17:I[462708,["/_next/static/chunks/3yo3kiro3bmlp.js","/_next/static/chunks/3vr2wvd8f2efb.js","/_next/static/chunks/2vtmb68_vu-9t.js","/_next/static/chunks/2s8mt6_8wrpfo.js","/_next/static/chunks/3vkulz2i3l61y.js","/_next/static/chunks/1cqw2i1silz0i.js","/_next/static/chunks/14dbm3lm_t629.js","/_next/static/chunks/335_v2mb569ld.js","/_next/static/chunks/3ykn5ops9bft5.js","/_next/static/chunks/3cmavum774kjt.js","/_next/static/chunks/3th-0-a2xf9qs.js","/_next/static/chunks/0p0xpwde6kzmv.js","/_next/static/chunks/401-sxxnzbtf_.js","/_next/static/chunks/0wywtv698a1v0.js","/_next/static/chunks/2botzqwpnrzyj.js"],"ArticleReader"] 18:T6ce0,## Summary Postpartum hemorrhage (PPH) is acute bleeding after birth that threatens maternal physiology. Recognition and treatment must occur **before cardiovascular collapse**, because pregnancy-related physiologic reserve can mask severe blood loss until deterioration is advanced.[1] The 2025 WHO/FIGO/ICM consolidated guideline recommends initiating first-response PPH treatment within 24 hours of birth when either **objectively measured blood loss is ≥500 mL**, or **blood loss is ≥300 mL plus any abnormal hemodynamic sign**: pulse >100/min, shock index >1, systolic BP <100 mmHg, or diastolic BP <60 mmHg. Vigilance is especially important during the first 2 hours after birth.[1,2] Deliver first-response treatment **rapidly and concurrently**, not as a slow sequence. The core bundle is uterine massage, oxytocic therapy, tranexamic acid (TXA), IV isotonic crystalloid, genital-tract/source assessment, and escalation of care.[1,3] The practical cause framework is the **4 Ts**: **Tone** (uterine atony), **Trauma** (laceration, hematoma, uterine rupture or inversion), **Tissue** (retained placenta/fragments or placenta accreta spectrum), and **Thrombin** (coagulopathy).[1] For treatment, WHO recommends **IV oxytocin first line**. A commonly implemented regimen is **10 IU IV, diluted and administered slowly**, followed when needed by **10–20 IU diluted in crystalloid over approximately 4 hours**, titrated to uterine response and clinical status.[1] Give **TXA 1 g IV over 10 minutes as soon as PPH is diagnosed and within 3 hours of birth**; repeat **1 g IV** if bleeding continues after 30 minutes or restarts within 24 hours.[1,4] Do not persist with ineffective medical therapy while bleeding continues. Repair trauma, remove retained tissue when indicated, use uterine balloon tamponade for selected refractory atony, and proceed to operative or endovascular source control without delay when needed. Hysterectomy is lifesaving definitive treatment when conservative measures are failing or inappropriate.[1,5] > **Caution:** A normal early hemoglobin does not exclude major acute hemorrhage. Resuscitate according to active blood loss and physiology, not a delayed laboratory fall. ## Definition and diagnostic threshold ### Primary versus secondary PPH | Category | Timing | Common causes | |---|---|---| | **Primary PPH** | Within 24 hours of birth | Uterine atony, genital-tract trauma, retained placenta/tissue, coagulopathy, uterine inversion or rupture | | **Secondary PPH** | After 24 hours through the later postpartum period | Retained products, endometritis, placental-site subinvolution, vascular lesions, coagulation disorders | This article emphasizes **acute primary PPH**, where treatment delays can be rapidly fatal. ### WHO 2025 first-response trigger Initiate PPH treatment when the first of the following occurs within 24 hours after birth:[1,2] - objectively measured blood loss **≥500 mL**, or - objectively measured blood loss **≥300 mL** plus at least one: - pulse **>100/min**; - shock index **>1**; - systolic BP **<100 mmHg**; - diastolic BP **<60 mmHg**. Do not allow numeric thresholds to delay treatment when ongoing bleeding is visibly heavy, concealed hemorrhage is likely, or maternal physiology is deteriorating. The 2025 WHO individual-participant-data meta-analysis included more than 300,000 patients and found that a lower measured blood-loss threshold combined with abnormal hemodynamics improved sensitivity for predicting severe maternal outcomes compared with waiting for 500 mL alone.[2] ## Prevention and preparedness PPH is not fully predictable. Every delivery unit needs rapid access to uterotonics, TXA, IV access supplies, quantified blood-loss equipment, transfusion pathways, anesthesia, and operative escalation.[1,6] ### Preventive uterotonic therapy WHO recommends a quality-assured uterotonic for all births. **Oxytocin 10 IU IM or IV** is a standard preventive option.[1] When IV access is already present during vaginal birth, WHO recommends **10 IU IV diluted and administered slowly over 1–2 minutes** rather than a rapid IV injection.[1] Other WHO preventive options include **carbetocin 100 micrograms IM/IV** and **misoprostol 400 or 600 micrograms orally**, selected according to setting, cold-chain reliability, availability, and local protocol.[1] Routine prophylactic TXA for all vaginal or cesarean births is not recommended by WHO; TXA is a core treatment once PPH is diagnosed.[1] ### Antenatal and intrapartum risk reduction - identify and treat anemia; - identify placenta previa and placenta accreta spectrum risk; - review anticoagulant or bleeding-disorder history; - plan delivery location and blood access for high-risk patients; - use objective blood-loss measurement after birth; - prepare a multidisciplinary hemorrhage plan for known accreta spectrum disease or prior catastrophic PPH.[1,6] ## Etiology: the 4 Ts | Cause | Mechanism | Key clues | Immediate direction | |---|---|---|---| | **Tone** | Poor myometrial contraction | Boggy enlarged uterus, diffuse bleeding | Massage, oxytocin, additional uterotonics, empty bladder, escalate if refractory | | **Trauma** | Cervical/vaginal/perineal laceration, hematoma, rupture, inversion | Persistent bleeding despite firm uterus; focal pain/swelling; shock out of proportion to visible loss | Inspect source, repair trauma, treat inversion/rupture urgently | | **Tissue** | Retained placenta/fragments or abnormal adherence | Incomplete placenta, persistent atony/bleeding, failure of placental separation | Remove retained tissue when appropriate; suspect accreta if abnormally adherent | | **Thrombin** | Pre-existing or acquired coagulopathy | Diffuse oozing, abnormal coagulation, abruption/sepsis/amniotic fluid embolism context | Balanced blood-component therapy and treatment of cause | More than one cause may coexist. Reassess all four categories if bleeding continues after an apparently successful intervention. ## Risk factors ### Atony - prolonged or precipitous labor; - uterine overdistension from multiple gestation, polyhydramnios, or large fetus; - chorioamnionitis; - prolonged oxytocin exposure; - high parity; - fibroids; - prior PPH; - magnesium exposure or general anesthesia in relevant settings. ### Tissue / abnormal placentation - placenta previa; - prior cesarean delivery or uterine surgery; - known or suspected placenta accreta spectrum; - previous retained placenta; - accessory placental lobe. ### Trauma - operative vaginal birth; - episiotomy; - macrosomia; - precipitous birth; - cesarean birth; - uterine rupture risk factors. ### Coagulopathy - placental abruption; - severe preeclampsia or HELLP syndrome; - sepsis; - amniotic fluid embolism; - massive hemorrhage with dilution/consumption; - anticoagulant therapy; - inherited bleeding disorder. Risk factors should increase preparedness, but absence of risk factors must not lower surveillance. ## Recognition in the first minutes ### Measure and trend - objective cumulative blood loss; - pulse and blood pressure; - **shock index = heart rate / systolic blood pressure**; - respiratory rate and oxygen saturation; - mental status; - uterine tone and size; - ongoing vaginal bleeding; - temperature when infection is relevant.