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PPH

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WHO postpartum haemorrhage guideline prevention diagnosis treatment 2025

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"postpartum hemorrhage" AND treatment

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https://iris.who.int/server/api/core/bitstreams/88bf11a5-93b…

PPH = postpartum haemorrhage, excessive bleeding after childbirth.
Definition: Blood loss ≥1,000 mL after vaginal or caesarean birth, or any postpartum bleeding with signs of hypovolaemia, within 24 hours. This is primary PPH. Secondary PPH occurs from 24 hours to several weeks postpartum. Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9e, p. 1968.

Main causes: the “4 Ts”

  • Tone: uterine atony, the commonest cause
  • Tissue: retained placenta or placental fragments
  • Trauma: cervical/vaginal/perineal tears, uterine rupture or inversion
  • Thrombin: coagulation disorder/DIC

Immediate management

PPH is an obstetric emergency:
  1. Call for senior obstetric, anaesthetic, and blood-bank support.
  2. Assess ABCs, give oxygen if needed, insert two large-bore IV lines, warm the patient, quantify blood loss, send CBC, coagulation tests and cross-match.
  3. Uterine massage and empty the bladder.
  4. Give an uterotonic for suspected atony, usually oxytocin first-line.
  5. Give tranexamic acid 1 g IV within 3 hours of birth. Repeat 1 g if bleeding continues after 30 minutes or restarts within 24 hours.
  6. IV crystalloids initially, then blood products guided by ongoing bleeding, haemodynamics and coagulation results.
  7. Examine for genital-tract trauma and retained tissue; address the cause.
  8. If bleeding persists: balloon tamponade, compression sutures, uterine/iliac artery embolisation where available, or hysterectomy as a life-saving last resort.
WHO recommends a rapid first-response bundle: uterine massage, uterotonic, tranexamic acid, IV fluids, genital-tract examination, and escalation of care. See the WHO 2025 PPH guideline.
Recent evidence also supports structured PPH care bundles, though implementation and resources affect outcomes (systematic review, PMID 38336124).

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Postpartum haemorrhage (PPH): learning map

  1. Definition and classification
    • Primary versus secondary PPH
    • Blood-loss thresholds and clinical definition
    • Severity grading
  2. Normal physiology and why PPH occurs
    • Placental separation
    • Myometrial contraction and the “living ligature” mechanism
    • Haemodynamic changes of pregnancy and shock
  3. Causes: the 4 Ts
    • Tone: uterine atony
    • Tissue: retained placenta/products, placenta accreta spectrum
    • Trauma: lacerations, haematoma, rupture, inversion
    • Thrombin: coagulopathy, DIC
  4. Risk factors and prevention
    • Antenatal, intrapartum, and operative-delivery risk factors
    • Active management of the third stage of labour
    • Prevention in high-risk patients
  5. Recognition and assessment
    • Quantifying blood loss
    • Clinical signs of compensated and decompensated shock
    • Focused examination and investigations
  6. First-response resuscitation
    • Team activation, ABCDE, IV access, blood products, monitoring
    • PPH treatment bundle
    • Escalation principles and massive-transfusion concepts
  7. Cause-directed management
    • Stepwise management of atony
    • Retained placenta and retained products
    • Genital tract trauma, uterine inversion and rupture
    • Management of coagulopathy
  8. Drugs used in PPH
    • Oxytocin and other uterotonics
    • Tranexamic acid
    • Key contraindications and adverse effects
  9. Mechanical, radiological, and surgical treatment
    • Bimanual compression and aortic compression
    • Balloon tamponade
    • Compression sutures, vessel ligation, embolisation, hysterectomy
  10. Secondary PPH and post-event care
  • Causes, diagnosis, and treatment after 24 hours
  • Anaemia treatment, debriefing, documentation, future-pregnancy planning
  1. Exam approach
  • Algorithms, viva answers, mnemonics, and clinical scenarios.
PPH is time-critical. The practical framework is: recognize bleeding early, resuscitate while identifying the 4 Ts, start uterine massage + uterotonic + tranexamic acid promptly, inspect for trauma/tissue, and escalate rapidly if bleeding continues. The latest WHO guideline describes this as a standardized first-response treatment bundle.
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Do you mean you want PPH questions with their answers in an exam-style Q&A format, or a full teaching note with questions and answers after each section?

No2 as a general topic teach me everything about PPH

Postpartum haemorrhage (PPH): complete-topic map

1. Definition and classification

  • Primary PPH: within 24 hours of birth.
  • Secondary PPH: from 24 hours to up to 6 weeks postpartum.
  • Common clinical definition: cumulative blood loss ≥1,000 mL after any birth, or any bleeding causing signs/symptoms of hypovolaemia within 24 hours.

2. Normal haemostasis after delivery

After placental delivery, uterine muscle fibres contract and compress the vessels at the placental bed. This is the “living ligature” mechanism. PPH results when this fails, a vessel is injured, placental tissue remains, or clotting fails.

3. Causes: the 4 Ts

  1. Tone - uterine atony, the commonest cause.
  2. Tissue - retained placenta, retained products, placenta accreta spectrum.
  3. Trauma - perineal, vaginal or cervical tears; haematoma; uterine inversion; uterine rupture.
  4. Thrombin - inherited/acquired coagulopathy, DIC, severe pre-eclampsia, placental abruption, anticoagulant use.

