Guideline sources The following summarized guidelines for the evaluation and management of postpartum hemorrhage (PPH) are prepared by our editorial team based on guidelines from the International Federation of Gynecology and Obstetrics (FIGO 2022), the British Society for Haematology (BSH 2022; 2018), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2022; 2018), the European Society of Intensive Care Medicine (ESICM 2021), the American College of Obstetricians and Gynecologists (ACOG 2020; 2017), the World Health Organization (WHO 2018), the Royal College of Obstetricians and Gynaecologists (RCOG 2017), and the American Association of Family Physicians (AAFP 2017). 1 2 3 4 5 6 7 8 9 10 11 12 13 Guidelines 1. Classification and risk stratification https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 1/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway Risk assessment: obtain an individualized risk assessment for PPH, including calculation of the maximum allowable blood loss, E documented in a checklist upon arrival to a labor unit and updated throughout labor and delivery. A 2. Diagnostic investigations Physical examination: As per FIGO 2022 guidelines, obtain postpartum abdominal uterine tonus assessment for early identification of uterine atony in all patients. E As per SOGC 2022 guidelines, assess patients with ongoing bleeding for the presence of clots, retained placental tissue, or genital tract lacerations. E Blood loss estimation: As per SOGC 2022 guidelines, obtain quantitative blood loss measurement, whenever possible, to replace estimated blood loss in all patients. B As per SOGC 2018 guidelines, use clinical markers (signs and symptoms) for rather than a visual estimation for blood loss estimation. B As per RCOG 2017 guidelines, assess clinical signs and symptoms, rather than estimating visually, for the evaluation of PPH. B Viscoelastic testing: As per BSH 2022 guidelines, consider obtaining viscoelastic hemostatic assays to guide transfusion therapy in patients with PPH, taking into account the costs and benefits of these tests and ensuring policies are in place to maintain these devices on a daily basis. B As per BSH 2018 guidelines: Avoid obtaining viscoelastic hemostatic assays during labor in non-bleeding pregnant woman for predicting PPH. D Consider obtaining viscoelastic testing as part of an agreed algorithm to manage PPH when the local institution's major obstetric hemorrhage protocol is activated. C 3. Medical management Multidisciplinary care: As per SOGC 2022 guidelines, use a multidisciplinary team approach consisting of obstetrics, anesthesia, nursing, and transfusion medicine for the management of severe obstetrical hemorrhage. A As per SOGC 2018 guidelines, use a multidisciplinary approach involving maintaining hemodynamic stability while simultaneously identifying and treating the cause of blood loss for the management of ongoing PPH. B As per RCOG 2017 guidelines, summon a multidisciplinary team involving senior members of staff to attend to women with major PPH (blood loss of > 1,000 mL) and ongoing bleeding or clinical shock. B Show 3 more General principles: https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 2/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway As per FIGO 2022 guidelines, take measures to stop the bleeding before the patient develops coagulation problems and organ damage from underperfusion. Try conservative approaches first and rapidly move to more invasive procedures if these do not work. E As per SOGC 2022 guidelines, stage and manage PPH based on quantitative blood loss. A As per RCOG 2017 guidelines: Initiate a combination of pharmacological, mechanical and surgical methods to arrest PPH directing these methods towards the causative factor. B Institute a sequence of mechanical and pharmacological measures in turn until the bleeding stops if uterine atony is perceived to be a cause of the bleeding. B Initial resuscitation: As per FIGO 2022 guidelines, administer isotonic crystalloids over colloids for the initial IV fluid resuscitation of patients with PPH. E As per SOGC 2022 guidelines, undertake the following measures in patients with PPH: institute IV access 2 obtain ECG monitor oxygen saturation monitor BP place an indwelling urethral catheter maintain euthermia administer balanced crystalloids for volume replacement. E As per RCOG 2017 guidelines: Undertake the following measures in patients with minor PPH (blood loss 500-1,000 mL) without clinical shock: institute an IV access (one 14-gauge cannula) perform urgent venipuncture (20 mL) for blood type and