[1,2] ### Look for concealed bleeding Red flags include: - tachycardia or hypotension disproportionate to visible blood loss; - severe abdominal or pelvic pain; - abdominal distension; - vaginal or broad-ligament hematoma; - concern for uterine rupture; - persistent shock after external bleeding appears controlled. > **Clinical pearl:** A firm uterus with continued brisk vaginal bleeding should immediately shift attention toward genital-tract trauma or another non-atony source. ## First-response bundle The E-MOTIVE model combines objective blood-loss detection with concurrent treatment. In the cluster-randomized trial across 80 hospitals and 210,132 vaginal births, the primary composite of severe PPH, laparotomy for bleeding, or death from bleeding occurred in **1.6%** with the intervention versus **4.3%** with usual care (risk ratio 0.40, 95% CI 0.32–0.50).[3] | Component | Immediate action | Purpose | Reassess | |---|---|---|---| | **Uterine massage** | Massage a boggy uterus until contraction improves | Treat atony | Tone and blood-loss rate | | **Oxytocic** | Start IV oxytocin; add another appropriate uterotonic if needed | Restore sustained uterine contraction | Tone, bleeding, adverse effects | | **TXA** | 1 g IV over 10 min, within 3 h of birth | Antifibrinolytic treatment | Ongoing bleeding at 30 min; repeat if indicated | | **IV fluid** | Isotonic crystalloid while blood products are mobilized | Support perfusion | BP, pulse, mental status, urine output | | **Genital/source assessment** | Identify laceration, hematoma, retained tissue, inversion, rupture, or other source | Direct source control | Is the cause identified and controlled? | | **Escalation** | Senior obstetrics, anesthesia, transfusion service, operating room, critical care, interventional radiology when appropriate | Prevent delay to definitive care | Is bleeding controlled now? | ## Team activation and resuscitation ### Mobilize early For major or rapidly progressing bleeding, activate: - senior obstetric care; - anesthesia; - experienced nursing/midwifery support; - blood bank/transfusion medicine; - operating room; - critical care; - interventional radiology when relevant and immediately available. Use closed-loop communication, explicit role assignment, time-stamped blood-loss totals, and a named decision-maker for escalation. ### Access and monitoring For significant ongoing PPH: - obtain two large-bore peripheral IV lines when feasible; - continuous pulse oximetry and ECG monitoring; - frequent BP measurement; - urinary catheter when urine output will guide resuscitation; - active warming of the patient and blood products where indicated. ### Initial laboratory tests Send and repeat according to severity: - CBC; - type and crossmatch; - PT/INR and aPTT; - fibrinogen; - electrolytes and renal function; - ionized calcium during substantial transfusion; - blood gas and lactate in significant shock; - viscoelastic coagulation testing where validated and available. The hemoglobin concentration may remain deceptively preserved early in acute hemorrhage. ## Fluids and blood products ### Crystalloid WHO recommends **isotonic crystalloid** rather than colloid for initial PPH resuscitation.[1] Use enough crystalloid to support circulation while blood products are prepared, but avoid replacing major hemorrhage with large crystalloid volumes alone because dilution, hypothermia, edema, and coagulopathy can worsen. ### Major hemorrhage / massive transfusion Activate the local obstetric major-hemorrhage protocol when there is: - ongoing rapid blood loss; - shock or deteriorating shock index; - anticipated need for substantial blood products; - failure of first-response measures; - operative source control underway or imminent. Early emergency transfusion may be required before laboratory results return. Blood-component ratios and laboratory/viscoelastic targets vary by institution; follow the local massive-transfusion protocol while repeatedly reassessing active bleeding. ### Fibrinogen Fibrinogen can fall early in severe obstetric hemorrhage. Low fibrinogen predicts severe bleeding and should prompt replacement with cryoprecipitate or fibrinogen concentrate according to the local protocol and product availability. ### Calcium Citrate in transfused products can produce hypocalcemia, impairing coagulation and myocardial function. Monitor ionized calcium during substantial transfusion and replace calcium according to the major-hemorrhage pathway. ### Warming and acid-base management Prevent the reinforcing cycle of **hemorrhage → hypoperfusion → acidosis → hypothermia → coagulopathy → further hemorrhage**. Active warming and rapid source control are core resuscitative measures. ## Uterotonic therapy ### Oxytocin: first-line treatment WHO recommends **IV oxytocin** as the first-line uterotonic for established PPH.[1] A commonly implemented WHO regimen is: - **10 IU IV**, diluted and administered slowly over **1–2 minutes**, or diluted in a small crystalloid volume and infused over 5–10 minutes; - avoid rapid IV injection because of hypotension and tachycardia risk; - after initial control, **10–20 IU diluted in crystalloid over approximately 4 hours** may be used, titrated to uterine response and clinical condition.[1] Exact infusion concentrations vary among health systems. ### Additional uterotonics If oxytocin is unavailable or insufficient, WHO supports an ergot agent, an oxytocin–ergometrine combination, or a prostaglandin drug, including **misoprostol 800 micrograms sublingually**.