PPH Bundle: Recent Advances in Obstetrics

What is the PPH Bundle?

1. Readiness - Risk stratification, hemorrhage carts, protocols
2. Recognition - Objective blood loss quantification, vital sign triggers
3. Response - Staged treatment protocol
4. Reporting & Systems Learning - Debriefs, audits, quality improvement

Recent Major Advances (2023-2026)

1. Objective Blood Loss Quantification - The Diagnostic Revolution

• Calibrated blood collection drapes are now WHO/FIGO/ICM recommended for objective quantification of blood loss - replacing subjective estimation
• The E-MOTIVE trial (Lancet, 2026) showed that pairing objective measurement with a standardised first-response bundle produced a 60% reduction in adverse PPH outcomes - [PMID 42285120]
• A process evaluation (Lancet Global Health, 2025) across Kenya, Nigeria, South Africa, and Tanzania confirmed high fidelity (96.9% of PPH cases received the full bundle) and that treatment was initiated within 15 minutes in 66.8% of cases - [PMID 39890233]

2. The Six Delays Framework (Coomarasamy et al., Lancet 2026)

3. Uterotonics - Optimised Combinations

• Ergometrine + oxytocin: Highest ranked combination, reduces PPH ≥500 mL vs oxytocin alone (RR 0.76, 95% CI 0.64-0.90; high-certainty evidence)
• Misoprostol + oxytocin: Second-highest ranked (RR 0.70, 95% CI 0.57-0.87; moderate certainty)
• Carbetocin (heat-stable): Comparable to oxytocin with high certainty - preferred for hot/resource-limited settings where cold chain is unavailable
• After caesarean: Carbetocin or oxytocin as bolus are the most effective regimens
• The term "Active Management of the Third Stage of Labour (AMTSL)" as a combined intervention is now recommended to be retired and replaced with "Third Stage Care" - selecting individual evidence-based interventions - [PMID 38462248]
• Early cord clamping is no longer recommended as part of the bundle; delayed cord clamping is favoured

4. Tranexamic Acid (TXA) - Major Clarifications

• The Lancet IPD meta-analysis (2024) pooled 54,404 women from 5 trials: TXA reduces life-threatening bleeding (OR 0.77, 95% CI 0.63-0.93; p=0.008) with no increase in thromboembolism - [PMID 39461793]
• Must be given within 3 hours of diagnosis (after cord clamping, as it crosses the placenta)
• WOMAN-2 trial (2024): In women with moderate-to-severe anaemia (high-risk group), prophylactic TXA reduced PPH mortality - [PMID 39461792]

• Evidence remains inconsistent - the TRAAP trial found no reduction in PPH rates when given after vaginal birth prophylactically
• The Cochrane review (2024) confirmed TXA reduces blood loss after caesarean section - [PMID 39535297]
• Current guidance: TXA prophylaxis should be considered for high-risk patients (notably at caesarean) but is not recommended universally for all births

5. Haemostatic Monitoring - Point-of-Care Tests

• Viscoelastic haemostatic assays (TEG/ROTEM) with specific algorithms can diagnose coagulopathy early, predict fibrinogen deficiency, and guide targeted component therapy - reducing unnecessary transfusions
• Fibrinogen-first strategy: Cryoprecipitate or fibrinogen concentrate should be given early in resuscitation, as fibrinogen levels fall critically in PPH haemocoagulation
• Recombinant FVIIa (rFVIIa) is not universally recommended due to reported adverse events with off-label use

6. Uterine Balloon Tamponade (UBT)

• WHO now formally recommends UBT (including Bakri balloon, Condom catheter, ESM-UBT) as a second-line measure for atonic PPH refractory to uterotonics
• Simulation-based paired-operator training for balloon placement has been shown to improve placement fidelity - [PMID 41946411]
• ACOG published a Clinical Practice Update (October 2025) revising guidance on nonsurgical hemorrhage-control devices

7. Non-Pneumatic Anti-Shock Garment (NASG)

• Recommended in the six-delays framework as a temporising bridge to definitive care in resource-limited settings
• Compresses lower body vasculature, autotransfusing ~0.5-1L of blood centrally while definitive treatment is arranged

8. Artificial Intelligence (AI) in Risk Prediction

9. Workforce and System Advances

• Midwife-led bundle delivery: E-MOTIVE demonstrated that empowering midwives to independently administer the full MOTIVE bundle (without waiting for a physician) was a key success factor
• California Model (2015-16): 99 hospital collaborative implementing the NPMS bundle achieved a 20.8% reduction in severe maternal morbidity from hemorrhage - Creasy & Resnik's MFM
• The AIM (Alliance for Innovation on Maternal Health) programme now has 99% of US state birthing facilities enrolled in bundle implementation (as of 2024)

Summary: The Modern PPH Bundle (2025-26)

READINESS
  ├── Haemorrhage risk scoring at admission, 2nd stage, and postpartum transfer
  ├── Haemorrhage cart/kit with all medications immediately available
  └── Trained teams + massive transfusion protocol

RECOGNITION
  ├── Calibrated blood-collection drape (objective quantification)
  └── Vital sign trigger criteria (not just blood loss volume)

RESPONSE (MOTIVE Bundle)
  ├── M - Uterine Massage
  ├── O - Oxytocics (ergometrine+oxytocin or misoprostol+oxytocin preferred)
  ├── T - Tranexamic Acid (within 3 hours of PPH diagnosis)
  ├── I - IV Fluids
  ├── V - Vaginal/uterine Examination (assess 4Ts)
  └── E - Escalation (UBT, NASG, IR embolisation, surgery)

HAEMOSTASIS
  ├── TEG/ROTEM-guided component therapy
  ├── Early fibrinogen/cryoprecipitate
  └── MTP (1:1:1 PRBCs:FFP:platelets)

• Coomarasamy et al. Lancet 2026 - PPH: a race against time [PMID 42285120]
• Gallos et al. Cochrane 2025 - Uterotonic network meta-analysis [PMID 40237648]
• Ker et al. Lancet 2024 - TXA IPD meta-analysis [PMID 39461793]
• Bohren et al. Lancet Glob Health 2025 - E-MOTIVE process evaluation [PMID 39890233]
• Creasy & Resnik's Maternal-Fetal Medicine, Box 47.2 (NPMS bundle components)
• Miller's Anesthesia 10e, Chapter on Massive Obstetric Hemorrhage (TEG/ROTEM, TXA, cell salvage)