DNB Answer Notes: Postpartum Haemorrhage (PPH)

Based on: WHO Consolidated Guidelines for Prevention, Diagnosis and Treatment of PPH (2025)

DEFINITION & EPIDEMIOLOGY

• PPH = blood loss ≥500 mL within 24 hours of vaginal birth; ≥1000 mL after caesarean section
• Accounts for ~1/5 of all global maternal deaths
• In most low-income countries, it is the leading cause of maternal mortality
• Uterine atony = most common cause globally (4T's: Tone, Tissue, Trauma, Thrombin)
• SDG Target 3.1: Reduce global MMR to <70/100,000 live births by 2030

SECTION 1: ANTENATAL INTERVENTIONS TO PREVENT PPH

1. Anaemia Diagnosis in Pregnancy

• Full blood count (FBC) is the recommended method for diagnosing anaemia in pregnancy
• Where FBC is unavailable: haemoglobinometer is preferred over haemoglobin colour scale
• (Context-specific recommendation)

2. Iron and Folic Acid Supplementation

• Daily oral iron + folic acid supplementation is recommended throughout pregnancy to reduce risk of anaemia and low birth weight (Recommended)

3. Intravenous Iron for Iron-Deficiency Anaemia

• IV iron therapy is recommended in pregnancy when oral iron is ineffective or not tolerated (Context-specific)
• Treat iron-deficiency anaemia before delivery to reduce PPH mortality risk

4. Antenatal Care & Risk Stratification

• All pregnant women should have antenatal care for early identification of PPH risk factors
• Risk factors: multiple pregnancy, previous PPH, grande multiparity, polyhydramnios, placenta praevia/accreta, bleeding disorders, anticoagulant use

SECTION 2: INTRAPARTUM INTERVENTIONS TO PREVENT PPH

5. Prophylactic Oxytocin (MOST IMPORTANT)

6. Alternative Uterotonics (Hierarchy)

7. Episiotomy

• Routine/liberal use of episiotomy is NOT recommended for spontaneous vaginal birth (Not recommended)
• If performed: medio-lateral incision preferred (midline = higher risk of anal sphincter injury)
• Requires informed consent + effective local anaesthesia
• No routine prophylactic antibiotics needed for episiotomy

SECTION 3: POSTPARTUM INTERVENTIONS TO PREVENT PPH

8. Active Management of Third Stage of Labour (AMTSL)

1. Uterotonic drug (primary, essential)
2. Controlled cord traction (CCT) - small additional benefit when oxytocin is used
3. Late cord clamping (1-3 min delay recommended)
4. Uterine massage - NOT recommended routinely if uterotonic given

9. Cord Clamping

• Recommended even in HIV-positive mothers (no evidence of increased HIV transmission risk)

10. Uterine Massage

• However, intermittent uterine tone assessment (periodic palpation) remains important for early PPH detection

11. Prophylactic Tranexamic Acid (TXA) - NEW

• Prophylactic TXA is NOT recommended routinely for all women
• Context-specific for high-risk women (e.g. placenta praevia, history of PPH, coagulopathy)

SECTION 4: DIAGNOSING PPH

12. Blood Loss Measurement - CRITICAL

• Visual estimation consistently underestimates blood loss by 30-50%
• Calibrated drapes improve early PPH detection and trigger timely treatment

13. PPH Diagnosis Thresholds

• Measured blood loss ≥500 mL, OR
• Measured blood loss ≥300 mL with early warning signs (tachycardia, hypotension, dizziness)

14. Uterine Tone Monitoring

• Uterine tone assessment should occur regularly postpartum as part of monitoring
• Boggy/soft uterus = suspect atony, act immediately

SECTION 5: FIRST-RESPONSE TREATMENT OF PPH

15. Treatment Bundle (PPH Care Bundle) - MOST IMPORTANT

"U-TITE" Mnemonic:

1. Uterine massage
2. Tranexamic acid (IV 1g)
3. IV fluids (isotonic crystalloids)
4. Toxic/uterotonics (additional oxytocin/ergometrine)
5. Examination of genital tract + Escalation of care

16. Oxytocin for Treatment

• Dose: 20-40 IU in 500-1000 mL normal saline IV infusion
• If not available: ergometrine or misoprostol (600-800 mcg SL/sublingual)

17. Tranexamic Acid (TXA) - KEY

• Should be given within 3 hours of birth; ideally within 1 hour of PPH onset
• Repeat dose of 1g IV if bleeding continues after 30 minutes
• Mechanism: antifibrinolytic (inhibits plasminogen activation)
• WHO WOMAN trial: TXA reduces death from haemorrhage by 19% when given within 3 hours