[1] | Drug/class | Common treatment role | Major caution | |---|---|---| | Misoprostol | Alternative prostaglandin therapy; WHO-supported 800 micrograms SL | Fever and shivering; avoid unplanned repeated high-dose use | | Ergometrine / methylergometrine | Potent uterotonic in selected patients | Avoid in hypertension or preeclampsia because of vasoconstrictive effects | | Carboprost | Useful second-line uterotonic where available | Avoid or use strong caution in asthma because of bronchospasm risk | Specific methylergometrine and carboprost dosing varies by national labeling and local protocol; use the institutional hemorrhage pathway. Do not cycle through repeated uterotonic doses while the patient is deteriorating. Persistent bleeding requires renewed source assessment and escalation. ## Tranexamic acid WHO recommends early IV TXA in addition to standard care for PPH after vaginal or cesarean birth:[1] - **1 g IV** using a 100 mg/mL preparation, administered at **1 mL/minute over 10 minutes**; - give as soon as possible and **within 3 hours of birth**; - if bleeding continues after **30 minutes**, or restarts within **24 hours**, give a second **1 g IV** dose.[1,4] The 3-hour window starts at the time of birth. WHO does not support routine initiation beyond 3 hours because benefit has not been demonstrated and effect estimates do not favor late treatment.[1] TXA is not a uterotonic and does not replace oxytocin or source control. It is appropriate regardless of whether bleeding is caused by uterine atony or genital trauma, unless a clear contraindication to antifibrinolytic therapy exists.[1] ## Cause-specific source control ### Tone: uterine atony Actions occur in parallel: - uterine massage; - oxytocin; - TXA; - empty a distended bladder; - add an appropriate second-line uterotonic; - bimanual uterine compression as a temporizing maneuver when bleeding is severe; - proceed to balloon tamponade or surgery when medical therapy fails.[1,5] ### Trauma Persistent bleeding with a well-contracted uterus requires inspection for laceration or concealed hematoma. **Laceration:** obtain exposure, identify the bleeding site, and repair promptly. Transfer to an operating room when visualization, anesthesia, or repair requirements exceed bedside capability. **Hematoma:** suspect when severe pelvic/perineal pain, pressure symptoms, hemodynamic deterioration, or falling hemoglobin is disproportionate to visible loss. Expanding or unstable hematomas require operative or endovascular control. **Uterine inversion:** replace the uterus urgently while resuscitation proceeds. Uterine relaxation/anesthesia may be needed for replacement; uterotonics are then used after the uterus is restored to position. **Uterine rupture:** requires immediate laparotomy and repair or hysterectomy based on injury and maternal physiology. ### Tissue **Retained placenta or placental fragments:** initiate the PPH bundle while arranging manual or operative removal when indicated. Reassess for trauma and atony after removal. **Placenta accreta spectrum:** do not forcibly detach a placenta that is abnormally adherent. In a planned accreta pathway, cesarean hysterectomy with placenta left in situ is a common definitive strategy. Unexpected accreta with hemorrhage requires rapid senior surgical, anesthesia, and transfusion escalation. ### Thrombin: coagulopathy Treat the underlying cause and provide blood components/fibrinogen guided by clinical bleeding, laboratory results, and validated point-of-care testing where available. Potential settings include: - massive hemorrhage; - placental abruption; - amniotic fluid embolism; - sepsis; - severe preeclampsia/HELLP; - anticoagulant exposure; - inherited bleeding disorders. ## Uterine balloon tamponade WHO recommends uterine balloon tamponade for PPH due to uterine atony after vaginal birth when first-line treatment fails **only in systems where key safety conditions are met**:[1] - immediate access to surgical intervention if needed; - access to blood products; - a functioning first-line PPH protocol; - reasonable exclusion of retained tissue and trauma; - trained personnel; - close monitoring with rapid escalation capability. Balloon placement must not postpone definitive surgery in an unstable patient. WHO does **not** recommend routine uterine packing with gauze for PPH because benefit is unproven and concealed ongoing hemorrhage may delay escalation.[1] ## Operative and endovascular control ### Uterine artery embolization Embolization can control hemorrhage and preserve the uterus when skilled interventional radiology is immediately available and the patient's physiology permits the procedure. Do not transfer an unstable, exsanguinating patient away from timely operative control merely because embolization is theoretically possible.[5] ### Surgical options Depending on cause and urgency: - repair laceration or rupture; - remove retained tissue; - uterine compression sutures; - uterine or internal iliac artery ligation in selected settings; - hysterectomy.[5] ### Hysterectomy Hysterectomy is definitive lifesaving treatment, not a failure of conservative care. Escalate before profound shock, acidosis, hypothermia, and disseminated coagulopathy make surgery more dangerous. Strong indications include uncontrollable bleeding from placenta accreta spectrum, uterine rupture, or refractory atony when conservative options are ineffective or inappropriate. ## Reassessment during active hemorrhage PPH management is iterative. Reassess continuously rather than waiting for a scheduled interval. | Domain | Reassess | Escalation signal | |---|---|---| | Blood loss | Objective cumulative volume and current rate | Continued rapid loss despite first-response bundle | | Uterus | Tone, size, position | Persistent atony or inversion | | Hemodynamics | HR, BP, shock index, mental status, urine output | Rising shock index, falling BP, confusion, oliguria | | Respiratory status | RR, oxygen saturation, lung findings | Pulmonary edema, transfusion reaction, worsening shock | | Coagulation | Fibrinogen, platelets, PT/aPTT, viscoelastic results | Progressive coagulopathy | | Metabolic state | Lactate, pH, ionized calcium, temperature | Acidosis, hypocalcemia, hypothermia | | Source control | Effect of each intervention | No prompt reduction in bleeding | Ask explicitly after each intervention: **Is the bleeding controlled? If not, what is the next source-control action now?