Evaluate and manage a patient presenting with postpartum haemorrhage (PPH)

Clinical overview

Postpartum haemorrhage is the single largest direct cause of maternal death in South Africa and worldwide, and the most reliably preventable one. The Saving Mothers reports (NCCEMD) have consistently ranked obstetric haemorrhage among the top contributors to maternal mortality in South Africa, alongside hypertension and non-pregnancy-related infections (predominantly HIV-associated). Critically, a large proportion of haemorrhage deaths are judged avoidable — the woman bled, the response was late, disorganised, or under-resourced, and she died of something we know exactly how to stop. Your job as a registrar is to convert that knowledge into a fast, choreographed, escalating response, every single time.

The classic definition is blood loss ≥500 mL after vaginal birth or ≥1000 mL after caesarean, with severe (or major) PPH usually taken as ≥1000 mL or any loss causing haemodynamic compromise. The 2025 WHO/FIGO/ICM consolidated guideline shifts the trigger earlier: diagnose and act on measured blood loss ≥300 mL with abnormal haemodynamics (pulse >100, shock index >1, systolic BP <100 or diastolic BP <60 mmHg), OR ≥500 mL — whichever comes first, with the greatest vigilance in the first 2 hours. The point is to stop waiting for the old 500 mL mark. These thresholds are clinically useful but treacherous: visual estimation systematically under-reads blood loss, a healthy young woman compensates until she suddenly does not, and the antenatally anaemic patient — extremely common in South African practice — tolerates far less. Treat the trajectory and the physiology, not a number on a swab. PPH is timed: primary PPH occurs within 24 hours of birth (overwhelmingly atonic), secondary PPH from 24 hours to 6 (or 12) weeks (usually retained products or endometritis). This chapter is weighted to the verb — evaluate and manage — so the emphasis is on a structured assessment and a relentless, escalating drill. Closely linked are antepartum-haemorrhage, uterine-rupture, shock-management and resuscitation-in-pregnancy.

Core knowledge

The four T's — causes by frequency

Almost all PPH fits one (or more) of four mechanisms. Memorise them in order of frequency because that order drives your initial actions.

Tone dominates. The contracted myometrium mechanically occludes the spiral arteries supplying the placental bed — the "living ligatures." Anything that prevents sustained contraction causes atony: an over-distended uterus (multiple pregnancy, polyhydramnios, macrosomia — see macrosomia and multiple-pregnancy), prolonged or augmented labour with an exhausted myometrium, chorioamnionitis, tocolytics, retained tissue, high parity, and uterine fibroids (fibroids).

Figure J12.1 — The 4 T bedside source finder for primary postpartum haemorrhage, linking clues to first-line targets while resuscitation runs.

Risk factors and why they matter

Antenatal and intrapartum risk factors should raise your guard and your preparation — IV access, group-and-save, delivery in an appropriate level of care — but they do not predict the individual: a majority of PPH occurs in women with no identified risk factor, which is exactly why active management of the third stage of labour is given to everyone. Key flags include previous PPH, previous caesarean (placenta praevia/accreta risk — antepartum-haemorrhage), grand multiparity, anaemia, prolonged third stage, instrumental delivery (instrumental-delivery), and pre-eclampsia/HELLP (pre-eclampsia-and-hellp, which also brings thrombocytopenia and impaired coagulation).

Placenta accreta spectrum

In a woman with placenta praevia overlying a previous caesarean scar, suspect placenta accreta spectrum (PAS) — abnormally adherent or invasive placentation. With rising caesarean rates in South Africa this is an increasing cause of catastrophic, often torrential, PPH and peripartum hysterectomy. Where antenatal imaging raises the suspicion, the woman should be delivered in a setting with blood-bank, anaesthetic and surgical capacity — a planning problem, not a labour-ward surprise.

Physiology of compensation

At term, uterine blood flow approaches ~500–700 mL/min, so atony empties a circulation fast. A healthy parturient maintains blood pressure by vasoconstriction and tachycardia until roughly 30–40% of blood volume is lost, then decompensates abruptly. The anaemic, pre-eclamptic, or septic woman has far less reserve. Hypothermia, acidosis and coagulopathy form the "lethal triad" that perpetuates bleeding once massive haemorrhage is established — which is why early, warmed, balanced resuscitation and early tranexamic acid matter so much.

Assessment

Assessment and resuscitation happen simultaneously, not in sequence — but you must still answer, within minutes, how much, how fast, and from where.