4. Risk factors

  • Previous PPH, multiple pregnancy, macrosomia, polyhydramnios
  • Induction/augmentation and prolonged labour
  • Operative vaginal delivery or caesarean birth
  • Placenta praevia, abruption, retained placenta, placenta accreta spectrum
  • Chorioamnionitis, uterine fibroids, maternal anaemia or coagulopathy
A PPH may still occur without an identifiable risk factor, so every delivery needs readiness.

5. Prevention

  • Identify and correct antenatal anaemia.
  • Screen for placental location/accreta risk when indicated.
  • Active management of third stage of labour, particularly prophylactic uterotonic therapy.
  • Quantify blood loss rather than relying only on visual estimation.
  • Have a team protocol, emergency drugs, blood access, and escalation pathway available.

6. Recognition and initial assessment

  • Call for help early: obstetric senior, anaesthesia, theatre staff, blood bank.
  • Assess A-B-C-D-E, vital signs, mental status, urine output and ongoing blood loss.
  • Insert two wide-bore IV cannulas; obtain CBC, group and crossmatch, coagulation screen and fibrinogen.
  • Warm the patient and fluids/blood products; monitor continuously.
  • Look systematically for the 4 Ts while resuscitation is underway.

7. First-response PPH bundle

The current WHO approach uses early, coordinated treatment:
  • Uterine massage
  • Uterotonic
  • Tranexamic acid
  • IV fluids
  • Examination of the genital tract
  • Escalation of care if bleeding persists
TXA is given as early as possible and within 3 hours of birth: 1 g IV over 10 minutes; repeat 1 g if bleeding continues after 30 minutes or restarts within 24 hours.

8. Treatment of uterine atony

  • Massage uterus; empty bladder.
  • First-line uterotonic is generally oxytocin.
  • If bleeding persists, use an appropriate additional uterotonic according to local protocol and contraindications.
  • Perform bimanual uterine compression.
  • Consider uterine balloon tamponade.
  • Move promptly to surgery or embolisation if conservative treatment fails.
Important contraindication patterns:
  • Avoid ergometrine in hypertension, pre-eclampsia, or significant cardiac disease.
  • Avoid carboprost in asthma and use caution with cardiac, hepatic, or renal disease.
  • Misoprostol can cause fever, shivering and gastrointestinal adverse effects.

9. Management by cause

CauseClueKey action
ToneBoggy, enlarged uterusMassage, uterotonics, TXA, compression, tamponade
TissuePlacenta incomplete or undelivered, continuing bleedManual removal or evacuation as appropriate
TraumaFirm uterus but persistent bleedingInspect and repair tears, drain significant haematoma
ThrombinDiffuse ooze, abnormal tests, poor clot formationReplace blood components and correct coagulopathy

10. Blood products and coagulopathy

Major PPH can rapidly cause dilutional coagulopathy, hypofibrinogenaemia, acidosis, hypothermia and DIC. Use a local massive obstetric haemorrhage protocol. Treatment includes red cells, plasma, platelets, and fibrinogen replacement when indicated, while preventing hypothermia and correcting calcium and acidosis.

11. Mechanical and surgical options

  • Bimanual uterine compression
  • External aortic compression as a temporary life-saving manoeuvre
  • Uterine balloon tamponade
  • Compression sutures such as B-Lynch
  • Uterine, utero-ovarian, or internal iliac artery ligation
  • Uterine artery embolisation in a stable patient where interventional radiology is available
  • Peripartum hysterectomy when bleeding cannot be controlled or definitive treatment is required, especially in severe placenta accreta spectrum

12. Special emergencies

  • Retained placenta: assess for separation; manual removal when indicated with appropriate analgesia/anaesthesia and preparation for haemorrhage.
  • Uterine inversion: immediate manual replacement, resuscitation, then uterotonics only after the uterus is repositioned.
  • Uterine rupture: laparotomy and repair or hysterectomy.
  • Genital tract haematoma: suspect with pain, pressure, shock, or falling haemoglobin despite minimal visible bleeding.
  • Placenta accreta spectrum: planned multidisciplinary delivery and readiness for massive haemorrhage, often hysterectomy.

13. Secondary PPH

Typical causes include retained products, endometritis, subinvolution of the placental site, and less commonly a bleeding disorder. Assess severity, exclude ongoing major bleeding, examine, perform appropriate imaging/laboratory testing, and treat the cause. Urgent review is needed for heavy bleeding, faintness, fever, foul-smelling lochia, or severe pain.

14. Aftercare

  • Monitor for recurrent bleeding, anaemia, infection, thrombosis and psychological trauma.
  • Replace iron and manage anaemia.
  • Debrief the patient and family.
  • Document estimated/quantified loss, interventions, response, transfusion, and cause.
  • Review recurrence risk and make an antenatal delivery plan for a future pregnancy.

Core exam answer

PPH management is simultaneous resuscitation and cause control: activate help; assess ABCs; obtain access, tests and blood; massage uterus; give uterotonic and early TXA; inspect for tissue and trauma; correct coagulopathy; and escalate without delay to tamponade, radiological intervention, surgery, or hysterectomy if bleeding continues.
Which one should I now teach in full detail with clinical algorithms, drug doses, case-based questions, and answers?
  1. Definitions, causes and risk factors
  2. Step-by-step emergency management
  3. Uterine atony and PPH medications
  4. Surgical and advanced management
  5. Secondary PPH and exam cases
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