Primary PPH is 500 mL or more within 24 h; 1000 mL or more, or any bleeding with shock, is major. Call for help early, resuscitate, give tranexamic acid 1 g IV, and treat the cause.
Four Ts (causes)
- Tone: uterine atony (commonest)
- Trauma: perineal, vaginal or cervical tears, uterine rupture
- Tissue: retained placenta or clots
- Thrombin: coagulopathy (including dilutional)
First steps (ABC)
- Call for help; two large-bore cannulae; FBC, coagulation, crossmatch
- Oxygen, warmed IV fluids, lie flat, keep warm
- Empty the bladder; rub up a contraction; bimanual compression
- Activate the major haemorrhage protocol if major PPH
Minor (500 to 1000 mL)
- No shock
- IV access, bloods, monitor
- Find the cause (4 Ts)
Major (over 1000 mL)
- Ongoing bleeding or shock
- Uterotonics, bimanual compression
- Activate major haemorrhage, TXA
Massive / refractory
- Over 2000 mL or continuing
- Balloon tamponade, theatre
- Balanced transfusion, senior team
PPH response
1
1. Assess and resuscitate
Estimate blood loss by weighing swabs (it is usually underestimated). Monitor observations and urine output. ABC and blood products.
Estimate blood loss by weighing swabs (it is usually underestimated). Monitor observations and urine output. ABC and blood products.
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2
2. Stop uterine atony
Uterotonic ladder: oxytocin bolus then infusion, ergometrine (avoid in hypertension), carboprost (avoid in asthma), misoprostol. Give TXA 1 g.
Uterotonic ladder: oxytocin bolus then infusion, ergometrine (avoid in hypertension), carboprost (avoid in asthma), misoprostol. Give TXA 1 g.
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3
3. Mechanical and surgical
Examination under anaesthesia and repair of tears, remove retained tissue. If still bleeding: intrauterine balloon tamponade, then brace suture, uterine or internal iliac artery ligation or embolisation; hysterectomy as a last resort.
Examination under anaesthesia and repair of tears, remove retained tissue. If still bleeding: intrauterine balloon tamponade, then brace suture, uterine or internal iliac artery ligation or embolisation; hysterectomy as a last resort.
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4
4. After
High-dependency care, correct anaemia (iron or transfusion), VTE prophylaxis once bleeding controlled, debrief and document.
High-dependency care, correct anaemia (iron or transfusion), VTE prophylaxis once bleeding controlled, debrief and document.
Uterotonic cautions
- Ergometrine: avoid in hypertension and pre-eclampsia
- Carboprost: avoid in asthma
- Secure IV access and continue oxytocin infusion
Pitfalls
- Underestimating visually assessed blood loss
- Delaying the major haemorrhage call
- Forgetting TXA
- Not systematically working through the four Ts
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026