** ## Secondary postpartum hemorrhage Bleeding after the first 24 hours requires a different differential: - retained products of conception; - endometritis; - subinvolution of the placental site; - uterine artery pseudoaneurysm or arteriovenous lesion; - coagulation disorder; - less common gestational trophoblastic or other pathology. ### Assessment - stabilize hemodynamics first; - CBC and type/screen or crossmatch according to severity; - pelvic assessment; - pelvic ultrasound, often with Doppler when a vascular lesion is possible; - infection testing when clinically indicated. > **Caution:** Blind uterine curettage can be dangerous when a vascular lesion such as a pseudoaneurysm or arteriovenous malformation is plausible. Obtain appropriate imaging and specialist input. ## Special situations ### Preeclampsia or significant hypertension Avoid ergometrine/methylergometrine when vasoconstriction creates unacceptable hypertensive risk. Be cautious with large crystalloid volumes because pulmonary edema risk is increased. ### Asthma Avoid or use strong caution with carboprost because bronchospasm may occur. ### Placenta accreta spectrum Antenatal recognition and planned delivery in a multidisciplinary center improve preparedness. Ensure blood products, senior pelvic surgery, anesthesia, and critical care are available before delivery when high-grade disease is suspected. ### Refusal of blood products Antenatal planning is essential: optimize hemoglobin and iron stores, document which products and procedures are acceptable, plan blood conservation strategies, and involve anesthesia, hematology, ethics, and surgical teams as appropriate. ### Low-resource settings WHO designed the 2025 guideline for adaptation across resource settings. Priorities include objective blood-loss measurement, reliable uterotonic and TXA access, rapid referral pathways, staff training, and dependable access to blood and surgery.[1,6] ## Disposition and post-hemorrhage care After bleeding control, continue monitoring until recurrence risk, hemodynamics, coagulation, and organ perfusion are stable. Assess and treat: - postpartum anemia and iron deficiency; - acute kidney injury; - transfusion complications; - venous thromboembolism risk once hemostasis is secure; - lactation impact and recovery needs; - psychological trauma after severe hemorrhage or emergency hysterectomy. Before transfer from high-acuity care, document cumulative blood loss, interventions, transfusion totals, source of hemorrhage, ongoing uterotonic/antibiotic needs, laboratory trends, and a clear trigger for re-escalation. ## Acute management pathway ```text Birth completed ↓ Objective blood-loss measurement + vital signs + uterine tone ↓ WHO PPH trigger reached? ≥500 mL measured blood loss OR ≥300 mL + pulse >100 / shock index >1 / SBP <100 / DBP <60 ↓ ACTIVATE OBSTETRIC HEMORRHAGE RESPONSE ↓ Concurrent first response • uterine massage • IV oxytocin • TXA 1 g IV over 10 min within 3 h of birth • isotonic crystalloid + mobilize blood products • genital/source assessment • senior escalation ↓ Identify 4 Ts: Tone / Trauma / Tissue / Thrombin ↓ Cause-specific source control ↓ Bleeding or shock persists? ├─ Yes → major hemorrhage protocol + mechanical/operative/endovascular control │ + do not delay hysterectomy when required └─ No → continued monitoring + correct anemia/coagulopathy + reassess recurrence risk ``` ## Acute management checklist - [ ] Quantify blood loss objectively. - [ ] Record pulse, BP, shock index, respiratory status, and mental status. - [ ] Assess uterine tone and placental completeness. - [ ] Activate the hemorrhage team early. - [ ] Massage a boggy uterus. - [ ] Give IV oxytocin. - [ ] Give TXA 1 g IV over 10 minutes within 3 hours of birth. - [ ] Establish large-bore IV access and start isotonic crystalloid. - [ ] Send CBC, crossmatch, coagulation studies, fibrinogen, calcium, and gas/lactate as indicated. - [ ] Mobilize blood products early for major hemorrhage. - [ ] Identify Tone, Trauma, Tissue, and Thrombin causes. - [ ] Repair trauma or remove retained tissue when appropriate. - [ ] Escalate to balloon, embolization, surgery, or hysterectomy without ineffective delays. - [ ] Warm the patient and monitor calcium during substantial transfusion. - [ ] Reassess bleeding and physiology after every intervention. ## Common pitfalls | Pitfall | Why it is unsafe | Better approach | |---|---|---| | Waiting for 500 mL despite abnormal hemodynamics | Delays treatment in early physiologic compromise | Use the ≥300 mL + abnormal hemodynamic sign trigger | | Visual estimation alone | Commonly underestimates blood loss | Use objective measurement | | Giving treatments serially with long waits | Wastes time while hemorrhage continues | Deliver the first-response bundle concurrently | | Repeating uterotonics without finding the source | Misses laceration, retained tissue, rupture, or coagulopathy | Reassess the 4 Ts immediately | | Waiting for hemoglobin to fall | Early hemoglobin may be normal | Treat active hemorrhage and shock | | Replacing major blood loss mainly with crystalloid | Promotes dilution, hypothermia, and coagulopathy | Use blood products early when major hemorrhage is evident | | Delaying definitive surgery | Shock and coagulopathy become harder to reverse | Move to source control as soon as medical therapy is failing | | Giving TXA after the evidence-based window as routine initiation | Benefit is time dependent | Give as soon as possible and within 3 hours of birth | ## Current guideline and evidence changes The **2025 WHO/FIGO/ICM consolidated guideline** introduced a major operational shift toward objective measurement and earlier treatment at **≥300 mL plus abnormal hemodynamics**, while retaining ≥500 mL as an independent trigger.[1,2] The guideline also consolidates uterine massage, uterotonic therapy, TXA, IV fluid, source assessment, and escalation into a **concurrent first-response bundle**, building on the E-MOTIVE trial's reduction in severe PPH-related outcomes.[1,3] WHO's **2026 implementation guide** focuses on translating these recommendations into national protocols, procurement, training, monitoring, and health-system workflows.[6] Jurisdictions still differ in exact uterotonic concentrations, transfusion ratios, balloon devices, and operative sequencing. Follow the locally standardized obstetric hemorrhage protocol while preserving the core evidence-based principles: objective detection, early concurrent therapy, rapid source control, and decisive escalation.[1,5] ## References 1. World Health Organization; International Federation of Gynecology and Obstetrics; International Confederation of Midwives. **Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage.** Geneva: World Health Organization; 2025. ISBN 978-92-4-011563-7. https://www.who.int/publications/i/item/9789240115637 2. Gallos I, Williams CR, Price MJ, et al. Prognostic accuracy of clinical markers of postpartum bleeding in predicting maternal mortality or severe morbidity: a WHO individual participant data meta-analysis. *The Lancet.* 2025. doi:10.1016/S0140-6736(25)01639-3. PMID:41056961. 3. Gallos ID, Papadopoulou A, Man R, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage. *New England Journal of Medicine.* 2023;389:11-21. doi:10.1056/NEJMoa2303966. 4. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage: an international, randomised, double-blind, placebo-controlled trial. *The Lancet.* 2017;389:2105-2116. doi:10.1016/S0140-6736(17)30638-4. 5. Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. *International Journal of Gynecology & Obstetrics.* 2022;157(Suppl 1):3-50. doi:10.1002/ijgo.14116. PMCID:PMC9313855. 6. World Health Organization; FIGO; ICM; Jhpiego; UNFPA. **Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage: implementation guide.