Primary postpartum haemorrhage

Minutes, not hours. The baby is out, the placenta is out, and the bleeding has not stopped. At term the uterus receives roughly 600–900 mL of blood every minute, so an atonic uterus can exsanguinate a young woman while the obs chart still looks respectable. Rehearse the sequence below.^[2][20]

Overview and definition

PPH is defined by volume and by physiology, and you should quote both. ^[1][2]

• Volume: 500 mL or more after vaginal birth, 1000 mL or more after caesarean — the classic FIGO/RCOG thresholds. ACOG's modern framing: cumulative loss of 1000 mL or more, or any bleeding with signs of hypovolaemia, within 24 hours.^[1][2][3]
• Severity (RCOG): minor 500–1000 mL; major over 1000 mL — moderate 1000–2000 mL, severe over 2000 mL.^[1]
• Tempo: primary PPH strikes within 24 hours of birth. Secondary PPH (24 hours to 6 weeks) is a different topic with a different driver — infection and retained tissue.

One number anchors the whole topic: uterine atony causes roughly 70–80% of PPH. Start with tone in your head — but prove it with your hands and eyes, because the woman with the cervical tear also has a soft uterus.^[1][20]

References20ShowHide

1. [1]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
2. [2]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
3. [3]Escobar MF, Nassar AH, Theron G, et al. FIGO recommendations on the management of postpartum hemorrhage 2022 Int J Gynaecol Obstet, 2022.PMID 35297039
4. [4]Robinson D, Basso M, Chan WS, et al. Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock J Obstet Gynaecol Can, 2022.PMID 36567097
5. [5]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
6. [6]Gayet-Ageron A, Prieto-Merino D, Ker K, et al. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients Lancet, 2018.PMID 29126600
7. [7]Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage N Engl J Med, 2023.PMID 37158447
8. [8]Parry Smith WR, Papadopoulou A, Thomas E, et al. Uterotonic agents for first-line treatment of postpartum haemorrhage: a network meta-analysis Cochrane Database Syst Rev, 2020.PMID 33232518
9. [9]Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis Cochrane Database Syst Rev, 2018.PMID 30569545
10. [10]Widmer M, Blum J, Hofmeyr GJ, et al. Misoprostol as an adjunct to standard uterotonics for treatment of post-partum haemorrhage: a multicentre, double-blind randomised trial Lancet, 2010.PMID 20494730
11. [11]Attilakos G, Psaroudakis D, Ash J, et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial BJOG, 2010.PMID 20482535
12. [12]Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis Am J Obstet Gynecol, 2020.PMID 31917139
13. [13]Bakri YN, Amri A, Abdul Jabbar F Tamponade-balloon for obstetrical bleeding Int J Gynaecol Obstet, 2001.PMID 11502292
14. [14]B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported Br J Obstet Gynaecol, 1997.PMID 9091019
15. [15]Kallianidis AF, Rijntjes D, van den Akker T, et al. Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis Obstet Gynecol, 2023.PMID 36701608
16. [16]Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial Br J Anaesth, 2015.PMID 25586727
17. [17]Khan KS, Moore PAS, Wilson MJ, et al. Cell salvage and donor blood transfusion during cesarean section: A pragmatic, multicentre randomised controlled trial (SALVO) PLoS Med, 2017.PMID 29261655
18. [18]Nathan HL, El Ayadi AM, Hezelgrave NL, et al. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG, 2015.PMID 25546050
19. [19]Nathan HL, Seed PT, Hezelgrave NL, et al. Shock index thresholds to predict adverse outcomes in maternal hemorrhage and sepsis: A prospective cohort study Acta Obstet Gynecol Scand, 2019.PMID 31001814
20. [20]Anderson JM, Etches D Prevention and management of postpartum hemorrhage Am Fam Physician, 2007.PMID 17390600