Recognise and quantify

• Detect early. Use a calibrated under-buttock drape after birth where available; the E-MOTIVE bundle showed that objective measurement of loss with a calibrated drape dramatically improves early detection. Do not wait for visible flooding.
• Quantify, don't guess. Weigh swabs and linen (1 g ≈ 1 mL). Visual estimation under-reads, often by half.
• Read the physiology. Pulse, blood pressure, respiratory rate, capillary refill, conscious level, urine output. A rising pulse and narrowing pulse pressure precede the fall in systolic BP. Tachycardia plus a soft, anxious, cold woman is decompensating shock until proven otherwise. Remember the obstetric "shock index" (HR ÷ systolic BP): a value persistently ≥1 is a useful early warning that loss is significant — standard teaching, exact action thresholds vary, so treat it as a trigger to escalate, not a number to wait for.

Find the cause — work the four T's at the bedside

• Tone: Palpate the fundus immediately. A boggy, poorly contracted, often high uterus = atony (the commonest finding). A well-contracted uterus with ongoing bleeding points you away from tone toward trauma or tissue.
• Trauma: With good light and assistance, inspect the cervix, vagina, perineum and episiotomy for lacerations or an extending tear; consider a concealed vulvovaginal/broad-ligament haematoma (severe pain, swelling, shock out of proportion to visible loss). Sudden severe pain with a non-palpable fundus and a mass at the introitus suggests uterine inversion; a tearing pain, fetal-part palpability, and collapse — especially with a scarred uterus — suggests uterine rupture (uterine-rupture).
• Tissue: Examine the placenta and membranes for completeness. A ragged placenta or missing cotyledon means retained tissue until excluded.
• Thrombin: Suspect coagulopathy when blood fails to clot, when there is oozing from venepuncture sites, or in the context of abruption, sepsis, severe pre-eclampsia/HELLP, amniotic fluid embolism, or after large-volume crystalloid/red-cell replacement without clotting factors.

Investigations

Send FBC, coagulation screen (PT/aPTT/fibrinogen), urea & electrolytes, and a crossmatch early — and repeat during ongoing bleeding. A fibrinogen that falls (broadly, below ~2 g/L in established PPH) is a strong predictor of severe haemorrhage; near-patient viscoelastic testing (TEG/ROTEM) guides factor replacement where available but is not assumed in district settings. Send an HIV test if status is unknown, as it informs broader care. Do not let phlebotomy delay treatment.

Management

PPH IS A "STOP THE BLEEDING NOW" EMERGENCY. Call for help, resuscitate, and treat the cause in parallel — do not work through steps one at a time while she bleeds.

The opening drill (do these together, within minutes)

1. CALL FOR HELP. Shout it out, declare a PPH/"major obstetric haemorrhage," summon senior midwife, registrar/consultant, and anaesthetist. Note the time.
2. ABC + position. High-flow oxygen, keep her flat and warm.
3. Two large-bore IV cannulae (14–16 G). Take bloods on insertion (FBC, clotting, crossmatch — for major haemorrhage crossmatch ~4 units).
4. Resuscitate. Warmed crystalloid initially; move early to blood. Activate the massive transfusion protocol for ongoing major loss — give red cells, and don't forget plasma and platelets (avoid the dilutional coagulopathy of crystalloid-only resuscitation). Keep her warm; use a fluid warmer; insert a urinary catheter to monitor output and empty the bladder (a full bladder impairs uterine contraction).
5. Tranexamic acid 1 g IV as early as possible. The WOMAN trial showed TXA given within 3 hours of onset reduces death due to bleeding by roughly one-third; benefit falls the longer you wait, so give it early — a repeat 1 g dose may be given if bleeding continues per protocol.

The MOTIVE bundle as your mental scaffold

The 2025 WHO/FIGO/ICM guideline formalises the first-response MOTIVE bundle, deployed immediately once PPH is diagnosed: uterine Massage, Oxytocin (uterotonic), Tranexamic acid, IV fluids, Vaginal/genital-tract examination, and Escalation if bleeding persists — sitting on top of early detection with a calibrated drape (the "E" of the original E-MOTIVE trial that proved the approach, NEJM 2023). Run the whole package as a reflex, not a checklist worked one step at a time.

Unlock with Pro

You found the good stuff

Unlock the full edition.

Everything behind the blur — and the study system built to walk you into the exam ready.

• Every figure & infographic, full resolution
• ~1,000 exam-format SBAs
• Spaced repetition tuned to your forgetting curve

Plan

Most popularProThe full editionR400 /monthMaxPro + early accessR800 /month

Monthly6 months−17%

🇿🇦 ZAR

Unlock Pro — R400/month→

Secured by Stripe · Cancel anytime · Discount codes apply at checkout

Figure J12.2 — The E-MOTIVE first-response drill for early detection, parallel resuscitation, tranexamic acid, examination and escalation.

