WHO Guidelines for Managing Postpartum Hemorrhage
Definition and Immediate Recognition
The WHO defines PPH as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean section, or any blood loss compromising hemodynamic stability 1. This is the leading cause of maternal mortality globally, with most deaths occurring within the first 24 hours after birth 1.
First-Line Immediate Management (Within Minutes)
Administer tranexamic acid 1 g IV over 10 minutes PLUS oxytocin 5-10 IU (IV or IM) immediately upon PPH diagnosis 1, 2. This dual pharmacologic approach forms the cornerstone of WHO-recommended PPH treatment.
Critical Timing for Tranexamic Acid
- TXA MUST be given within 3 hours of birth—effectiveness decreases by approximately 10% for every 15-minute delay 1, 2, 3
- Do NOT administer TXA beyond 3 hours postpartum as it may be harmful rather than beneficial 1, 2, 3
- A second 1 g dose of TXA can be given if bleeding continues after 30 minutes or restarts within 24 hours 1, 2, 3
- TXA should be administered in ALL cases of PPH regardless of etiology (uterine atony, genital tract trauma, retained tissue) 1, 2
Oxytocin Administration
- Oxytocin 5-10 IU can be given either slow IV or IM immediately 1, 2
- Follow with maintenance infusion not exceeding a cumulative dose of 40 IU 2, 4
- IV route is more effective than IM for PPH prevention 1
Simultaneous Non-Pharmacologic Interventions
Initiate uterine massage, bimanual compression, and fluid resuscitation with physiologic electrolyte solutions immediately 1, 2.
- Perform manual uterine examination with antibiotic prophylaxis 1
- Conduct careful visual assessment of the lower genital tract for trauma 1, 2
- Begin IV fluid resuscitation with physiologic electrolyte solutions 5, 1
- Monitor vital signs continuously 5, 1
Sequential Escalation Algorithm (Less to More Invasive)
The WHO emphasizes a stepwise approach, moving from less invasive to more invasive interventions as required 5, 1.
Second-Line Mechanical Interventions (If Bleeding Persists)
- Intrauterine balloon tamponade should be implemented before proceeding to surgery or interventional radiology 1, 2
- Balloon tamponade has a 79.4-88.2% success rate in uterine atony cases 1
- Non-pneumatic antishock garment for temporary stabilization 5, 1, 2
- External aortic compression 5, 1
- Pelvic pressure packing (can remain for 24 hours) 2
Surgical Interventions (If Conservative Measures Fail)
- Uterine compression sutures (B-Lynch or similar brace sutures) 5, 1, 2
- Arterial ligation 5, 1
- Arterial embolization (particularly useful when no single bleeding source is identified; requires hemodynamic stability for transfer) 1, 2
- Hysterectomy as last resort 5, 1
Resuscitation and Blood Product Management
Initiate massive transfusion protocol if blood loss exceeds 1,500 mL 2.
- Transfuse packed RBCs, fresh frozen plasma, and platelets in fixed ratio 2
- Do NOT delay transfusion waiting for laboratory results in severe bleeding 2
- Target hemoglobin >8 g/dL and fibrinogen ≥2 g/L during active hemorrhage 2
- Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL 2
Essential Supportive Measures
- Maintain normothermia: warm all infusion solutions and blood products; use active skin warming (clotting factors function poorly at lower temperatures) 2
- Administer oxygen in severe PPH 2
- Continue hemodynamic monitoring for at least 24 hours post-delivery due to significant fluid shifts 1, 2
Critical Contraindications and Pitfalls
Methylergonovine Contraindications
- Methylergonovine is absolutely contraindicated in hypertensive patients due to >10% risk of severe vasoconstriction and hypertensive crisis 1, 2, 3
- Also contraindicated in women with asthma due to bronchospasm risk 2
Manual Placenta Removal
- Manual removal of placenta should NOT be performed routinely except in cases of severe, uncontrollable PPH 1, 3
- Routine manual removal before 30 minutes increases infection and hemorrhage risk 3
TXA Timing Error
- The most critical pitfall is administering TXA beyond 3 hours postpartum—this represents a shift from benefit to potential harm 1, 2, 3
Prevention: Active Management of Third Stage
The WHO strongly recommends active management of the third stage of labor, which includes prophylactic uterotonic administration, delayed cord clamping for approximately 60 seconds, and controlled cord traction 3.
- Prophylactic oxytocin administration is the criterion standard for PPH prevention 1, 3
- Spontaneous placental delivery should occur within 30 minutes; retained placenta beyond this increases PPH risk 3
Facility Requirements
Health facilities providing emergency obstetric care must have: