidly as possible give 2L of warmed Hartmann’s solution.

o Institute the Major Obstetric Haemorrhage Call with the trigger phrase if bleeding is more than
1.5 L and ongoing.

o Aim to maintain Hb > 80g/l, platelets > 50*109 /L, PT < 1.5 times normal, APTT < 1.5 times
normal and fibrinogen > 2g/l

o Blood transfusion: the decision should depend on the clinical picture and haematological
assessment. Blood transfusion should be part of multi-disciplinary management. MDT approach
with haematology required especially in the presence of red cell autoantibodies

o After 4 units of red blood cells, FFP should be infused at a dose of 12–15 ml/kg until
haemostatic test results are known. If no haemostatic tests are available, early FFP should be
considered for conditions with a suspected coagulopathy, such as placental abruption or
amniotic fluid embolism, or where detection of PPH has been delayed. If prothrombin
time/activated partial thromboplastin time is more than 1.5 times normal and haemorrhage is
ongoing, volumes of FFP in excess of 15 ml/kg are likely to be needed to correct coagulopathy

o A plasma fibrinogen level of greater than 2 g/l should be maintained during ongoing PPH.
Cryoprecipitate should be used for fibrinogen replacement

o During PPH, platelets should be transfused when the platelet count is less than 75 × 109/l
based on laboratory monitoring

o Documentation of fluid balance, blood, blood products and procedures using the PPH Checklist
on Badgernet

o “Stand Down” call to Blood Bank when clinical situation has resolved

o Consider physiological monitoring: arterial line/CVP

o Consider the most appropriate place to monitor patient following PPH, this may be HDU or ITU
o Documentation of parameters on a modified early obstetric warning score (MEOWS) chart
acting and escalating promptly when abnormal scores from a MEOWS chart are observed

o Allocate a member of the healthcare team to stay with the woman and her birth
companion(s), explain what is happening, answer any questions and offer support throughout
the emergency situation

1st LINE UTEROTONIC DRUG TREATMENT

No particular uterotonic drug can be recommended over any, options include:

o Repeat bolus of:

• Oxytocin 5 units by slow IV injection (may have repeat dose)

• Ergometrine 500 micrograms (IM or slow IV) – do not give Ergometrine if woman is
hypertensive or in cases of retained placenta

o Oxytocin infusion – 40 units oxytocin in 500ml 0.9% sodium chloride by IV infusion at

125ml/hour unless fluid restriction necessary

o Tranexamic acid 1g IV (over 10mins). This should be given promptly if haemorrhage is known
to be mainly from trauma to the perineum or a vascular surgical procedure. This can be repeated
after 30mins if bleeding ongoing. Contraindicated in severe renal impairment THIS IS NOT A
UTEROTONIC DRUG

https://clinicalguidelines.nhsggc.org.uk/obstetrics/common-obstetric-problems-intrapartum-
labour-ward/tranexamic-acid-for-use-in-post-partum-haemorrhage-619/

o Carboprost (IM) – 250micrograms every 15 minutes. Max 8 doses. (contraindicated if woman

has severe cardiac/pulmonary/renal or hepatic disease)

o Misoprostol – 1000 micrograms per rectum or 800micrograms sublingually ( this takes 1-2.5
hours to increase uterine tone)

If pharmacological measures fail to control haemorrhage, surgical intervention should be

initiated.

Surgical Intervention

• EUA Examination Under Anaesthetic

Check for tears or retained placenta

• Bakri Tamponade Balloon (Intra Uterine Catheter)

This device is intended as a means of establishing haemostasis in cases indicating conservative

management of postpartum uterine bleeding.

The balloon portion of the Tamponade is inserted through the internal os or abdominally at
Caesarean Section (the incision is then closed normally).
An indwelling Foleys catheter should be in place whilst the Tamponade is in place and fluid
balance closely observed with hourly volumes.

The balloon of the Tamponade is inflated with sterile water up to about 350mls. Record the
amount of sterile water used on Badgernet.

Patient’s observations should be monitored for signs of increased bleeding and uterine
cramping.

The balloon can be left in for up to 24 hours.

Tamponade balloon removal: Consultant to be involved in timing of this.