screen, CBC, and coagulation screen including fibrinogen record pulse, respiratory rate and BP every 15 minutes administer warmed crystalloid infusion. B Undertake the following measures in patients with major PPH (blood loss > 1,000 mL) and continuing to bleed or clinical shock: assess airway and breathing evaluate circulation position the patient flat keep the patient warm using appropriate available measures administer blood transfusion as soon as possible, if clinically required administer up to 3.5 L of warmed clear fluids, initially 2 L of warmed isotonic crystalloid, until blood is available; consider continuing further fluid resuscitation with additional isotonic crystalloid or colloid (succinylated gelatin); do not use hydroxyethyl starch use the best equipment available to achieve rapid warmed infusion of fluids do not use special blood filters. B Uterotonics: https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 3/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway As per FIGO 2022 guidelines, administer IV oxytocin alone as the first-line uterotonic drug for the treatment of PPH. E Show 2 more As per SOGC 2022 guidelines: Administer IM ergotamine or IM or intramyometrial carboprost for the management of active PPH. A Do not use rectal misoprostol for the management of PPH. D As per AAFP 2017 guidelines, administer oxytocin for the treatment of PPH, even if already used for labor induction or augmentation or as part of active management of the third stage of labor. A Tranexamic acid: As per BSH 2022 guidelines, administer an initial dose of tranexamic acid (1 g IV) in patients with PPH within 3 hours of onset. Administer a second dose of 1 g if bleeding continues after 30 minutes or if it stopped and restarted within 24 hours of the first tranexamic acid dose. A As per FIGO 2022 guidelines, administer early IV tranexamic acid as soon as PPH is diagnosed but within 3 hours of birth in addition to standard care in patients with clinically diagnosed PPH following vaginal birth or Cesarean delivery. E Show 2 more As per SOGC 2022 guidelines, consider administering tranexamic acid as an adjunct to uterotonics in all patients with PPH. B As per ESICM 2021 guidelines, consider administering early tranexamic acid in critically ill patients with PPH. B As per BSH 2018 guidelines, do not withhold tranexamic acid in bleeding pregnant or postpartum patients based on the thromboelastography or rotational thromboelastometry parameters. D As per AAFP 2017 guidelines, administer tranexamic acid within the first 3 hours after birth to reduce mortality due to bleeding in patients with PPH. B As per RCOG 2017 guidelines, consider administering tranexamic acid in the management of PPH. C Recombinant activated factor VII: As per SOGC 2018 guidelines, do not use routine recombinant activated factor VII in patients with PPH. D As per RCOG 2017 guidelines, do not administer routine recombinant activated factor VII in the management of major PPH unless as part of a clinical trial. D Management of secondary postpartum hemorrhage: obtain vaginal microbiology testing (high vaginal and endocervical swabs) and initiate appropriate antimicrobial therapy when endometritis is suspected in patients presenting with secondary PPH. B Show 2 more 4. Inpatient care https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 4/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway Hemodynamic monitoring: Obtain the following monitoring and investigations in major PPH (blood loss > 1,000 mL) and ongoing hemorrhage or clinical shock: perform immediate venipuncture (20 mL) for cross-match (4 units minimum), CBC, coagulation screen including fibrinogen, renal and liver function for baseline monitor temperature every 15 minutes record pulse, BP and respiratory rate continuously (using oximeter, ECG and automated BP recording) place a Foley catheter to monitor urine output place 2 peripheral cannulae (14-gauge) consider monitoring arterial line (once appropriately experienced staff available for insertion) consider transfer to ICU once the bleeding is controlled or monitoring at high dependency unit on delivery suite, if appropriate record parameters on a MEOWS chart act and escalate promptly when abnormal scores from a MEOWS chart are observed document fluid balance, blood/blood products and procedures. B Coagulation monitoring: As per BSH 2022 guidelines, monitor patients with PPH to detect coagulopathy and/or low fibrinogen levels. Administer fibrinogen in patients with ongoing bleeding and fibrinogen levels < 2.0 g/L. B As per SOGC 2022 guidelines, measure fibrinogen