** Geneva: World Health Organization; 2026. ISBN 978-92-4-011611-5. https://www.who.int/publications/i/item/978924011611519:T6d00,## Summary Postpartum hemorrhage (PPH) is acute bleeding after birth that threatens maternal physiology. Recognition and treatment must occur **before cardiovascular collapse**, because pregnancy-related physiologic reserve can mask severe blood loss until deterioration is advanced.[1] The 2025 WHO/FIGO/ICM consolidated guideline recommends initiating first-response PPH treatment within 24 hours of birth when either **objectively measured blood loss is ≥500 mL**, or **blood loss is ≥300 mL plus any abnormal hemodynamic sign**: pulse >100/min, shock index >1, systolic BP <100 mmHg, or diastolic BP <60 mmHg. Vigilance is especially important during the first 2 hours after birth.[1,2] Deliver first-response treatment **rapidly and concurrently**, not as a slow sequence. The core bundle is uterine massage, oxytocic therapy, tranexamic acid (TXA), IV isotonic crystalloid, genital-tract/source assessment, and escalation of care.[1,3] The practical cause framework is the **4 Ts**: **Tone** (uterine atony), **Trauma** (laceration, hematoma, uterine rupture or inversion), **Tissue** (retained placenta/fragments or placenta accreta spectrum), and **Thrombin** (coagulopathy).[1] For treatment, WHO recommends **IV oxytocin first line**. A commonly implemented regimen is **10 IU IV, diluted and administered slowly**, followed when needed by **10–20 IU diluted in crystalloid over approximately 4 hours**, titrated to uterine response and clinical status.[1] Give **TXA 1 g IV over 10 minutes as soon as PPH is diagnosed and within 3 hours of birth**; repeat **1 g IV** if bleeding continues after 30 minutes or restarts within 24 hours.[1,4] Do not persist with ineffective medical therapy while bleeding continues. Repair trauma, remove retained tissue when indicated, use uterine balloon tamponade for selected refractory atony, and proceed to operative or endovascular source control without delay when needed. Hysterectomy is lifesaving definitive treatment when conservative measures are failing or inappropriate.[1,5] > **Caution:** A normal early hemoglobin does not exclude major acute hemorrhage. Resuscitate according to active blood loss and physiology, not a delayed laboratory fall. ## Definition and diagnostic threshold ### Primary versus secondary PPH | Category | Timing | Common causes | |---|---|---| | **Primary PPH** | Within 24 hours of birth | Uterine atony, genital-tract trauma, retained placenta/tissue, coagulopathy, uterine inversion or rupture | | **Secondary PPH** | After 24 hours through the later postpartum period | Retained products, endometritis, placental-site subinvolution, vascular lesions, coagulation disorders | This article emphasizes **acute primary PPH**, where treatment delays can be rapidly fatal. ### WHO 2025 first-response trigger Initiate PPH treatment when the first of the following occurs within 24 hours after birth:[1,2] - objectively measured blood loss **≥500 mL**, or - objectively measured blood loss **≥300 mL** plus at least one: - pulse **>100/min**; - shock index **>1**; - systolic BP **<100 mmHg**; - diastolic BP **<60 mmHg**. Do not allow numeric thresholds to delay treatment when ongoing bleeding is visibly heavy, concealed hemorrhage is likely, or maternal physiology is deteriorating. The 2025 WHO individual-participant-data meta-analysis included more than 300,000 patients and found that a lower measured blood-loss threshold combined with abnormal hemodynamics improved sensitivity for predicting severe maternal outcomes compared with waiting for 500 mL alone.[2] ## Prevention and preparedness PPH is not fully predictable. Every delivery unit needs rapid access to uterotonics, TXA, IV access supplies, quantified blood-loss equipment, transfusion pathways, anesthesia, and operative escalation.[1,6] ### Preventive uterotonic therapy WHO recommends a quality-assured uterotonic for all births. **Oxytocin 10 IU IM or IV** is a standard preventive option.[1] When IV access is already present during vaginal birth, WHO recommends **10 IU IV diluted and administered slowly over 1–2 minutes** rather than a rapid IV injection.[1] Other WHO preventive options include **carbetocin 100 micrograms IM/IV** and **misoprostol 400 or 600 micrograms orally**, selected according to setting, cold-chain reliability, availability, and local protocol.[1] Routine prophylactic TXA for all vaginal or cesarean births is not recommended by WHO; TXA is a core treatment once PPH is diagnosed.[1] ### Antenatal and intrapartum risk reduction - identify and treat anemia; - identify placenta previa and placenta accreta spectrum risk; - review anticoagulant or bleeding-disorder history; - plan delivery location and blood access for high-risk patients; - use objective blood-loss measurement after birth; - prepare a multidisciplinary hemorrhage plan for known accreta spectrum disease or prior catastrophic PPH.[1,6] ## Etiology: the 4 Ts | Cause | Mechanism | Key clues | Immediate direction | |---|---|---|---| | **Tone** | Poor myometrial contraction | Boggy enlarged uterus, diffuse bleeding | Massage, oxytocin, additional uterotonics, empty bladder, escalate if refractory | | **Trauma** | Cervical/vaginal/perineal laceration, hematoma, rupture, inversion | Persistent bleeding despite firm uterus; focal pain/swelling; shock out of proportion to visible loss | Inspect source, repair trauma, treat inversion/rupture urgently | | **Tissue** | Retained placenta/fragments or abnormal adherence | Incomplete placenta, persistent atony/bleeding, failure of placental separation | Remove retained tissue when appropriate; suspect accreta if abnormally adherent | | **Thrombin** | Pre-existing or acquired coagulopathy | Diffuse oozing, abnormal coagulation, abruption/sepsis/amniotic fluid embolism context | Balanced blood-component therapy and treatment of cause | More than one cause may coexist. Reassess all four categories if bleeding continues after an apparently successful intervention. ## Risk factors ### Atony - prolonged or precipitous labor; - uterine overdistension from multiple gestation, polyhydramnios, or large fetus; - chorioamnionitis; - prolonged oxytocin exposure; - high parity; - fibroids; - prior PPH; - magnesium exposure or general anesthesia in relevant settings. ### Tissue / abnormal placentation - placenta previa; - prior cesarean delivery or uterine surgery; - known or suspected placenta accreta spectrum; - previous retained placenta; - accessory placental lobe. ### Trauma - operative vaginal birth; - episiotomy; - macrosomia; - precipitous birth; - cesarean birth; - uterine rupture risk factors. ### Coagulopathy - placental abruption; - severe preeclampsia or HELLP syndrome; - sepsis; - amniotic fluid embolism; - massive hemorrhage with dilution/consumption; - anticoagulant therapy; - inherited bleeding disorder. Risk factors should increase preparedness, but absence of risk factors must not lower surveillance. ## Recognition in the first minutes ### Measure and trend - objective cumulative blood loss; - pulse and blood pressure; - **shock index = heart rate / systolic blood pressure**; - respiratory rate and oxygen saturation; - mental status; - uterine tone and size; - ongoing vaginal bleeding; - temperature when infection is relevant.[1,2] ### Look for concealed bleeding Red flags include: - tachycardia or hypotension disproportionate to visible blood loss; - severe abdominal or pelvic pain; - abdominal distension; - vaginal or broad-ligament hematoma; - concern for uterine rupture; - persistent shock after external bleeding appears controlled. > **Clinical pearl:** A firm uterus with continued brisk vaginal bleeding should immediately shift attention toward genital-tract trauma or another non-atony source. ## First-response bundle The E-MOTIVE model combines objective blood-loss detection with concurrent treatment. In the cluster-randomized trial across 80 hospitals and 210,132 vaginal births, the primary composite of severe PPH, laparotomy for bleeding, or death from bleeding occurred in **1.6%** with the intervention versus **4.3%** with usual care (risk ratio 0.40, 95% CI 0.32–0.50).[3] | Component | Immediate action | Purpose | Reassess | |---|---|---|---| | **Uterine massage** | Massage a boggy uterus until contraction improves | Treat atony | Tone and blood-loss rate | | **Oxytocic** | Start IV oxytocin; add another appropriate uterotonic if needed | Restore sustained uterine contraction | Tone, bleeding, adverse effects | | **TXA** | 1 g IV over 10 min, within 3 h of birth | Antifibrinolytic treatment | Ongoing bleeding at 30 min; repeat if indicated | | **IV fluid** | Isotonic crystalloid while blood products are mobilized | Support perfusion | BP, pulse, mental status, urine output | | **Genital/source assessment** | Identify laceration, hematoma, retained tissue, inversion, rupture, or other source | Direct source control | Is the cause identified and controlled? | | **Escalation** | Senior obstetrics, anesthesia, transfusion service, operating room, critical care, interventional radiology when appropriate | Prevent delay to definitive care | Is bleeding controlled now? | ## Team activation and resuscitation ### Mobilize early For major or rapidly progressing bleeding, activate: - senior obstetric care; - anesthesia; - experienced nursing/midwifery support; - blood bank/transfusion medicine; - operating room; - critical care; - interventional radiology when relevant and immediately available. Use closed-loop communication, explicit role assignment, time-stamped blood-loss totals, and a named decision-maker for escalation. ### Access and monitoring For significant ongoing PPH: - obtain two large-bore peripheral IV lines when feasible; - continuous pulse oximetry and ECG monitoring; - frequent BP measurement; - urinary catheter when urine output will guide resuscitation; - active warming of the patient and blood products where indicated. ### Initial laboratory tests Send and repeat according to severity: - CBC; - type and crossmatch; - PT/INR and aPTT; - fibrinogen; - electrolytes and renal function; - ionized calcium during substantial transfusion; - blood gas and lactate in significant shock; - viscoelastic coagulation testing where validated and available. The hemoglobin concentration may remain deceptively preserved early in acute hemorrhage. ## Fluids and blood products ### Crystalloid WHO recommends **isotonic crystalloid** rather than colloid for initial PPH resuscitation.[1] Use enough crystalloid to support circulation while blood products are prepared, but avoid replacing major hemorrhage with large crystalloid volumes alone because dilution, hypothermia, edema, and coagulopathy can worsen. ### Major hemorrhage / massive transfusion Activate the local obstetric major-hemorrhage protocol when there is: - ongoing rapid blood loss; - shock or deteriorating shock index; - anticipated need for substantial blood products; - failure of first-response measures; - operative source control underway or imminent. Early emergency transfusion may be required before laboratory results return. Blood-component ratios and laboratory/viscoelastic targets vary by institution; follow the local massive-transfusion protocol while repeatedly reassessing active bleeding. ### Fibrinogen Fibrinogen can fall early in severe obstetric hemorrhage. Low fibrinogen predicts severe bleeding and should prompt replacement with cryoprecipitate or fibrinogen concentrate according to the local protocol and product availability. ### Calcium Citrate in transfused products can produce hypocalcemia, impairing coagulation and myocardial function. Monitor ionized calcium during substantial transfusion and replace calcium according to the major-hemorrhage pathway. ### Warming and acid-base management Prevent the reinforcing cycle of **hemorrhage → hypoperfusion → acidosis → hypothermia → coagulopathy → further hemorrhage**. Active warming and rapid source control are core resuscitative measures. ## Uterotonic therapy ### Oxytocin: first-line treatment WHO recommends **IV oxytocin** as the first-line uterotonic for established PPH.[1] A commonly implemented WHO regimen is: - **10 IU IV**, diluted and administered slowly over **1–2 minutes**, or diluted in a small crystalloid volume and infused over 5–10 minutes; - avoid rapid IV injection because of hypotension and tachycardia risk; - after initial control, **10–20 IU diluted in crystalloid over approximately 4 hours** may be used, titrated to uterine response and clinical condition.[1] Exact infusion concentrations vary among health systems. ### Additional uterotonics If oxytocin is unavailable or insufficient, WHO supports an ergot agent, an oxytocin–ergometrine combination, or a prostaglandin drug, including **misoprostol 800 micrograms sublingually**.[1] | Drug/class | Common treatment role | Major caution | |---|---|---| | Misoprostol | Alternative prostaglandin therapy; WHO-supported 800 micrograms SL | Fever and shivering; avoid unplanned repeated high-dose use | | Ergometrine / methylergometrine | Potent uterotonic in selected patients | Avoid in hypertension or preeclampsia because of vasoconstrictive effects | | Carboprost | Useful second-line uterotonic where available | Avoid or use strong caution in asthma because of bronchospasm risk | Specific methylergometrine and carboprost dosing varies by national labeling and local protocol; use the institutional hemorrhage pathway. Do not cycle through repeated uterotonic doses while the patient is deteriorating. Persistent bleeding requires renewed source assessment and escalation. ## Tranexamic acid WHO recommends early IV TXA in addition to standard care for PPH after vaginal or cesarean birth:[1] - **1 g IV** using a 100 mg/mL preparation, administered at **1 mL/minute over 10 minutes**; - give as soon as possible and **within 3 hours of birth**; - if bleeding continues after **30 minutes**, or restarts within **24 hours**, give a second **1 g IV** dose.