Management of Postpartum Hemorrhage (PPH) — Current Guidelines for India

Definition

Key India context: PPH causes ~25–30% of maternal deaths in India. The MMR has declined but PPH remains the leading direct obstetric killer. FOGSI, FIGO, and the 2024–2025 WHO Consolidated Guidelines all align on core management bundles.

Causes — The 4 T's

Step 1 — Prevention: Active Management of Third Stage of Labour (AMTSL)

Uterotonic Prophylaxis (choose one)

• Oxytocin 10 IU IM/IV — first choice for ALL births (Rec. 7.1, WHO 2025) ✅
• Carbetocin 100 µg IM/IV — recommended for all births; heat-stable carbetocin preferred where cold chain cannot be guaranteed — highly relevant for rural India (Rec. 7.2) ✅
• Misoprostol (600 µg oral or 400 µg sublingual) — when oxytocin unavailable, especially for community/home births (Rec. 7.3)

NOT Recommended for Prophylaxis (WHO 2025 Update)

• ❌ Ergometrine/methylergometrine alone
• ❌ Fixed-dose oxytocin + ergometrine combination (5 IU/500 µg IM)
• ❌ Injectable prostaglandins (carboprost/sulprostone) for prophylaxis

Additional Preventive Measures

• Controlled cord traction (reduces retained placenta) ✅
• Uterine tone check post-delivery ✅
• Tranexamic acid (TXA) 1g IV prophylactically before caesarean — Cochrane 2024 meta-analysis (PMID 39535297) confirms significant reduction in PPH at CS; a 2025 Lancet Global Health network meta-analysis (PMID 40712613) supports prophylactic TXA at CS

Step 2 — Diagnosis: Objective Blood Loss Measurement

• Use calibrated blood-collection drapes — visual estimation underestimates blood loss by 30–50%
• The E-MOTIVE trial strategy (WHO/FIGO endorsed) uses drapes for early detection → triggers bundle activation → reduces severe PPH (>1000 mL) by 60%
• Input indicators: availability of drapes, uterotonics, TXA, IV fluids at facility level

Step 3 — First-Line Treatment Bundle (First 15 Minutes)

This bundle approach is endorsed by WHO (Rec. 29), FIGO, FOGSI, and ACOG. Never administer components sequentially — all must be started simultaneously.

Second-Line Uterotonics (if oxytocin fails — Rec. 25):

• Ergometrine 0.2 mg IM/IV (contraindicated in hypertension)
• Carboprost 250 µg IM every 15–90 min (max 8 doses) — contraindicated in asthma
• Misoprostol 800 µg sublingual
• Oxytocin + Ergometrine fixed combination

Step 4 — Second-Line / Mechanical Interventions (15–30 Min)

Uterine Balloon Tamponade (UBT)

• Bakri balloon: inflate with 300–500 mL saline — success rate up to 91%
• Condom catheter / Chhattisgarh balloon: cost-effective alternative validated in India for low-resource settings
• "Tamponade Test": if bleeding controlled → keep 24 hrs; if bleeding continues → immediate surgical escalation
• Endorsed by ACOG Practice Bulletin 183, FOGSI, and FIGO bundles

Bimanual Compression

• External + internal compression for persistent atony while awaiting further intervention

Step 5 — Surgical Management (30+ Minutes / If Bundles Fail)

1. B-Lynch compression suture — when abdomen is open (CS); effective for atony
2. Uterine artery ligation (O'Leary suture) ± internal iliac artery ligation
3. Uterine artery embolisation (UAE) — interventional radiology; uterus-sparing; preferred before hysterectomy when IR is available; bilateral embolisation usually required (good pelvic collaterals)
4. Peripartum hysterectomy — definitive; last resort for uncontrolled atony or PAS — Grainger & Allison's Diagnostic Radiology

For Placenta Accreta Spectrum (PAS): Planned caesarean hysterectomy at a tertiary centre is the standard of care. Conservative options (placenta in situ, uterine artery embolisation, balloon occlusion) are considered only in selected cases with fertility desire.

Step 6 — Haematological / Resuscitation Support

India-Specific Considerations

FOGSI 2022 / India-Specific PPH Algorithm Summary

PPH diagnosed (blood loss ≥500 mL vaginal / ≥1000 mL CS)
        ↓
CALL FOR HELP + 2 large-bore IVs + crossmatch
        ↓
BUNDLE (simultaneous, <15 min):
  Oxytocin IV + TXA 1g IV + Uterine massage + IV fluids + Examine genital tract
        ↓ (if bleeding continues >15–30 min)
2nd-line uterotonics (ergometrine/carboprost/misoprostol)
+ Balloon tamponade (Bakri/condom catheter)
+ Activate MTP
        ↓ (if bleeding continues)
SURGICAL: B-Lynch → Uterine artery ligation → UAE → Hysterectomy

Key Recent Evidence Updates