18. IV Fluids for Resuscitation

• Crystalloids: widely available, inexpensive, no anaphylaxis risk
• Goal: stabilize circulation while definitive treatment is underway
• Caution: fluid overload in pre-eclampsia/cardiac disease

19. Uterine Massage for Treatment

• Different from prophylactic sustained massage (which is not recommended)

SECTION 6: TREATMENT OF REFRACTORY PPH

20. Carboprost (PGF2α)

• Recommended for atony not responding to first-line oxytocics
• 250 mcg IM/intramyometrial, can repeat every 15-90 min (max 8 doses)
• Contraindicated in asthma

21. Bimanual Uterine Compression

22. External Aortic Compression

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

24. Uterine Balloon Tamponade (UBT)

• Immediate surgical intervention + blood products are accessible
• First-line protocol (uterotonics + TXA + IV fluids) is already implemented
• Other causes (retained tissue, trauma) are reasonably excluded
• Trained health personnel available
• Maternal condition can be adequately monitored

25. Uterine Packing

26. Uterine Artery Embolization (UAE)

27. Surgical Interventions

• Compression sutures (B-Lynch, modified Hayman)
• Bilateral uterine artery ligation
• Internal iliac artery ligation
• Hysterectomy (peripartum) - definitive last resort

28. Cell Salvage

29. Blood Transfusion

• Underlying risk + continuous clinical + haematological assessment
• Clear protocols for optimizing blood product use
• Not on a single haemoglobin value alone

SECTION 7: RETAINED PLACENTA MANAGEMENT

30. Retained Placenta

• Placenta not delivered within 15 min: initiate CCT, mobilize, empty bladder
• Not delivered within 30 min: prepare for manual removal of placenta (MRP)

31. Antibiotic Prophylaxis for MRP

• Regimens: ampicillin, first-generation cephalosporins, or single dose IV amoxicillin 1g + clavulanic acid 200mg
• Avoid ergometrine and PGE2 (dinoprostone/sulprostone) in retained placenta

32. IV Oxytocin for Retained Placenta

• IV oxytocin for retained placenta in absence of PPH - very limited evidence; consensus-based use

SECTION 8: SUPPORTIVE CARE AFTER PPH

33. Iron Supplementation Post-PPH

• Oral/IV iron to replenish iron stores after significant blood loss
• Helps recovery from anaemia without mandatory transfusion

34. Monitoring

• Close monitoring: pulse, BP, respiratory rate, urine output, uterine tone
• Watch for: DIC, acute kidney injury, Sheehan syndrome (pituitary necrosis)

35. Psychological Support

• Women who experience PPH have increased risk of PTSD and postnatal depression
• Counselling and follow-up recommended

SECTION 9: HEALTH SYSTEM INTERVENTIONS

36. PPH Protocols and Drills

• Every facility should have a written PPH protocol
• Regular simulation drills improve team response time and outcomes

37. Task-Shifting

• Misoprostol can be task-shifted to community/lay health workers
• TXA self-injection being studied in community settings

38. Supply Chain

• Ensure uninterrupted supply of uterotonics (oxytocin requires cold chain; carbetocin does not)
• Calibrated drapes should be available at all birth facilities

HIGH-YIELD SUMMARY TABLE FOR DNB

QUICK RECALL - 10 MARKS ANSWER STRUCTURE

• Antenatal: FBC for anaemia, iron+folate supplementation
• Intrapartum: No routine episiotomy, oxytocin as primary uterotonic
• AMTSL: Uterotonic + CCT + late cord clamping (not routine massage)

• Calibrated drape for objective blood loss measurement
• Trigger at ≥500 mL or ≥300 mL + warning signs

• First-line bundle: uterine massage + TXA 1g IV + crystalloids + uterotonic + genital exam
• TXA must be given within 3 hours
• Second-line: bimanual compression, UBT, UAE, surgical (B-Lynch/hysterectomy)

• MRP after 30 min; antibiotic prophylaxis recommended
• Post-PPH: iron, monitoring, psychological support

Source: WHO Consolidated Guidelines for the Prevention, Diagnosis and Treatment of Postpartum Haemorrhage, 1st Edition, 2025 (ISBN 978-92-4-011563-7). 51 recommendations across antenatal, intrapartum, postpartum, diagnosis, treatment, supportive care and health systems domains.