[1,4] The 3-hour window starts at the time of birth. WHO does not support routine initiation beyond 3 hours because benefit has not been demonstrated and effect estimates do not favor late treatment.[1] TXA is not a uterotonic and does not replace oxytocin or source control. It is appropriate regardless of whether bleeding is caused by uterine atony or genital trauma, unless a clear contraindication to antifibrinolytic therapy exists.[1] ## Cause-specific source control ### Tone: uterine atony Actions occur in parallel: - uterine massage; - oxytocin; - TXA; - empty a distended bladder; - add an appropriate second-line uterotonic; - bimanual uterine compression as a temporizing maneuver when bleeding is severe; - proceed to balloon tamponade or surgery when medical therapy fails.[1,5] ### Trauma Persistent bleeding with a well-contracted uterus requires inspection for laceration or concealed hematoma. **Laceration:** obtain exposure, identify the bleeding site, and repair promptly. Transfer to an operating room when visualization, anesthesia, or repair requirements exceed bedside capability. **Hematoma:** suspect when severe pelvic/perineal pain, pressure symptoms, hemodynamic deterioration, or falling hemoglobin is disproportionate to visible loss. Expanding or unstable hematomas require operative or endovascular control. **Uterine inversion:** replace the uterus urgently while resuscitation proceeds. Uterine relaxation/anesthesia may be needed for replacement; uterotonics are then used after the uterus is restored to position. **Uterine rupture:** requires immediate laparotomy and repair or hysterectomy based on injury and maternal physiology. ### Tissue **Retained placenta or placental fragments:** initiate the PPH bundle while arranging manual or operative removal when indicated. Reassess for trauma and atony after removal. **Placenta accreta spectrum:** do not forcibly detach a placenta that is abnormally adherent. In a planned accreta pathway, cesarean hysterectomy with placenta left in situ is a common definitive strategy. Unexpected accreta with hemorrhage requires rapid senior surgical, anesthesia, and transfusion escalation. ### Thrombin: coagulopathy Treat the underlying cause and provide blood components/fibrinogen guided by clinical bleeding, laboratory results, and validated point-of-care testing where available. Potential settings include: - massive hemorrhage; - placental abruption; - amniotic fluid embolism; - sepsis; - severe preeclampsia/HELLP; - anticoagulant exposure; - inherited bleeding disorders. ## Uterine balloon tamponade WHO recommends uterine balloon tamponade for PPH due to uterine atony after vaginal birth when first-line treatment fails **only in systems where key safety conditions are met**:[1] - immediate access to surgical intervention if needed; - access to blood products; - a functioning first-line PPH protocol; - reasonable exclusion of retained tissue and trauma; - trained personnel; - close monitoring with rapid escalation capability. Balloon placement must not postpone definitive surgery in an unstable patient. WHO does **not** recommend routine uterine packing with gauze for PPH because benefit is unproven and concealed ongoing hemorrhage may delay escalation.[1] ## Operative and endovascular control ### Uterine artery embolization Embolization can control hemorrhage and preserve the uterus when skilled interventional radiology is immediately available and the patient's physiology permits the procedure. Do not transfer an unstable, exsanguinating patient away from timely operative control merely because embolization is theoretically possible.[5] ### Surgical options Depending on cause and urgency: - repair laceration or rupture; - remove retained tissue; - uterine compression sutures; - uterine or internal iliac artery ligation in selected settings; - hysterectomy.[5] ### Hysterectomy Hysterectomy is definitive lifesaving treatment, not a failure of conservative care. Escalate before profound shock, acidosis, hypothermia, and disseminated coagulopathy make surgery more dangerous. Strong indications include uncontrollable bleeding from placenta accreta spectrum, uterine rupture, or refractory atony when conservative options are ineffective or inappropriate. ## Reassessment during active hemorrhage PPH management is iterative. Reassess continuously rather than waiting for a scheduled interval. | Domain | Reassess | Escalation signal | |---|---|---| | Blood loss | Objective cumulative volume and current rate | Continued rapid loss despite first-response bundle | | Uterus | Tone, size, position | Persistent atony or inversion | | Hemodynamics | HR, BP, shock index, mental status, urine output | Rising shock index, falling BP, confusion, oliguria | | Respiratory status | RR, oxygen saturation, lung findings | Pulmonary edema, transfusion reaction, worsening shock | | Coagulation | Fibrinogen, platelets, PT/aPTT, viscoelastic results | Progressive coagulopathy | | Metabolic state | Lactate, pH, ionized calcium, temperature | Acidosis, hypocalcemia, hypothermia | | Source control | Effect of each intervention | No prompt reduction in bleeding | Ask explicitly after each intervention: **Is the bleeding controlled? If not, what is the next source-control action now?** ## Secondary postpartum hemorrhage Bleeding after the first 24 hours requires a different differential: - retained products of conception; - endometritis; - subinvolution of the placental site; - uterine artery pseudoaneurysm or arteriovenous lesion; - coagulation disorder; - less common gestational trophoblastic or other pathology. ### Assessment - stabilize hemodynamics first; - CBC and type/screen or crossmatch according to severity; - pelvic assessment; - pelvic ultrasound, often with Doppler when a vascular lesion is possible; - infection testing when clinically indicated. > **Caution:** Blind uterine curettage can be dangerous when a vascular lesion such as a pseudoaneurysm or arteriovenous malformation is plausible. Obtain appropriate imaging and specialist input. ## Special situations ### Preeclampsia or significant hypertension Avoid ergometrine/methylergometrine when vasoconstriction creates unacceptable hypertensive risk. Be cautious with large crystalloid volumes because pulmonary edema risk is increased. ### Asthma Avoid or use strong caution with carboprost because bronchospasm may occur. ### Placenta accreta spectrum Antenatal recognition and planned delivery in a multidisciplinary center improve preparedness. Ensure blood products, senior pelvic surgery, anesthesia, and critical care are available before delivery when high-grade disease is suspected. ### Refusal of blood products Antenatal planning is essential: optimize hemoglobin and iron stores, document which products and procedures are acceptable, plan blood conservation strategies, and involve anesthesia, hematology, ethics, and surgical teams as appropriate. ### Low-resource settings WHO designed the 2025 guideline for adaptation across resource settings. Priorities include objective blood-loss measurement, reliable uterotonic and TXA access, rapid referral pathways, staff training, and dependable access to blood and surgery.