Labor & Delivery: Postpartum Hemorrhage
Preventing and Managing Life-Threatening Bleeding After Birth
One of the leading causes of maternal death during childbirth is postpartum hemorrhage (PPH) – severe bleeding after delivery of more than 500 ml for a vaginal delivery or 1,000 ml for a cesarean section. Globally, PPH contributes to over 70,000 maternal deaths annually, despite being preventable and treatable.
The major causes of PPH are often summarized by the “4 Ts”:
- Tone – uterine atony, or failure of the uterus to contract after delivery, is the most common cause.
- Trauma – injury to the birth canal, including lacerations or uterine rupture.
- Tissue – retained placental tissue that prevents proper uterine contraction.
- Thrombin – coagulopathies or clotting disorders that impair normal blood clotting.
Preventing, detecting, and managing PPH effectively is crucial to saving lives. Studies have shown that the use of heat-stable carbetocin (100 mcg) for active management of the third stage of labor (AMTSL) and the E-MOTIVE bundle can significantly reduce maternal morbidity and mortality from PPH. The E-MOTIVE bundle is a first-response package for the management of PPH that prioritizes early detection and prompt action. This standardized set of interventions includes the use of a calibrated drape for accurate measurement of blood loss, uterine massage, administration of a uterotonic (such as oxytocin), tranexamic acid, intravenous (IV) fluids, and a thorough examination to identify the underlying cause.
This section focuses on practical guidance for managing PPH, while other key interventions during labor and delivery – such as ensuring skilled birth attendants, respectful maternity care, emergency obstetric interventions, and newborn resuscitation – are addressed in related sections. Strengthening health systems to deliver high-quality labor and delivery services ensures that every mother and newborn receives the highest standard of care for a safe and healthy birth.
What Are the Benefits of Managing PPH?
- PPH is the leading cause of maternal mortality. Effective use of these interventions will significantly reduce maternal deaths.
- Minimizes associated complications of PPH such as anemia, shock, and pituitary gland insufficiency.
- Improves maternal recovery and reduces hospital stay duration.
- Reduce the need for scarce resources such as blood and blood products.
How to Implement
Preventing PPH through Active Management of the Third Stage of Labor (AMTSL)
By implementing these proven AMTSL steps, providers can significantly reduce the risk of PPH and improve maternal survival, particularly in low-resource settings where alternative uterotonics like heat-stable carbetocin provide a sustainable and effective solution.
1. Administer a Uterotonic Immediately After Birth
Give a uterotonic within one minute of the baby’s birth, before delivering the placenta.
Use one of the following options based on availability:
- Oxytocin (10 IU IM/IV) – preferred first-line choice.
- Heat-stable carbetocin (100 mcg IM/IV) – an alternative recommended by WHO, especially in settings where refrigeration is limited.
2. Assist Placental Delivery with Controlled Cord Traction (CCT)
- Perform controlled cord traction (CCT) while ensuring that the uterus is contracting to facilitate placental expulsion.
- Monitor for signs of placental separation and assist with gentle traction, avoiding excessive pulling.
3. Perform Uterine Massage After Placental Delivery
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- Immediately massage the uterus to maintain uterine tone and prevent atony (a major cause of PPH).
- Encourage continuous uterine tone monitoring by trained healthcare providers.
Treating PPH Using the E-MOTIVE Bundle
By rapidly applying the E-MOTIVE bundle, healthcare providers can improve survival rates, reduce complications, and prevent maternal deaths from postpartum hemorrhage. To effectively manage and treat PPH, follow these E-MOTIVE Bundle steps for rapid, evidence-based intervention:
1. Detect PPH Early
- Use calibrated drapes to accurately measure blood loss and identify abnormal bleeding early.
- Take immediate action when blood loss exceeds 500 mL after vaginal birth or 1,000 mL after cesarean delivery.
2. Perform Uterine Massage
- Apply continuous uterine massage to promote uterine contraction and reduce bleeding.
- Monitor for signs of uterine atony, the leading cause of PPH.
3. Administer Uterotonics Promptly
If bleeding persists, give an additional dose of a uterotonic such as:
- Oxytocin (IV/IM): First-line choice.
- Misoprostol (sublingual or rectal): If oxytocin is unavailable.
- Carbetocin: If available, particularly in settings where refrigeration is a challenge.
4. Administer Tranexamic Acid (TXA) for Clot Stabilization
- Give Tranexamic Acid (TXA) 1g IV within 3 hours of birth to prevent excessive bleeding.
- If needed, repeat TXA after 30 minutes if bleeding persists.
5. Maintain Hemodynamic Stability with IV Fluids
- Initiate IV fluid resuscitation with crystalloids to support circulatory stability.
- Monitor vital signs closely to detect early signs of shock.
6. Perform Examination and Escalate Care If Needed
If bleeding does not improve, escalate to advanced interventions, including:
- Bimanual uterine compression to slow bleeding.
- Balloon tamponade to apply intrauterine pressure and stop hemorrhage.
- Surgical interventions, such as uterine artery ligation or hysterectomy, if bleeding is uncontrolled.
What's the Evidence
- WHO recommends AMTSL as a key strategy to prevent PPH.
- The E-MOTIVE trial demonstrated a significant reduction in severe PPH using the bundled approach.
- Tranexamic acid has been shown to reduce maternal mortality due to bleeding when administered within 3 hours of delivery.
- Uterine tamponade and surgical methods have high success rates in managing refractory PPH.
Key Indicators
- Uterotonic use within 1 minute of delivery.
- Incidence of PPH.
- Case fatality rate from PPH.
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Tips
- Advocate for Clear Policies & Guidelines: Ensure that your facility has up-to-date policies and protocols for PPH management, so every provider knows the standardized approach.
- Stay Prepared with Regular Training: Participate in ongoing simulations and refresher courses to improve your ability to recognize and respond to PPH quickly.
- Ensure Essential Supplies Are Always Available: Keep uterotonics (e.g., oxytocin, misoprostol, carbetocin), tranexamic acid (TXA), IV fluids, and resuscitation equipment stocked and accessible in the labor ward.
- Use Visual Aids & Checklists: Standardize your response with easy-to-follow checklists, algorithms, and posters that reinforce the E-MOTIVE bundle and key interventions.
- Document Vital Signs Accurately: Monitor and record blood pressure, pulse, and signs of shock to detect PPH early and escalate care when needed.
- Work as a Multidisciplinary Team: Involve midwives, obstetricians, anesthetists, and other specialists to coordinate care and improve outcomes for mothers experiencing PPH.
Challenges
- Staff Factors: Lack of knowledge and skills, lack of sufficient numbers of qualified staff, lack of self-efficacy and inappropriate expectations, and lack of teamwork and good communication.
- Commodity Shortages: Limited access to essential lifesaving commodities, supplies, and equipment such as uterotonics and blood products.
- Quality Issues: Poor quality of care due to insufficient adherence to guidelines, and inconsistent use of best practices in PPH management.
Key Resources
- Using Care Bundles to Improve Health Care Quality. IHI Innovation Series 2012
- Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation. IJGO 2019
- Research agenda for ending preventable maternal deaths from postpartum haemorrhage: a WHO research prioritisation exercise. BMJ Global Health 2024
- A roadmap to combat postpartum haemorrhage between 2023 and 2030. WHO 2023
