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Postpartum Haemorrhage

Educational clinical summary of Postpartum Haemorrhage for doctors and students: definition, workup, management, and key caveats. Not a substitute for guidelines.

Maintained by Dr. Vivek Karn Review process: editorial policy

Disclaimer: This document provides comprehensive medical information for clinicians, modeled after authoritative clinical references. It is intended for educational and informational purposes only and does not constitute medical advice. Clinical decisions must always be made by a qualified healthcare professional, taking into account the individual patient's condition, available resources, and local protocols. This information should not be used as a substitute for professional medical judgment.

Overview

  • Definition: Postpartum haemorrhage (PPH) is traditionally defined as blood loss of 500 mL or more after vaginal delivery or 1000 mL or more after caesarean section within 24 hours of birth. A more clinically relevant definition, often used by professional organizations like the American College of Obstetricians and Gynecologists (ACOG), also includes any blood loss that causes signs or symptoms of hypovolemia (e.g., orthostatic hypotension, tachycardia, oliguria) regardless of the measured volume.
    • Primary PPH: Occurs within the first 24 hours after birth.
    • Secondary PPH: Occurs more than 24 hours and up to 12 weeks postpartum.
  • Epidemiology: PPH is a leading cause of maternal mortality worldwide, accounting for approximately 25% of all maternal deaths.
    • Global incidence: Estimated at 6% of all births, with higher rates in low-resource settings.
    • Developed countries: Incidence ranges from 1-5%.
    • Risk factors can be identified in approximately 75% of cases, but PPH can occur in any patient, even with no identifiable risk factors.
  • Classification:
    • Mild PPH: 500-1000 mL blood loss.
    • Moderate PPH: 1000-2000 mL blood loss, or blood loss causing signs of hypovolemic shock.
    • Severe PPH: Greater than 2000 mL blood loss, or blood loss necessitating blood transfusion, or causing significant hemodynamic instability, or requiring surgical intervention.

Pathophysiology

  • Mechanism: The underlying causes of PPH are commonly remembered by the "4 Ts":
    1. Tone (Uterine Atony): Accounts for approximately 70-80% of all PPH cases. After placental delivery, the myometrial muscle fibers contract to constrict the spiral arteries and venules, preventing excessive bleeding. Uterine atony occurs when the uterus fails to contract adequately, leaving these vessels open.
    2. Trauma: Accounts for approximately 10-20% of PPH cases. This includes lacerations of the cervix, vagina, perineum, or uterus, and uterine rupture. Hematomas (vulvar, vaginal, retroperitoneal) can also contribute significantly.
    3. Tissue (Retained Placental Tissue): Accounts for approximately 5-10% of PPH cases. Fragments of placenta or membranes remaining in the uterus prevent complete myometrial contraction. This can also include placenta accreta spectrum disorders.
    4. Thrombin (Coagulopathy): Accounts for approximately 1% of PPH cases. Pre-existing coagulopathies (e.g., von Willebrand disease, hemophilia, factor deficiencies), or acquired coagulopathies (e.g., severe pre-eclampsia/HELLP syndrome, DIC secondary to severe PPH, amniotic fluid embolism, sepsis, massive transfusion) impair the body's ability to form clots.
  • Risk Factors:
    • Antepartum:
      • Previous PPH
      • Multiple gestation
      • Polyhydramnios
      • Grand multiparity (>5 deliveries)
      • Fetal macrosomia (>4000g)
      • Placenta previa or accreta spectrum disorders
      • Coagulopathies (inherited or acquired)
      • Anemia
      • Asian ethnicity
      • Obesity (BMI >30)
      • Uterine fibroids
    • Intrapartum:
      • Prolonged labor (>12 hours)
      • Precipitous labor (<3 hours)
      • Induction or augmentation of labor with oxytocin
      • Chorioamnionitis
      • General anesthesia (relaxes uterine tone)
      • Uterine overdistension (macrosomia, multiple gestation, polyhydramnios)
      • Operative vaginal delivery (forceps, vacuum extraction)
      • Caesarean section (especially repeat C-sections)
      • Manual removal of placenta
      • Uterine inversion
      • High parity
      • Magnesium sulfate use (tocolytic effect)
  • Protective Factors:
    • Active Management of Third Stage of Labor (AMTSL): Routine administration of uterotonics (e.g., oxytocin) immediately after birth, controlled cord traction, and uterine massage after placental delivery. This is the cornerstone of PPH prevention.
    • Early identification and management of risk factors.
    • Correction of severe anemia prenatally.
    • Availability of a well-trained team and necessary resources.

