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Postpartum Haemorrhage (PPH)
PPH is defined as blood loss ≥500ml after vaginal delivery (≥1000ml after caesarean). Primary PPH occurs within 24h (causes: 4 Ts — Tone 70%, Tissue 20%, Trauma 10%, Thrombin <1%). Major PPH ≥1500ml activates the Major Haemorrhage Protocol. Early…
RCOG Green-top Guideline 52
The pathway
1 · Call for help
Shout for help immediately. Senior midwife, registrar, anaesthetist, haematologist on call. Activate MHP if ≥1500ml. Two large-bore IV cannulae.
2 · Uterine massage & bimanual compression
Rub up the uterus (fundal massage). Bimanual compression if atonic. Empty bladder (catheterise).
3 · Uterotonics — the 4 Ts (Tone)
- Oxytocin 5 units slow IV bolus. Then oxytocin 40 units in 500ml saline over 4h
- Add ergometrine 500 micrograms IM (avoid in hypertension)
- Carboprost 250 micrograms IM every 15 min × 8 doses (avoid in asthma)
4 · Tranexamic acid
1g IV over 10 min within 3h of delivery (WOMAN trial). Repeat at 30 min if ongoing bleeding. Reduces mortality from haemorrhage.
5 · Tissue & Trauma
Examine for retained placenta (manual removal under GA if required), genital tract trauma (suture lacerations), uterine rupture, or uterine inversion.
6 · Surgical escalation
- Balloon tamponade (Bakri)
- Uterine compression sutures (B-Lynch)
- Uterine artery ligation
- Radiological embolisation
- Hysterectomy as last resort
Drugs
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Oxytocin | 5 units IV then 40 units/500ml | IV | Slow bolus (avoid hypotension). Infusion over 4h. |
| Ergometrine | 500 micrograms | IM (or slow IV) | Avoid in hypertension, pre-eclampsia, cardiac disease. |
| Carboprost (Hemabate) | 250 micrograms | IM every 15 min | Max 8 doses. Contraindicated in asthma. |
| Tranexamic acid | 1g | IV over 10 min | Within 3h of delivery. Repeat 1g at 30 min if still bleeding. |
| Misoprostol | 800 micrograms | Sublingual/PR | Alternative if no IV access. |
When to escalate
PPH ≥1000ml and continuing — activate MHP, O-negative blood if needed,Haemodynamic instability — anaesthetics, theatre, blood products,Suspected uterine rupture — emergency laparotomy,Failed medical management — balloon tamponade, then surgical/interventional radiology
Reference: RCOG Green-top Guideline No. 52 (PPH) 2016 / WOMAN Trial
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