[1,6] ## Disposition and post-hemorrhage care After bleeding control, continue monitoring until recurrence risk, hemodynamics, coagulation, and organ perfusion are stable. Assess and treat: - postpartum anemia and iron deficiency; - [acute kidney injury](/library/acute-kidney-injury); - transfusion complications; - venous thromboembolism risk once hemostasis is secure; - lactation impact and recovery needs; - psychological trauma after severe hemorrhage or emergency hysterectomy. Before transfer from high-acuity care, document cumulative blood loss, interventions, transfusion totals, source of hemorrhage, ongoing uterotonic/antibiotic needs, laboratory trends, and a clear trigger for re-escalation. ## Acute management pathway ```text Birth completed ↓ Objective blood-loss measurement + vital signs + uterine tone ↓ WHO PPH trigger reached? ≥500 mL measured blood loss OR ≥300 mL + pulse >100 / shock index >1 / SBP <100 / DBP <60 ↓ ACTIVATE OBSTETRIC HEMORRHAGE RESPONSE ↓ Concurrent first response • uterine massage • IV oxytocin • TXA 1 g IV over 10 min within 3 h of birth • isotonic crystalloid + mobilize blood products • genital/source assessment • senior escalation ↓ Identify 4 Ts: Tone / Trauma / Tissue / Thrombin ↓ Cause-specific source control ↓ Bleeding or shock persists? ├─ Yes → major hemorrhage protocol + mechanical/operative/endovascular control │ + do not delay hysterectomy when required └─ No → continued monitoring + correct anemia/coagulopathy + reassess recurrence risk ``` ## Acute management checklist - [ ] Quantify blood loss objectively. - [ ] Record pulse, BP, shock index, respiratory status, and mental status. - [ ] Assess uterine tone and placental completeness. - [ ] Activate the hemorrhage team early. - [ ] Massage a boggy uterus. - [ ] Give IV oxytocin. - [ ] Give TXA 1 g IV over 10 minutes within 3 hours of birth. - [ ] Establish large-bore IV access and start isotonic crystalloid. - [ ] Send CBC, crossmatch, coagulation studies, fibrinogen, calcium, and gas/lactate as indicated. - [ ] Mobilize blood products early for major hemorrhage. - [ ] Identify Tone, Trauma, Tissue, and Thrombin causes. - [ ] Repair trauma or remove retained tissue when appropriate. - [ ] Escalate to balloon, embolization, surgery, or hysterectomy without ineffective delays. - [ ] Warm the patient and monitor calcium during substantial transfusion. - [ ] Reassess bleeding and physiology after every intervention. ## Common pitfalls | Pitfall | Why it is unsafe | Better approach | |---|---|---| | Waiting for 500 mL despite abnormal hemodynamics | Delays treatment in early physiologic compromise | Use the ≥300 mL + abnormal hemodynamic sign trigger | | Visual estimation alone | Commonly underestimates blood loss | Use objective measurement | | Giving treatments serially with long waits | Wastes time while hemorrhage continues | Deliver the first-response bundle concurrently | | Repeating uterotonics without finding the source | Misses laceration, retained tissue, rupture, or coagulopathy | Reassess the 4 Ts immediately | | Waiting for hemoglobin to fall | Early hemoglobin may be normal | Treat active hemorrhage and shock | | Replacing major blood loss mainly with crystalloid | Promotes dilution, hypothermia, and coagulopathy | Use blood products early when major hemorrhage is evident | | Delaying definitive surgery | Shock and coagulopathy become harder to reverse | Move to source control as soon as medical therapy is failing | | Giving TXA after the evidence-based window as routine initiation | Benefit is time dependent | Give as soon as possible and within 3 hours of birth | ## Current guideline and evidence changes The **2025 WHO/FIGO/ICM consolidated guideline** introduced a major operational shift toward objective measurement and earlier treatment at **≥300 mL plus abnormal hemodynamics**, while retaining ≥500 mL as an independent trigger.[1,2] The guideline also consolidates uterine massage, uterotonic therapy, TXA, IV fluid, source assessment, and escalation into a **concurrent first-response bundle**, building on the E-MOTIVE trial's reduction in severe PPH-related outcomes.[1,3] WHO's **2026 implementation guide** focuses on translating these recommendations into national protocols, procurement, training, monitoring, and health-system workflows.[6] Jurisdictions still differ in exact uterotonic concentrations, transfusion ratios, balloon devices, and operative sequencing. Follow the locally standardized obstetric hemorrhage protocol while preserving the core evidence-based principles: objective detection, early concurrent therapy, rapid source control, and decisive escalation.[1,5] ## References 1. World Health Organization; International Federation of Gynecology and Obstetrics; International Confederation of Midwives. **Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage.** Geneva: World Health Organization; 2025. ISBN 978-92-4-011563-7. https://www.who.int/publications/i/item/9789240115637 2. Gallos I, Williams CR, Price MJ, et al. Prognostic accuracy of clinical markers of postpartum bleeding in predicting maternal mortality or severe morbidity: a WHO individual participant data meta-analysis. *The Lancet.* 2025. doi:10.1016/S0140-6736(25)01639-3. PMID:41056961. 3. Gallos ID, Papadopoulou A, Man R, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage. *New England Journal of Medicine.* 2023;389:11-21. doi:10.1056/NEJMoa2303966. 4. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage: an international, randomised, double-blind, placebo-controlled trial. *The Lancet.* 2017;389:2105-2116. doi:10.1016/S0140-6736(17)30638-4. 5. Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. *International Journal of Gynecology & Obstetrics.* 2022;157(Suppl 1):3-50. doi:10.1002/ijgo.14116. PMCID:PMC9313855. 6. World Health Organization; FIGO; ICM; Jhpiego; UNFPA. **Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage: implementation guide.** Geneva: World Health Organization; 2026. ISBN 978-92-4-011611-5. https://www.who.int/publications/i/item/97892401161157:["$","$L17",null,{"article":{"id":"medical-postpartum-hemorrhage","title":"Postpartum Hemorrhage","slug":"postpartum-hemorrhage","description":"Postpartum hemorrhage (PPH) is acute bleeding after birth that threatens maternal physiology. 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