Treat by cause — escalating ladder for ATONY (commonest)

1. Mechanical first — and continuously:

• Rub up a contraction with continuous firm fundal massage.
• Empty the bladder (catheter).
• Bimanual uterine compression if bleeding persists — one hand in the anterior fornix, the other compressing the fundus abdominally.

2. Uterotonics (SA EML / NDoH Maternity Guideline (NDoH, 2024) — confirm exact local doses against the EML before administering):

• Oxytocin — first-line in South Africa. A bolus is given (slowly IV) followed by an infusion to sustain contraction. (Oxytocin is also the routine active third-stage agent given to every woman at birth to prevent PPH.)
• Ergometrine — a second-line uterotonic; contraindicated in hypertension and pre-eclampsia — a crucial pitfall in the SA setting where hypertensive disease is so prevalent.
• Misoprostol — a prostaglandin available where injectable uterotonics or cold-chain are limited; valued in lower-level/primary settings.
• Carbetocin — a long-acting oxytocin analogue with a role in prevention/treatment, particularly attractive where the cold chain is unreliable (heat-stable formulations exist).
• For prevention at the third stage, the 2025 WHO/FIGO/ICM guideline lists three options (give ONE, oxytocin preferred): oxytocin 10 IU IM/IV, heat-stable carbetocin 100 µg IM/IV, or misoprostol 400–600 µg orally — confirm the local SA EML dose/route before giving.
• (Carboprost/PGF2α is a further prostaglandin option where available; avoid in asthma.)

The specific doses, dilutions and sequencing must follow the current South African EML (Hospital Level) and the NDoH Maternity Guideline (NDoH, 2024) — do not give from memory; the local protocol card on the labour ward is the authority.

3. Mechanical tamponade — bridge to theatre:

• If uterotonics fail to control atonic bleeding, place an intrauterine balloon tamponade (e.g. a balloon catheter or a purpose-made device; an improvised condom-catheter balloon is widely used in low-resource South African settings). A successful "tamponade test" buys time, allows transfer/resuscitation, and may definitively control bleeding.

4. Surgical / interventional — escalate without delay if bleeding continues:

• Examination under anaesthesia to exclude trauma/retained tissue.
• Uterine compression sutures (e.g. a B-Lynch–type brace suture) at laparotomy.
• Stepwise uterine devascularisation — uterine artery ligation, then internal iliac (hypogastric) artery ligation.
• Interventional radiology / uterine artery embolisation where available (tertiary).
• Peripartum hysterectomy — the definitive, life-saving last step. Do not delay it once conservative measures have failed in a woman who is exsanguinating — a slightly early hysterectomy saves a life; a slightly late one loses it. This is especially relevant in placenta accreta spectrum.

Unlock with Pro

You found the good stuff

Unlock the full edition.

Everything behind the blur — and the study system built to walk you into the exam ready.

• Every figure & infographic, full resolution
• ~1,000 exam-format SBAs
• Spaced repetition tuned to your forgetting curve

Plan

Most popularProThe full editionR400 /monthMaxPro + early accessR800 /month

Monthly6 months−17%

🇿🇦 ZAR

Unlock Pro — R400/month→

Secured by Stripe · Cancel anytime · Discount codes apply at checkout

Figure J12.3 — Escalation ladder for atonic postpartum haemorrhage, from mechanical measures and uterotonics to tamponade, surgery and hysterectomy.

Treat by cause — trauma, tissue, thrombin

• Trauma: Repair lacerations with adequate analgesia, light, and assistance — a high vaginal or cervical tear needs theatre. Drain/evacuate large or expanding haematomas. Uterine inversion is reduced immediately (push the fundus back through the cervix; relax the uterus with tocolytics/anaesthesia if a constriction ring has formed) — before the placenta is removed if still attached. Uterine rupture → immediate laparotomy.
• Tissue: Retained placenta → manual removal in theatre under anaesthesia; retained fragments → evacuation. (Avoid blind, repeated, vigorous curettage in the soft puerperal uterus — perforation risk.)
• Thrombin: Replace clotting factors guided by labs/viscoelastic testing — fresh frozen plasma, cryoprecipitate/fibrinogen concentrate for hypofibrinogenaemia, platelets — and treat the underlying driver (deliver/evacuate in abruption, antibiotics in sepsis — see infections-in-pregnancy). Keep her warm and correct acidosis to break the lethal triad. Refer to RCOG guidance on transfusion in obstetrics for thresholds.