Clinical Presentation

Signs and Symptoms

  • Cardinal Features:
    • Vaginal Bleeding: Often the first and most obvious sign. Can be heavy and continuous, or slow but persistent. Crucially, visible blood loss is often underestimated.
    • Signs of Hypovolemic Shock: Tachycardia, hypotension, pallor, cold extremities, altered mental status.
  • Early Signs:
    • Increased Heart Rate: Typically >100 bpm.
    • Mild Hypotension: Systolic BP <90-100 mmHg, or a significant drop from baseline.
    • Increased Capillary Refill Time: >2 seconds.
    • Oliguria: Urine output <30 mL/hour.
    • Uterine Atony: A boggy, poorly contracted uterus upon palpation.
  • Advanced Signs:
    • Profound Hypotension: Systolic BP <70 mmHg.
    • Severe Tachycardia: >120 bpm.
    • Altered Mental Status: Confusion, agitation, lethargy, unresponsiveness.
    • Anuria: Absence of urine output.
    • Disseminated Intravascular Coagulation (DIC): Bleeding from multiple sites (IV sites, gums, nose).
    • Air Hunger/Dyspnea.
  • Atypical Presentations:
    • Concealed Haemorrhage: Bleeding into a retroperitoneal space, broad ligament, or vaginal/vulvar hematoma may not be immediately obvious externally. Patients may present with severe pain, pressure, or signs of shock without significant visible blood loss.
    • Delayed Presentation of Shock: Young, healthy individuals may compensate well for significant blood loss, delaying overt signs of shock until a large volume has been lost. Close monitoring of vital signs and estimated blood loss is crucial.
    • Secondary PPH: Typically presents with irregular or heavy vaginal bleeding, sometimes with passage of clots or tissue, often accompanied by uterine tenderness or fever (if infection is present).

Physical Examination

  • Inspection:
    • Perineum and Vulva: Inspect for lacerations, active bleeding, expanding hematomas.
    • Vaginal Exam: Inspect vaginal walls for lacerations.
    • Uterine Fundus: Visually assess for height and position.
    • Blood Loss: Estimate amount of blood on pads, drapes, floor; weigh soiled materials (1 mL blood ≈ 1 g).
  • Palpation:
    • Uterine Fundus: Palpate the fundus to assess tone, size, and position. A soft, boggy, enlarged uterus above the umbilicus suggests atony. A firm, well-contracted uterus may point to other causes (trauma, retained tissue).
    • Abdomen: Assess for tenderness, distension, guarding.
    • Pulses: Assess peripheral pulses for rate, rhythm, and strength.
  • Special Tests:
    • Manual Uterine Exploration: Under appropriate anesthesia, a hand is inserted into the uterine cavity to feel for retained placental tissue, uterine rupture, or significant lacerations.
    • Speculum Examination: To visualize cervical and vaginal lacerations.
    • Bimanual Uterine Compression: A direct intervention, but also diagnostic for uterine atony (feel for contraction response).

Diagnostic Approach

History Taking

  • Key Questions:
    • Predisposing Factors: Ask about previous PPH, multiple gestation, large baby, prolonged labor, use of uterotonic agents during labor, manual removal of placenta, history of uterine fibroids, coagulopathies.
    • Symptoms: Onset and nature of bleeding (sudden gush, continuous trickle), passage of clots/tissue, pain level, dizziness, weakness, palpitations, any pressure sensation.
    • Delivery Details: Type of delivery (vaginal, C-section), estimated blood loss during delivery, condition of placenta (intact?), interventions during third stage.
    • Medications: Anticoagulants, NSAIDs, magnesium sulfate.
    • Allergies.
  • Red Flags:
    • Rapidly expanding hematoma in the vulva or vagina.
    • Sudden onset of severe, unremitting abdominal pain after delivery (suggests uterine rupture or concealed hemorrhage).
    • Massive, uncontrolled vaginal bleeding unresponsive to initial fundal massage and uterotonics.
    • Signs of hypovolemic shock despite seemingly modest blood loss.
    • Absence of uterine contraction despite aggressive fundal massage and uterotonics.
    • Difficulty delivering the placenta or palpable uterine tenderness (suggests retained products or uterine inversion).

Laboratory Tests

  • First-Line:
    • Complete Blood Count (CBC): Hemoglobin, hematocrit (baseline and trending), platelet count. Important for assessing severity and guiding transfusion.
    • Coagulation Profile: Prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen level. Fibrinogen is a critical early marker of coagulopathy in PPH; levels <200 mg/dL (or <1.5-2.0 g/L) are concerning and predictive of severe bleeding and need for transfusion.
    • Type and Crossmatch (or Type and Screen): Essential for preparing blood products. O negative blood should be available for immediate transfusion in emergencies.
  • Confirmatory:
    • Fibrinogen: Repeat levels to monitor for worsening coagulopathy.
    • Viscoelastic Hemostatic Assays (VHA): Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) can provide rapid, real-time assessment of coagulation status and guide targeted component therapy.
  • Monitoring:
    • Serial CBC: To track hemoglobin and hematocrit response to resuscitation.
    • Serial Coagulation Profile: To monitor for ongoing coagulopathy or response to treatment.
    • Electrolytes and Renal Function (BUN, creatinine): To assess for end-organ damage from hypoperfusion or guide fluid management.
    • Arterial Blood Gas (ABG): In severe cases, to assess acid-base status and oxygenation.

Imaging

  • Recommended:
    • Pelvic Ultrasound: Can identify retained placental fragments, intra-abdominal fluid collections (hematomas), or uterine anomalies. Useful for secondary PPH, or when retained tissue is suspected despite manual exploration.
  • Advanced:
    • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI): Rarely used in acute, severe PPH due to time constraints and need for patient stability. May be considered for diagnosing complex retroperitoneal hematomas or uterine artery pseudoaneurysms in stable patients with ongoing bleeding.
    • Angiography: Indicated for diagnostic and therapeutic purposes (uterine artery embolization) in cases of ongoing bleeding refractory to medical and surgical management, particularly when arterial source is suspected (e.g., trauma, pseudoaneurysm).

Management

Acute Management

Goal: Rapidly identify source of bleeding, restore hemodynamic stability, and stop the hemorrhage. "Call for Help, Act Quickly, Follow a Protocol."

  • Immediate (First-hour interventions):
    1. Call for help: Activate PPH protocol/emergency team (obstetrician, anesthesiologist, nurses, blood bank).
    2. A, B, C's: Assess airway, breathing, circulation.
    3. Two large-bore IVs: Establish 14- or 16-gauge IV access immediately.
    4. Fluid Resuscitation: Rapid infusion of crystalloids (Lactated Ringer's or normal saline) – initially 2-3 liters, or 3:1 ratio for estimated blood loss.
    5. Fundal Massage: Immediately and continuously massage the uterine fundus to stimulate contraction.
    6. Uterotonics: Administer first-line uterotonic (Oxytocin).
    7. Identify Source (4 Ts): Simultaneously assess for Tone, Trauma, Tissue, Thrombin.
  • Stabilization (Early management priorities):
    1. Blood Products: Initiate massive transfusion protocol if blood loss is severe or ongoing. Target ratios of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelets (1:1:1 or 1:1:2).
    2. Oxygen: Administer 10-15 L/min via non-rebreather mask.
    3. Temperature Management: Keep patient warm to prevent coagulopathy worsening.
    4. Urinary Catheter: Insert a Foley catheter to monitor urine output (indicator of renal perfusion and fluid status).
    5. Consider Tranexamic Acid (TXA): If administered within 3 hours of bleeding onset for PPH due to any cause, 1 gram IV over 10 minutes (repeat in 30 minutes if bleeding continues).
  • Emergency (Crisis management):
    1. Uterine Balloon Tamponade: Insertion of an intrauterine balloon (e.g., Bakri balloon, Sengstaken-Blakemore tube, condom catheter) to apply direct pressure to the uterine walls and control bleeding from atony.
    2. Surgical Intervention:
      • Uterine Artery Ligation: Bilateral ligation of uterine arteries (and potentially utero-ovarian arteries).
      • B-Lynch Suture: A compression suture applied to the uterus to mechanically compress the atonic uterus.
      • Internal Iliac Artery Ligation: More complex, higher morbidity, less effective than uterine artery ligation.
      • Hysterectomy: Life-saving measure for intractable bleeding, especially with placenta accreta spectrum disorders or severe uterine trauma/rupture.
    3. Interventional Radiology: Uterine artery embolization (UAE) by an interventional radiologist can be highly effective in stable patients or when other measures fail, preserving fertility. Requires patient stability for transport.
    4. Manual Removal of Placenta: If retained.
    5. Uterine Exploration/Repair: For lacerations or rupture.

Chronic Management

  • Pharmacological:
    • Iron Supplementation: For postpartum anemia (e.g., Ferrous sulfate 325 mg PO BID-TID) for several weeks/months.
    • Pain Management: As needed for recovery from surgical interventions or hematomas.
  • Non-pharmacological:
    • Nutritional Support: Encourage iron-rich diet.
    • Psychological Support: Address potential for PTSD, anxiety, depression related to a traumatic birth experience.
    • Rest and Activity Modification: As advised by clinicians based on recovery needs.
  • Monitoring:
    • Follow-up CBC: To assess resolution of anemia.
    • Mental Health Screening: For mood disorders.
    • Contraception Counseling: Discuss future pregnancies and risks.

Treatment Algorithms

A stepwise approach is essential for PPH management. While specific protocols vary, the general escalation is:

  • First-Line (Initial Response - within minutes):

    1. Call for help/Activate PPH protocol.
    2. Fundal massage and bimanual compression.
    3. Administer Oxytocin: 10 units IM or 10-40 units in 500-1000 mL IV crystalloid solution (infuse 10-20 units over 10-20 min, then 10-20 units/hour).
    4. Establish IV access, initiate rapid fluid resuscitation.
    5. Identify cause (4 Ts).
    6. Type & Crossmatch, initiate baseline labs.
    7. Tranexamic Acid (TXA): 1g IV over 10 min, within 3 hours of birth. Repeat in 30 min if bleeding persists.

  • Second-Line (Persistent Bleeding - within 15-30 minutes):

    1. Additional Uterotonics:
      • Methylergonovine (Methergine): 0.2 mg IM every 2-4 hours (max 5 doses). Contraindicated in hypertension/pre-eclampsia.
      • Carboprost (Hemabate): 0.25 mg IM every 15-90 minutes (max 8 doses). Contraindicated in asthma/pulmonary hypertension.
      • Misoprostol: 600-1000 mcg rectally (can also be oral/sublingual).
    2. Uterine Balloon Tamponade: Insert and inflate an intrauterine balloon.
    3. Consider Manual Removal of Placenta (if retained).
    4. Consider Uterine Exploration and Repair of lacerations/rupture.
    5. Initiate Massive Transfusion Protocol if clinically indicated.

  • Refractory Cases (Bleeding not controlled - within 30-60 minutes):

    1. Surgical Intervention:
      • Compression sutures (B-Lynch).
      • Uterine artery ligation.
      • Internal iliac artery ligation.
      • Hysterectomy (last resort, life-saving).
    2. Interventional Radiology: Uterine artery embolization (if available and patient stable for transport).
    3. Advanced Coagulation Management: Fibrinogen concentrate, Factor VIIa (off-label, controversial, use only after addressing all other coagulopathy and mechanical issues).

Complications

  • Common:
    • Anemia: Iron-deficiency anemia due to acute blood loss, leading to fatigue, weakness, and impaired recovery.
    • Blood Transfusion Reactions: Allergic reactions, febrile non-hemolytic reactions, TRALI (Transfusion-Related Acute Lung Injury).
  • Serious:
    • Disseminated Intravascular Coagulation (DIC): A life-threatening condition where systemic activation of coagulation leads to widespread microvascular thrombosis and consumption of clotting factors, resulting in further bleeding.
    • Acute Respiratory Distress Syndrome (ARDS): Can result from massive transfusion, fluid overload, or shock.
    • Sheehan's Syndrome: Postpartum pituitary necrosis due to severe hypovolemic shock, leading to hypopituitarism (e.g., failure of lactation, amenorrhea, adrenal insufficiency). Rare.
    • Hysterectomy: Required in severe, refractory cases, leading to loss of fertility.
    • Multi-organ Failure: Kidney injury, liver failure due to prolonged hypoperfusion.
    • Maternal Death: PPH remains a leading cause of maternal mortality globally.
  • Long-term:
    • Psychological Impact: Post-traumatic stress disorder (PTSD), depression, anxiety related to the traumatic birth experience.
    • Fertility Issues: After hysterectomy or severe uterine injury.
    • Chronic Anemia: If not adequately treated.