levels in all patients with moderate-to- severe PPH, and replace accordingly if the level is < 2 g/L. A 5. Nonpharmacologic interventions Uterine massage/compression: As per FIGO 2022 guidelines: Perform uterine massage for the management of PPH. E Perform bimanual uterine compression or external aortic compression for the management of PPH due to uterine atony after vaginal birth as a temporizing measure until appropriate care is available. E As per SOGC 2022 guidelines, perform bimanual uterine compression and bladder emptying as first-line measures while waiting for pharmacologic agents to take effect. E Non-pneumatic anti-shock garment: apply a non-pneumatic anti-shock garment as a temporizing measure until appropriate care is available. E 6. Therapeutic procedures Blood product transfusion: As per SOGC 2022 guidelines: Administer 4 units of RBCs before other blood products in patients with active bleeding approaching the maximum allowable blood loss, unless the patient has a coagulation defect. B https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 5/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway Consider using a massive hemorrhage protocol with ratios of RBCs-to-FFP-to-platelets of 1:1:1: or 2:1:1, in the absence of timely laboratory results. B As per ESICM 2021 guidelines, consider administering restrictive transfusion, guided by presence of shock and symptoms potentially attributable to anemia (such as dyspnea, syncope, tachycardia, angina, neurological symptoms) or Hgb < 6 g/dL, rather than at a liberal target Hgb of 9 g/dL in patients with non-massive PPH. C As per BSH 2018 guidelines: Avoid administering fibrinogen to improve clinical hemostasis in patients with ongoing major PPH, if the FIBTEM A5 is > 12 mm. D Consider administering fibrinogen to improve clinical hemostasis in patients with major PPH, if FIBTEM A5 is < 7 mm, or < 12 mm with ongoing bleeding. C As per AAFP 2017 guidelines, use massive transfusion protocols to decrease the risk of dilutional coagulopathy and other PPH complications. B As per RCOG 2017 guidelines, insufficient evidence to recommend firm criteria for initiating RBC transfusion. Decide on initiating blood transfusion based on both clinical and hematological assessment. I Show 10 more Uterine packing: do not perform uterine packing for the treatment of PPH due to uterine atony after vaginal birth. D Uterine balloon tamponade: As per FIGO 2022 guidelines, perform uterine balloon tamponade to improve survival in patients with PPH due to uterine atony after ruling out retained products of conception or uterine rupture as a contributing factor in patients not responding to treatment using uterotonics or if uterotonics are unavailable. E As per SOGC 2022 guidelines, consider performing uterine tamponade for ongoing mild-to- moderate bleeding. C As per SOGC 2018 guidelines, consider performing uterine tamponade to temporarily control active PPH due to uterine atony failed to respond to medical therapy. C As per RCOG 2017 guidelines, consider performing intrauterine balloon tamponade as an appropriate first-line 'surgical' intervention in most patients where uterine atony is the only or main cause of hemorrhage. C Uterine artery embolization: As per FIGO 2022 guidelines, consider performing uterine artery embolization as another conservative management measure for PPH, if technical conditions and skilled human resources are available for its use. E As per SOGC 2022 guidelines, consider performing uterine artery embolization to manage PPH while not delaying hysterectomy in unstable patients. B 7. Surgical interventions Indications for surgery: https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 6/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway As per FIGO 2022 guidelines, perform surgical interventions, including compression suture techniques, uterine and hypogastric artery ligation, or hysterectomy, if bleeding does not stop despite treatment with uterotonics and other available conservative interventions (such as uterine massage, balloon tamponade). E As per SOGC 2022 guidelines, transfer patients with uterine inversion to an operating room for uterine relaxation and patient stabilization if immediate reversion is not possible. E Show 2 more As per SOGC 2018 guidelines, consider performing surgery, such as ligation of the internal iliac artery, compression sutures and hysterectomy, for the management of intractable PPH unresponsive to medical therapy. C As per RCOG 2017 guidelines, perform early surgical interventions if pharmacological measures fail to control the hemorrhage. B