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ukmla 2026

Postpartum Haemorrhage

Excessive bleeding after delivery — defined as ≥500 mL after vaginal birth or ≥1,000 mL after CS — the leading cause of maternal death worldwide, with uterine atony accounting for 80% of cases

Review date
reviewed 2026-04-05
Reading time
7 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Obstetrics & Gynaecologycommonacute
On this page
Condition details
Obstetrics & Gynaecology
common
7 min read
reviewed 2026-04-05
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About This Page

This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

  • Primary PPH: ≥500 mL within 24 hours of delivery. Major PPH: ≥1,000 mL. Massive: ≥2,000 mL or haemodynamic instability
  • Causes — 4 Ts: Tone (atony, 80%), Tissue (retained placenta/products), Trauma (tears), Thrombin (coagulopathy)
  • Prevention: active management of 3rd stage — IM oxytocin 10 IU with delivery of anterior shoulder
  • First-line treatment: bimanual uterine compression + IV oxytocin 40 IU infusion + ergometrine 500 mcg IM
  • Escalation: carboprost (Hemabate) 250 mcg IM, misoprostol 800 mcg sublingual, intrauterine balloon tamponade
  • Surgical: B-Lynch suture, uterine artery ligation, interventional radiology embolisation, or hysterectomy as last resort

Overview

Postpartum haemorrhage (PPH) is the most common cause of maternal death worldwide and a leading cause of major obstetric morbidity. Primary PPH occurs within 24 hours of delivery; secondary PPH occurs between 24 hours and 12 weeks postpartum. The single most common cause is uterine atony (failure of the uterus to contract adequately), accounting for approximately 80% of cases. The key to managing PPH is prevention through active management of the third stage, early recognition, and a systematic stepwise approach to treatment.

Epidemiology

PPH complicates approximately 5–15% of deliveries worldwide. In the UK, major PPH (≥1,000 mL) occurs in approximately 1–3% of deliveries. Risk factors for PPH include: uterine overdistension (multiple pregnancy, polyhydramnios, macrosomia), prolonged labour, augmented labour, grand multiparity, previous PPH, placenta praevia or accreta, pre-eclampsia, obesity, fibroids, chorioamnionitis, and clotting disorders.

Clinical Features

Symptoms
Heavy vaginal bleeding after delivery — may be a sudden gush or continuous trickle
Dizziness, light-headedness, or collapse
Abdominal pain (may suggest uterine rupture or retained tissue)
Signs
Large-volume vaginal bleeding — visually underestimated, weigh swabs for accuracy
Soft, boggy, poorly-contracted uterus above umbilicus (atony)
Tachycardia, hypotension, pallor (haemodynamic compromise)
Visible genital tract trauma — perineal, vaginal, or cervical tears
Placenta not delivered or incomplete (retained tissue)
Ongoing ooze without clot formation (suggests coagulopathy)

Investigations

First-line
Clinical assessmentEstimate blood loss (weigh swabs, use drapes), assess uterine tone, inspect placenta for completeness, examine genital tract for tears
FBC and coagulation screenHb may be normal initially (haemodilution not yet occurred). Fibrinogen <200 mg/dL indicates DIC
CrossmatchGroup and save should already be on file — crossmatch 4+ units if major PPH
Second-line
Point-of-care testingTEG/ROTEM if available for guiding blood product replacement
Blood gasAssess lactate and base deficit — markers of tissue hypoperfusion
Specialist
UltrasoundIf retained products suspected — assess uterine cavity

Management

RCOG Green-top Guideline No. 52 (Prevention and management of PPH), 2016
1
Prevention — active management of 3rd stage
  • IM oxytocin 10 IU with delivery of the anterior shoulder (or after delivery of baby)
  • Controlled cord traction to deliver placenta
  • Early cord clamping only if specific indication — otherwise delayed clamping (≥1 min)
2
Initial management of PPH
  • Call for help — multidisciplinary team (obstetrician, anaesthetist, midwife, haematologist)
  • A-E approach. Two large-bore IV cannulae. Commence fluid resuscitation
  • Bimanual uterine compression (rubbing up the fundus and compressing)
  • IV oxytocin 40 IU in 500 mL normal saline infusion (125 mL/h)
  • IM ergometrine 500 mcg (contraindicated in hypertension/pre-eclampsia)
  • Catheterise bladder (full bladder impedes uterine contraction)
3
Escalation — ongoing haemorrhage
  • IM carboprost (Hemabate) 250 mcg — repeat every 15 min (max 8 doses). Contraindicated in asthma
  • Sublingual misoprostol 800 mcg
  • IV tranexamic acid 1 g (give within 3 hours of onset — WOMAN trial)
  • Intrauterine balloon tamponade (Bakri balloon)
  • Activate major haemorrhage protocol — O-negative or crossmatched blood, FFP, cryoprecipitate, platelets
4
Surgical (if medical management fails)
  • Examination under anaesthesia — exclude retained products and genital tract trauma
  • B-Lynch compression suture
  • Uterine artery ligation (bilateral)
  • Interventional radiology — uterine artery embolisation
  • Hysterectomy — life-saving last resort

Complications

  • Hypovolaemic shock: From massive blood loss — may require massive transfusion protocol
  • DIC: Consumptive coagulopathy — treat with blood products (FFP, cryoprecipitate, platelets)
  • Sheehan syndrome: Pituitary necrosis from severe PPH — presents with failure to lactate, amenorrhoea, hypothyroidism, and hypoadrenalism
  • Renal failure: Acute tubular necrosis from hypovolaemia
  • Hysterectomy: May be necessary as a life-saving measure
  • PTSD and psychological morbidity: Significant impact — debrief and refer as needed
UKMLA Exam Tips
  • 14 Ts of PPH: Tone (atony, 80%), Tissue (retained), Trauma (tears), Thrombin (coagulopathy)
  • 2Active management of 3rd stage = IM oxytocin 10 IU. Reduces PPH by 60%
  • 3Ergometrine is CONTRAINDICATED in hypertension/pre-eclampsia. Carboprost is CONTRAINDICATED in asthma
  • 4Tranexamic acid 1 g IV within 3 hours (WOMAN trial) — reduces death from bleeding
  • 5Bimanual uterine compression and rubbing up the fundus = first physical step for atony
  • 6Sheehan syndrome post-PPH: failure to lactate is the earliest sign
  • 7Secondary PPH (>24 h to 12 weeks): think retained products or endometritis

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Verified Sources & References

RCOG Green-top Guideline No. 52 — Prevention and management of PPH
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