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Postpartum haemorrhage
≥500 ml after birth; major >1000 ml or any signs of shock.
Source: RCOG GTG 52 · NICE NG235 Calculator
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Call for help: senior midwife, obstetric registrar, anaesthetist; activate major haemorrhage protocol if >1000 ml.
Act
- Airway, breathing, O2 15 L/min; lie flat; keep warm.
- Two 14–16G cannulas; FBC, clotting, fibrinogen, U&E, crossmatch 4 units.
- Rub up the fundus; empty bladder (catheter, hourly urine).
- Find the cause — 4 Ts: Tone, Trauma, Tissue, Thrombin.
- Uterotonics: oxytocin 5 IU slow IV → ergometrine 500 mcg IM (not if BP high) → oxytocin 40 IU infusion → carboprost 250 mcg IM every 15 min → misoprostol 800 mcg SL.
- Tranexamic acid 1 g IV over 10 min (within 3 h).
- Warmed fluids up to 3.5 L until blood arrives; give blood early.
- Bimanual compression while waiting; check placenta complete and look for tears.
- Still bleeding: theatre — EUA, balloon tamponade, B-Lynch, ligation, IR, hysterectomy.
- Weigh swabs; record times, drugs and blood loss.
Grade
| Minor | 500–1000 ml |
|---|---|
| Moderate | 1001–2000 ml |
| Severe | >2000 ml |
| Secondary | 24 h to 12 weeks after birth |
Blood products
| FFP | 12–15 ml/kg after 4 units red cells if no clotting results |
|---|---|
| Fibrinogen | Keep >2 g/L (cryoprecipitate) |
| Platelets | Give if <75 × 10⁹/L |
4 Ts
Tone ~70%Trauma ~20%Tissue ~10%Thrombin <1%
A summary for trained clinicians. Always check the full guideline, the patient in front of you and your hospital's protocol. Spotted an error? Tell us.