Prognosis

  • Factors:
    • Timeliness of diagnosis and intervention: Rapid response is critical.
    • Etiology of PPH: Atony generally has a better prognosis with timely uterotonics than uterine rupture or invasive placentation.
    • Severity of blood loss: More severe blood loss increases morbidity and mortality.
    • Availability of resources: Access to blood products, surgical expertise, and interventional radiology.
    • Patient comorbidities: Pre-existing cardiac disease, coagulopathies, or severe anemia worsen prognosis.
  • Survival: With modern management protocols and resources, maternal mortality from PPH in developed countries is low, but significant morbidity persists. Globally, it remains a major contributor to maternal deaths.
  • Quality of Life: Can be significantly affected by long-term complications such as chronic anemia, psychological distress (PTSD), and the impact of hysterectomy on fertility and body image. Emotional support and counseling are crucial for recovery.

Prevention

  • Primary (Preventing initial occurrence):
    1. Active Management of the Third Stage of Labor (AMTSL):
      • Uterotonic Administration: Administer oxytocin (10 units IM or 10-20 units IV over 1 min, or 10-40 units in 500-1000 mL IV crystalloid) immediately after birth of the anterior shoulder or by 1 minute after birth. Oxytocin is the first choice.
      • Controlled Cord Traction (CCT): Apply sustained gentle traction on the umbilical cord while simultaneously providing counter-traction above the symphysis pubis to support the uterus.
      • Uterine Massage: Gently massage the fundus through the abdomen after placental delivery for at least 15-30 seconds, then intermittently for the first hour.
    2. Identification and Management of Risk Factors:
      • Antenatal screening for anemia and treatment if present.
      • Close monitoring during labor for prolonged labor, rapid labor, or uterine overdistension.
      • Careful management of high-risk conditions (e.g., multiple gestation, placenta previa).
    3. Delayed Cord Clamping: Recommended for term and preterm infants (30-60 seconds) for improved infant outcomes, does not significantly increase PPH risk.
  • Secondary (Early detection and intervention):
    1. Readiness: Having PPH protocols, a PPH cart (with medications, equipment), and regular drills/simulations.
    2. Recognition: Accurate estimation of blood loss (quantitative measurement preferred over visual estimation). Routine weighing of blood-soaked materials (1g = 1mL).
    3. Response: Rapid activation of the PPH team, timely administration of uterotonics, and escalation of care.
    4. Monitoring: Close observation of vital signs and uterine tone postpartum.
  • Tertiary (Preventing complications):
    1. Prompt treatment of anemia.
    2. Psychological support and counseling.
    3. Rehabilitation and follow-up care for long-term sequelae.

Special Populations

  • Pregnancy: This topic is inherently related to pregnancy and postpartum.
  • Comorbidities:
    • Coagulopathies (e.g., von Willebrand disease, factor deficiencies, patients on anticoagulants): Requires early collaboration with hematology, availability of specific factor concentrates or reversal agents (e.g., prothrombin complex concentrate, vitamin K, cryoprecipitate). Avoidance of IM injections where possible.
    • Cardiac Disease: Patients with cardiac conditions require careful fluid management to prevent overload while maintaining perfusion. Close monitoring of cardiac function is essential.
    • Severe Pre-eclampsia/HELLP Syndrome: These conditions predispose to coagulopathy (thrombocytopenia, abnormal liver enzymes) and can complicate PPH management. Platelet transfusion may be needed for severe thrombocytopenia before invasive procedures.
    • Morbid Obesity: Poses challenges for physical examination (fundal massage, bimanual compression), surgical access, and IV access. Increased risk of PPH.
    • Placenta Accreta Spectrum (PAS): Highly specialized management, often involving planned caesarean hysterectomy, multi-disciplinary team, and blood product availability.