Show 3 more 8. Patient education Communication with the patient: Ensure communication with the patient and her birthing partner and provide clear information of what is happening. B Offer an opportunity to discuss the events surrounding the obstetric hemorrhage to the woman (possibly with her birthing partner) at a mutually convenient time. B 9. Preventative measures Management of risk factors: As per SOGC 2022 guidelines, identify both antenatal and postnatal anemia and treat it aggressively. A As per RCOG 2017 guidelines, modify care plans to address risk factors for PPH, which may present antenatally or intrapartum. B Show 3 more Active management of labor: offer active management of the third stage of labor in all women. A Prophylactic uterotonics: As per FIGO 2022 guidelines, administer uterotonics for the prevention of PPH during the third stage of labor in all births. Administer oxytocin (10 IU IV/IM) for the prevention of PPH for vaginal delivery and C-section. Pay attention to the oxytocin cold chain if oxytocin is used. E Show 3 more As per SOGC 2022 guidelines, consider administering prophylactic IM oxytocin in patients at low risk for PPH. B Show 5 more https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 7/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway As per SOGC 2018 guidelines, initiate active management of the third stage of labor in all patients to reduce the risk of PPH. A Show 8 more As per WHO 2018 guidelines, administer uterotonics for the prevention of PPH during the third stage of labor for all births. A Show 2 more As per WHO 2018 guidelines, do not use injectable prostaglandins (carboprost or sulprostone) for the prevention of PPH. D As per AAFP 2017 guidelines, initiate active management of the third stage of labor, preferably with oxytocin, to reduce the risks of PPH, postpartum maternal Hgb level < 9 g/d, and the need for manual removal of the placenta. A As per RCOG 2017 guidelines, offer routine prophylactic uterotonics in the management of the third stage of labor in all women to reduce the risk of PPH. A Show 4 more Prophylactic tranexamic acid: As per SOGC 2022 guidelines, consider administering prophylactic tranexamic acid in patients at high risk for PPH. B As per RCOG 2017 guidelines, consider administering IV tranexamic acid (0.5-1.0 g), in addition to oxytocin, at C-section to reduce blood loss in patients at increased risk of PPH. B Avoidance of episiotomy: avoid performing routine episiotomy unless urgent delivery is required and the perineum is thought to be a limiting factor. D Umbilical cord clamping: As per SOGC 2022 guidelines: Administer IV uterotonic medications after clamping the cord in preterm pregnancies due to concerns about a potential bolus of blood to preterm infants. B Administer IV uterotonic medications with delivery of the anterior shoulder of the final infant in term pregnancies with lower risk for bolus effects of blood, lower benefits of deferred cord clamping and higher risk for maternal PPH. B As per ACOG 2020 guidelines, recognize that delayed umbilical cord clamping does not increase the risk of PPH. E As per SOGC 2018 guidelines: Delay umbilical cord clamping by at least 60 seconds, whenever possible, in premature infants (< 37 weeks gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. A Weight the possible increased risk of neonatal jaundice requiring phototherapy against the physiological benefit of greater Hgb and iron levels up to 6 months of age conferred by delayed cord clamping in term newborns. B Placental cord drainage: insufficient evidence to recommend routine placental cord drainage for the prevention of PPH. I Delivery of placenta: https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 8/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway As per FIGO 2022 guidelines: Administer oxytocin IV/IM and perform controlled cord traction for removal of the placenta for the prevention of PPH in Cesarean delivery. E Do not perform controlled cord traction if skilled birth attendants are unavailable. D As per SOGC 2022 guidelines, undertake measures to expedite delivery of the placenta if the placenta has not been expelled spontaneously in the 30 minutes following delivery. A As per SOGC 2018 guidelines, insufficient evidence to recommend interventions to accelerate delivery of the placenta before the traditional 30-45 minutes to reduce the risk of PPH in an uncomplicated delivery without bleeding. I As per WHO 2018 guidelines, perform controlled cord traction, if skilled birth attendants are available, for vaginal births if the care provider and