• The B-Lynch Suture

• Uterine Artery Ligation

• Interventional radiology if available- contacted via Switchboard

 Resort to hysterectomy sooner rather than later especially in the cases of
ongoing haemorrhage and placenta accreta or uterine rupture
A second Consultant should be involved in the decision for hysterectomy

CELL SALVAGE https://obsgynhandbook.nhsggc.org.uk/nhsggc-obstetrics-gynaecology-

guidelines/guidelines-library/common-obstetric-problems-intrapartum-labour-ward/cg-
intraoperative-blood-cell-salvage-obstetrics/

At present the cell saver is not used for emergency haemorrhage but consideration should be
given to its use intraoperatively in elective surgery where major blood loss is anticipated

WOMEN WITH KNOWN BLOOD DISORDERS

These patients should have a documented birth plan including additional measures to be taken
in the event of bleeding made by Haematology and documented in Badgernet.

In the event of a post partum haemorrhage occurring in a woman with a known bleeding
disorder, contact the consultant haematologist on call immediately.

WOMEN PRESCRIBED LOW MOLECULAR WEIGHT HEPARIN

Reversal of LMWH is unlikely to be required if > 12 hours since last prophylactic dose, or > 24 hrs
since last treatment dose (unless significant renal impairment, i.e. CrCL<30ml/min). Otherwise,
contact the Consultant Haematologist On-Call to discuss the use of Protamine or FFP for
reversal.

Anti-factor Xa activity is incompletely neutralised (maximum about 60%) by Protamine

• Protamine is administered by Intravenous injection (rate not exceeding 5 mg/minute

maximum dose 50mg) or by continuous intravenous infusion.
• Protamine (50mg max dose) diluted up to 50ml with normal saline.
• Required dose infused over 10-20 minutes
• 1 mg of Protamine neutralises approx. 100IULMWH e.g. Dalteparin on Tinzaparin or 1mg
Enoxaparin (consult product literature of low molecular weight heparin for details)

Consider repeat dose 0.5mg/100IU LMWH after 2-4 hours if continued bleeding

Too rapid an injection or too large a dose of protamine may cause hypotension or
anaphylactoid-like reactions. Facilities to treat shock should be readily available. Patients who
have previously received protamine (eg diabetic patients taking Neutral Protamine Hagedorn
NPH insulin which contains Protamine) have a 1% risk of anaphylaxis
WOMEN WHO REFUSE BLOOD PRODUCTS https://obsgynhandbook.nhsggc.org.uk/nhsggc-
obstetrics-gynaecology-guidelines/guidelines-library/antenatal-general/cg-women-who-refuse-
blood-products-guideline-for-management/

SEVERE SECONDARY PPH

Causes are numerous and include endometritis, RPOC and subinvolution of the placental
implantation site.

Management should include assessment of haemodynamic status, assessment of blood loss and
an evaluation of the woman’s concerns

• Base line observations – Temp, Pulse, Respirations and Blood Pressure.

• IV access. Site 2 Grey venflons and obtain FBC, Cross-Match 4 Units, Coagulation Screen,
Cultures, U&E, CRP and lactate if Pyrexial – https://obsgynhandbook.nhsggc.org.uk/nhsggc-
obstetrics-gynaecology-guidelines/guidelines-library/infections/cg-maternal-sepsis/

• IV antibiotics

https://obsgynhandbook.nhsggc.org.uk/ggc-obstetrics-gynaecology-handbook/guidelines-
library/infections/cg-antibiotic-prophylaxis-in-obstetric-procedures/

https://obsgynhandbook.nhsggc.org.uk/nhsggc-obstetrics-gynaecology-
guidelines/guidelines-library/infections/cg-antibiotic-policy-obstetric-patients/

• Adequately resuscitate and give Ergometrine 500micrograms (unless hypertensive or

maternal cardiac history) and Oxytocin infusion as above.

• Consultant Obstetrician to be informed.

• High vaginal and endocervical swab.

• A pelvic ultrasound may help to exclude the presence of retained products of conception,
although the diagnosis of retained products is unreliable

• Senior Obstetrician should be present to undertake or supervise surgical evacuation of

retained products of conception. Risks include uterine perforation and Asherman’s
Syndrome
 Datix DEBRIEFING AND FOLLOW UP

An opportunity to discuss the events surrounding the obstetric haemorrhage should be offered
to the woman possibly with her birthing partner at a mutually convenient time. Address future
pregnancy/ risk of recurrence. A follow up appointment should be offered to the woman
postnatally when necessary consideration of the use of psychology services where necessary

Author: Dr Julie Murphy

Title: Management of Postpartum Haemorrhage (PPH)

Implementation /Review Dates

Implemented: Aug 2022
Review Date: 31st August 2027
Approval: Obstetric Guideline Group Aug 2022