Clinical Pearls

  • Diagnostic:
    • "Don't Wait, Act Fast": PPH can progress rapidly. Early recognition and aggressive management are key.
    • Underestimation is Common: Visual estimation of blood loss is often inaccurate and typically underestimates the actual volume lost. Quantify blood loss by weighing sponges and collecting blood in calibrated drapes.
    • Know Your 4 Ts: Always systematically consider Tone, Trauma, Tissue, and Thrombin to identify the cause of bleeding.
    • Vitals Can Be Deceiving: Young, healthy patients may maintain normal vital signs until a significant amount of blood (up to 30-40% of blood volume) has been lost. Trends are more important than single readings.
    • Listen to the Patient: Reports of dizziness, weakness, or "feeling strange" should be taken seriously, even if vitals seem stable initially.
  • Treatment:
    • Call for Help Early: Do not hesitate to activate the PPH team/protocol. A multi-disciplinary approach improves outcomes.
    • Establish Two Large-Bore IVs: Critical for rapid fluid and blood product administration.
    • Uterotonics First: Oxytocin is the first-line uterotonic for atony. Have a clear algorithm for second-line agents.
    • Tranexamic Acid (TXA): Administer 1g IV within 3 hours of birth for any cause of PPH. It reduces mortality.
    • Balloon Tamponade is Effective: Intrauterine balloon tamponade is often underutilized but can be a life-saving, fertility-sparing intervention for atonic PPH.
    • Don't Delay Blood Transfusion: If signs of shock or significant blood loss are present, initiate massive transfusion protocol promptly.
    • Keep the Patient Warm: Hypothermia exacerbates coagulopathy.
  • Pitfalls:
    • Delay in Escalation: Waiting too long to call for help, administer additional uterotonics, or proceed to surgical/interventional options.
    • Inadequate Resuscitation: Insufficient fluid replacement or delayed initiation of blood products.
    • Failure to Re-evaluate: Sticking to an initial diagnosis when bleeding persists, rather than systematically re-evaluating the 4 Ts.
    • Reluctance to Perform Manual Uterine Exploration/Examination: Missing retained tissue or lacerations.
    • Ignoring Coagulopathy: Not recognizing or treating acquired coagulopathy early.

Recent Updates

  • Guidelines:
    • WHO (2022) Recommendations on PPH Prevention and Treatment: Reaffirmed oxytocin as first-line for prevention and treatment. Strong recommendation for tranexamic acid within 3 hours of PPH onset. Emphasizes early recognition and a multi-component "PPH bundle" approach.
    • ACOG (2017/2023) Guidelines for PPH: Emphasizes institutional readiness, recognition/prevention, and response. Promotes quantitative blood loss measurement. Supports a tiered approach to PPH management.
    • RCOG (2016/2022) Green-top Guidelines: Comprehensive guidance on prevention, detection, and management, including specific drug dosages and surgical interventions.
  • Evidence:
    • WOMAN Trial (2017): Pivotal randomized controlled trial demonstrating that tranexamic acid significantly reduces death due to bleeding in PPH when given within 3 hours of onset, with no increase in thrombotic events. This has led to widespread adoption of TXA in PPH protocols.
    • Multiple systematic reviews and meta-analyses continue to support the effectiveness of AMTSL with uterotonics, particularly oxytocin, in reducing the incidence of PPH.
    • Ongoing research into new uterotonic agents, PPH simulation training, and non-pneumatic anti-shock garments (NASG) in low-resource settings.
  • Controversies:
    • Optimal timing and dosage of additional uterotonics: While oxytocin is first-line, the sequence and specific doses of second-line agents can vary by protocol.
    • Role of recombinant activated factor VIIa (rFVIIa): Reserved for life-threatening refractory PPH after all other interventions have failed and coagulopathy has been addressed. Its use remains controversial due to cost, thrombotic risk, and limited evidence in PPH.
    • Specific ratios for massive transfusion: While 1:1:1 (PRBC:FFP:Platelets) is a common target, ongoing research explores optimal ratios and component therapy based on real-time viscoelastic testing.

Key References

  • World Health Organization (WHO). WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2022.
  • American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 183: Postpartum Hemorrhage. Obstetrics & Gynecology. 2017;130(4):e168-e186. Reaffirmed 2023.
  • Royal College of Obstetricians and Gynaecologists (RCOG). Green-top Guideline No. 52: Prevention and Management of Postpartum Haemorrhage. 2016 (Minor amendments 2022).
  • WOMAN Trial Collaborators. Effect of tranexamic acid on death due to bleeding in women with postpartum haemorrhage: an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.
  • Sentilhes L, et al. Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR). European Journal of Obstetrics & Gynecology and Reproductive Biology. 2016;197:141-147.
  • Della Torre M, et al. A PPH management bundle reduces maternal morbidity: a multicenter study. American Journal of Obstetrics & Gynecology. 2014;210(3):207.e1-7.

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