the patient regard a small reduction in blood loss and a small reduction in the duration of the third stage of labor as important. A Uterine massage: As per FIGO 2022 guidelines, do not perform sustained uterine massage for the prevention of PPH in patients receiving prophylactic oxytocin. D As per WHO 2018 guidelines, do not offer sustained uterine massage to prevent PPH in women received prophylactic oxytocin. D As per RCOG 2017 guidelines, do not offer uterine massage for prophylaxis of PPH. D 10. Quality improvement Hospital requirements and protocols: As per SOGC 2022 guidelines: Implement an obstetrical massive hemorrhage protocol, including defined roles and responsibilities of each team member. B Conduct simulation training with all multidisciplinary team members regularly, ideally by a trained facilitator. A As per SOGC 2018 guidelines, check PPH emergency equipment tray containing appropriate equipment regularly in all obstetric units. B As per AAFP 2017 guidelines, implement interdisciplinary team training with realistic simulation to improve perinatal safety. B As per RCOG 2017 guidelines, ensure that every maternity unit has a multidisciplinary protocol for the management of PPH. B Show 5 more Clinical findings Symptoms Past obstetric history Anxiety Macrosomia Low urine output Multiple gestation Pelvic pain Placenta previa https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 9/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway Rectal pain Polyhydramnios Rectal pressure Postpartum Vital signs Vascular exam Hypotension capillary refill time Signs of shock Gynecologic exam Tachycardia Tachypnea Excessive bleeding after childbirth Neurological exam Uterine atony Altered mental status Hematological findings Integument exam Coagulopathy Diaphoresis Studies 2018 TRAAP In women in labor who had a planned vaginal delivery of a singleton live fetus at 35 weeks of gestation and were receiving prophylactic oxytocin after delivery, tranexamic acid was not superior to placebo with respect to postpartum hemorrhage of at least 500 ml. Sentilhes L et al. N Engl J Med. 2018 Aug 23. 2017 WOMAN In women 16 years with a clinical diagnosis of postpartum hemorrhage after vaginal birth or C- section, tranexamic acid was superior to placebo with respect to death due to bleeding. WOMAN Trial Collaborators. Lancet. 2017 May 27. References 1. Maria Fernanda Escobar, Anwar H Nassar, Gerhard Theron et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022 Mar;157 Suppl 1 3 50. Open 2. Simon J Stanworth, Kerry Dowling, Nikki Curry et al. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. Open 3. Debbie Robinson, Melanie Basso, Cynthia Chan et al. Guideline No. 431 Postpartum Hemorrhage and Hemorrhagic Shock. J Obstet Gynaecol Can. 2022 Dec;44 12 1293 1310.e1. Open 4. No authors listed. Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG. 2017 Apr;124 5):e106-e149. Open 5. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183 Postpartum Hemorrhage. Obstet Gynecol. 2017 Oct;130 4):e168-e186. Open https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 10/11 6/29/23, 11:24 PM Postpartum hemorrhage Pathway 6. Dean Leduc, Vyta Senikas, Andr B Lalonde. No. 235 Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage. J Obstet Gynaecol Can. 2018 Dec;40 12):e841-e855. Open 7. Ann Evensen, Janice M Anderson, Patricia Fontaine. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017 Apr 1;95 7 442 449. Open 8. Nicola S Curry, Ross Davenport, Sue Pavord et al. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol. 2018 Sep;182 6 789 806. Open 9. No authors listed. Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion Summary, Number 814. Obstet Gynecol. 2020 Dec;136 6 1238 1239. Open 10. Alexander P J Vlaar, Joanna C Dionne, Sanne de Bruin et al. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2021 Dec;47 12 1368 1392. Open 11. No authors listed. WHO recommendations: Intrapartum care for a positive childbirth experience. WHO. 2018. Open 12. Sarah D McDonald, Michael Narvey, William Ehman et al. Guideline No. 424 Umbilical Cord Management in Preterm and Term Infants. J Obstet Gynaecol Can. 2022 Mar;44 3 313 322.e1. Open 13. No authors listed. WHO recommendations Uterotonics for the prevention of postpartum haemorrhage. WHO. 2018. Open 14. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage WOMAN an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27;389 10084 2105 2116. Open 15. Royal College of Obstetricians and Gynaecologists. Blood Transfusion in Obstetrics. RCOG. 2015 May. Open https://web.pathway.md/diseases/reclsTwSTOmNDOoEq 11/11