Secondary PPH

Bleeding after 24 hours is usually retained products of conception and/or endometritis. Assess with examination, FBC, and pelvic ultrasound (interpret a "retained products" picture cautiously — clot and normal involutional debris mimic it). Treat with antibiotics for infection and consider surgical evacuation if significant retained tissue and bleeding; involve seniors, as evacuation of the soft, infected puerperal uterus carries perforation risk.

South African systems context

• Level of care matters. A district (level 1) facility manages the opening drill, uterotonics, balloon tamponade and resuscitation, and transfers early — with the bleeding controlled or tamponaded, IV lines running, blood started, and the receiving regional/tertiary unit forewarned. Surgical devascularisation, interventional radiology and complex accreta surgery belong at regional/tertiary level. Know your referral pathway before the emergency.
• Anaemia is endemic — antenatal correction of iron-deficiency anaemia (see antenatal-booking) reduces both the likelihood and the lethality of PPH. The anaemic woman has no reserve.
• HIV is highly prevalent; while not a direct cause of atony, it shapes the patient's reserve, infection risk, and the broader Saving Mothers picture.
• Drill and skills-and-drills training, an emergency trolley/PPH box, a posted protocol, and a massive transfusion protocol are the system-level interventions that turn knowledge into survival.

Red flags / pitfalls

• Under-estimating blood loss. Visual estimation under-reads; weigh swabs. A "stable" pulse can be late compensation.
• Treating the number, not the woman. A 400 mL loss in an anaemic, pre-eclamptic woman can be decompensating. Act on physiology.
• Forgetting the bladder. A full bladder prevents uterine contraction — catheterise early.
• Giving ergometrine to a hypertensive/pre-eclamptic woman — contraindicated; a dangerous, common error in the SA setting.
• Carboprost in an asthmatic — avoid.
• Crystalloid-only resuscitation in major haemorrhage → dilutional coagulopathy. Move to blood and clotting products early; activate the massive transfusion protocol.
• Late tranexamic acid. Benefit is time-critical (give within 3 hours). Prophylactic TXA in anaemic women without bleeding was not beneficial (WOMAN-2) — give TXA to treat PPH, not as routine prophylaxis.
• Delaying definitive surgery / hysterectomy in someone who is exsanguinating. Conservative measures have a time limit.
• Blaming atony and missing trauma or retained tissue when the uterus is well contracted but bleeding continues — re-examine systematically.
• Missing a concealed haematoma or broad-ligament bleed — shock out of proportion to visible loss.
• Not calling for help early enough. The commonest avoidable factor in haemorrhage deaths is a slow, unled response. Declare it, lead it, time it.

Evidence anchors

• South African NDoH — National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) — the SA obstetric source of truth: active third-stage management, uterotonic choice (oxytocin first-line), and the PPH response.
• South African EML — Hospital Level (Adults), current edition — definitive source for exact uterotonic and TXA doses/dilutions; confirm before administering.
• Saving Mothers / NCCEMD reports (latest triennium) — obstetric haemorrhage as a leading, largely avoidable cause of SA maternal death; emphasises early recognition and organised response.
• RCOG Green-top Guideline No. 52 — Prevention and Management of Postpartum Haemorrhage.
• RCOG Green-top Guideline No. 47 — Blood Transfusions in Obstetrics — transfusion and massive haemorrhage principles.
• WOMAN trial (Lancet 2017) — tranexamic acid 1 g IV within 3 hours of PPH onset reduces death due to bleeding (give early).
• WOMAN-2 trial (Lancet 2024) — prophylactic TXA in anaemic women did not reduce PPH (TXA is treatment, not routine prophylaxis).
• E-MOTIVE trial (NEJM 2023) — calibrated-drape early detection + bundle (massage, oxytocic, TXA, IV fluids, examine/escalate) reduced severe PPH outcomes substantially.
• WHO/FIGO/ICM Consolidated Guidelines for the Prevention, Diagnosis and Treatment of Postpartum Haemorrhage (5 October 2025) — the current global standard (first joint WHO+FIGO+ICM guideline, 51 recommendations; Lancet Glob Health 2025). Key shifts adopted in this chapter: act earlier — ≥300 mL with abnormal haemodynamics OR ≥500 mL; the MOTIVE first-response bundle on diagnosis; calibrated drape for objective measurement; prevention uterotonic triad oxytocin 10 IU / heat-stable carbetocin 100 µg / misoprostol 400–600 µg; early IV TXA within 3 h; uterine balloon tamponade for refractory atony; plus antenatal anaemia correction and avoiding routine episiotomy.

Where specific drug doses, dilutions, and sequencing are not line-itemed above, follow the current South African EML and the NDoH Maternity Guideline (NDoH, 2024) — do not administer from memory.