REFERENCES

Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52: 16

December 2016

Care in third stage of labour. Nice: April 2021

Intrapartum care for healthy women and babies. NICE Clinical guideline CG190

MBRRACE-UK: Saving Lives, Improving Mothers' Care 2020: Lessons to inform maternity care from
the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2016-18
 Appendix 1 Post Partum Haemorrhage Management

PPH identified

Blood loss >500mls and/or signs of clinical shock Measure all blood loss

Inform Obstetric & Anaesthetic middle grade

Inform Labour Ward co-ordinator

Blood pressure & Pulse Bimanual compression

Gain IV access & obtain FBC,Coag, G&S Insert Urinary Catheter

Begin resuscitation & facial oxygen Identify cause(s) Remember there may be multiple causes

Uterine Atony Perineal Trauma Retained Uterine

Placenta Inversion

5 units Syntocinon IV

Start Syntocinon Infusion 40 units in Tranexamic Acid 1g IV Controlled cord Replace Uterus
500ml Hartmann’s at 125ml/hour over 10mins can be traction if manually do
repeated after 30 mins placenta has NOT give
500micrograms Ergometrine IV slow not yet been uterotonics or
injection avoid in Repair all lacerations delivered – attempt to
hypertension/Sepsis/Heart disease remove any remove
Promptly transfer to
clots or placenta until
theatre if required
remaining tissue uterus
replaced
Uterus Uterus remains Promptly
contracted but atonic transfer to Promptly
bleeding theatre if transfer to
ongoing required theatre if
Repeat Ergometrine 500micrograms
required
IV slow injection if no contra
indications
Consider other
cause of PPH Consider Carboprost 250micrograms
IM only repeated every 15mins max
Tranexamic 8 doses caution in
Acid 1g IV over asthmatics/glaucoma
10mins can be
repeated after Misoprostol 1000 micrograms PR
30 mins

Bleeding Ongoing

Coagulopathy
Tranexamic Acid is not a
Intra uterine Balloon (Bakri) uterotonic drug.
Liase with
Senior Laparotomy IV bolus should be
Haematologist administered over 10 mins
Interventional Radiology
 Appendix 2 Postpartum Haemorrhage Resuscitation
Measure all blood loss at every delivery

Attach suction to under buttock drape in

instrumental deliveries at increased risk of PPH,
recording measured liquor at time of delivery

Major PPH Measured

Minor PPH
≥1000mls +/or Blood Loss
500ml-1000ml
Signs of clinical >1500mls With
No signs of clinical
shock Ongoing
shock
Bleeding

Inform;
LW Co-ordinator Call Obstetric & Anaesthetic
Obstetric Middle Grade Doctor Middle Grade & Senior
Anaesthetic Middle Grade Doctor Obstetrician/Anaesthetist- On
Site CALL 2222
State “Major
Haemorrhage” giving
hospital, ward, location
• Assign a scribe and staff required
• Site 16G IV Cannula • Oxygen 15L/min
• FBC, COAG, G&S • Site 2x 16G Cannulae
• Hartmann’s Solution up to 2L
• FBC,COAG,UEs,LFTs,Crossmatch
commenced (Watch Fluid
minimum 2 units PRC
Balance if Pre-
eclampsia/Maternal Cardiac • Consider bedside testing for
Hx) Hb/coag
• Maternal Observations every • Urinary Catheter Request consultant
Obstetrician and Anaesthetist
15 mins • Hartmann’s solution via warmer
• Review Antenatal Hb to attend
up to 2 L
• Identify cause and manage as • Identify cause and manage as per
Inform senior haematologist
per protocol protocol
• Inform Senior • Maternal Observations every 15
Obstetric/Anaesthetic Staff if mins or as per MEWS
bleeding ongoing • Measure blood loss continuously
• Document in Badgernet PPH and communicate clearly to
tool obstetric/anaesthetic team
When haemorrhage
• Consider CVP/arterial line
controlled consider
• Transfuse O Neg blood if bleeding transfer to HDU/ITU
life threatening
AIM TO MAINTAIN; • Transfuse if measured blood loss Step down the major
Hb> 80g/l >2.5L and ongoing obstetric haemorrhage call
Platelets > 50*109 /L • After 4 Units of PRC infuse FFP
PT < 1.5 times normal, Document in Badgernet
• Document in Badgernet PPH tool
APTT < 1.5 times normal PPH tool
Fibrinogen > 2g/l