2025 Postpartum Hemorrhage (PPH) Management Guidelines

1. Updated Definition (New 2025)

Key change: The previous sole threshold of ≥500 mL is replaced by this "whichever comes first" dual criterion, enabling earlier intervention before hemodynamic decompensation.

2. Diagnosis: Objective Blood Loss Quantification

• Calibrated drapes (rather than visual estimation) are now recommended for all vaginal births — visual estimation consistently underestimates blood loss
• Objective quantification combined with vital sign monitoring is the cornerstone of early recognition
• Secondary PPH = bleeding after 24 hours (usually from retained products or infection)

3. Prevention

Uterotonics after Vaginal Birth

1. IV Oxytocin — preferred first-line uterotonic (10 IU IV or IM)
2. Heat-stable carbetocin — recommended when cold chain for oxytocin cannot be maintained
3. Misoprostol — recommended when neither oxytocin nor carbetocin is available

Antenatal / Intrapartum Measures

• Avoid prolonged second stage of labour: PPH risk rises ~10% per hour beyond 1 hour, and ~40% at ≥4 hours
• Controlled cord traction (active management of third stage)
• Antenatal iron supplementation and correction of anaemia
• Risk stratification for placenta praevia/accreta in prior caesarean section patients

4. Treatment: The MOTIVE Bundle

Recommendation 29 (Revalidated): A standardized and timely approach comprising objective blood loss assessment and the MOTIVE care bundle is recommended for all women with vaginal birth.

5. Step-Up Management (If MOTIVE Bundle Fails)

Second-Line Uterotonics

• Ergometrine / methylergometrine (contraindicated in hypertension)
• Carboprost (15-methyl PGF2α)
• Misoprostol (if not already given)
• IV tranexamic acid (if not yet given — 1 g, can repeat once after 30 min)

Uterine Tamponade

• Intrauterine balloon tamponade — simple, effective next step after uterotonics fail; success rates up to 91%
• Uterine packing with gauze (if balloon unavailable)
• 2025 ACOG Update: revised guidance on nonsurgical hemorrhage-control devices including intrauterine balloons, junctional/abdominal compression devices (e.g., REBOA in select centers) — ACOG 2025 Clinical Practice Update, PMID 40743526

Surgical Options (If Uterus Open / Bleeding Continues)

• Uterine compression sutures (e.g., B-Lynch suture)
• Bilateral uterine artery ligation / internal iliac artery ligation
• Uterine artery embolisation (UAE) — preferred when fertility preservation desired and interventional radiology available; should not be first-line but not a last resort either; performed empirically even with negative angiogram given pelvic collateral circulation
• Peripartum hysterectomy — definitive treatment if all else fails (leading cause: placenta accreta spectrum)

6. Blood Transfusion & Supportive Care

• Massive haemorrhage protocol (MHP): activate early when blood loss >1000 mL or rapid ongoing bleeding
• Balanced ratio transfusion: pRBC : FFP : Platelets in 1:1:1 ratio (trauma-driven evidence now extrapolated to obstetric hemorrhage)
• Fibrinogen concentrate or cryoprecipitate when fibrinogen <2 g/L
• Cell salvage is a safe adjunct (Cochrane 2024, PMID 39704317) — can be used intraoperatively to reduce allogeneic transfusion
• Correct hypothermia, acidosis, coagulopathy ("lethal triad")
• Calcium supplementation if receiving massive transfusion (citrate chelates calcium)

7. Special Scenarios

Retained Placenta

• Uterotonic administration for retained placenta only recommended if PPH is already present (Recommendation 30 — context-specific, updated)
• Manual removal under regional/GA anaesthesia

Placenta Accreta Spectrum (PAS)

• If suspected prenatally: planned delivery at tertiary centre with multidisciplinary team, cell salvage, IR/vascular surgery on standby
• MRI/US sensitivity 33–95%; severe cases with bladder invasion are easier to detect
• Leading cause of peripartum hysterectomy; maternal mortality up to 7%

Caesarean Section

• Same MOTIVE principles apply; uterine compression sutures and embolisation more accessible
• Consider B-Lynch or Hayman suture at time of CS if atony unresponsive to uterotonics

8. Health Systems & Implementation (New Emphasis in 2025)

• Simulation-based team training (multidisciplinary: obstetricians, midwives, anaesthetists, nurses)
• Each unit should develop its own PPH algorithm and audit peripartum hysterectomy rate as a quality indicator
• Functional supply chains for drugs and equipment (especially cold-chain for oxytocin)
• Monitoring with locally adapted indicators
• October 5 declared World PPH Day at the FIGO World Congress 2025

Summary Algorithm

PPH identified (≥300 mL + haemodynamic signs OR ≥500 mL)
        ↓
MOTIVE Bundle simultaneously
(Massage + Oxytocin + TXA + IV fluids + Examine/Escalate)
        ↓ If not controlled
Second-line uterotonics (ergometrine, carboprost, misoprostol)
        ↓ If not controlled
Uterine tamponade (balloon, packing)
        ↓ If not controlled
Surgical: B-Lynch / artery ligation / UAE / Hysterectomy
        ↓ All along
Activate MHP → Blood transfusion → Fibrinogen → Cell salvage

• WHO/FIGO/ICM. Consolidated Guidelines for the Prevention, Diagnosis and Treatment of Postpartum Haemorrhage. Geneva: WHO; 2025. Full text on NCBI Bookshelf
• ACOG Clinical Practice Update 2025: Nonsurgical Hemorrhage-Control Devices for PPH — PMID 40743526
• Williams et al. Cochrane 2025: Transfusion for PPH management — PMID 39911088
• Dey et al. Cochrane 2024: Cell salvage for PPH — PMID 39704317