A Clinical guideline for: the Management of Obstetric Haemorrhage

For Use in: Maternity Services

By: Maternity staff
For: Antenatal and Postnatal women

Division responsible for document: Women and Children’s Services

Obstetric haemorrhage, APH, PPH, Oxytocic’s,
Key words:
placental abruption, uterine atony
Daisy Nirmal, Consultant Obstetrician
Rosie Goodsell, Practice Development Midwife
Name and job titles of document Jon Francis, Consultant Anaesthetist
author: Amanda Anderson, Practice Development
Midwife
Sue Holland, Clinical Effectiveness Midwife
Name of document author’s Line
Anna Haestier
Manager:
Job title of author’s Line Manager: Chief of Maternity Service
Maternity Guidelines Committee
Assessed and approved by the:
If approved by Committee or Governance Lead
Chair’s Action; tick here 
Date of approval: 09/06/2022
Ratified by or reported as approved
Clinical Safety and Effectiveness Sub-Board
to (if applicable):
To be reviewed before:
This document remains current after this 09/06/2025
date but will be under review
To be reviewed by: Daisy Nirmal and Practice Development Midwives
Reference and / or Trust Docs ID No: 852
Version No: 11
RCOG. Green-top guideline no.52 (2016)
Compliance links: National Institute for Health and Care Excellence
CG190
If Yes - does the strategy/policy
Yes – New evidence regarding Tranexamic acid
deviate from the recommendations of
See section in text.
NICE? If so, why?

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 1 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Version and Document Control:

Version Date of
Change Description Author
Number Update
Change from Oxytocin to Syntometrine Daisy Nirmal
9.2 09/09/2019 for routine active management 3rd stage Rosie Goodsell
after Cochrane review Jon Francis
Added rate of post-partum oxytocin post Daisy Nirmal
10 05/03/2021 infusion - 166mL now, not 160mL as Rosie Goodsell
previously stated. Jon Francis
Daisy Nirmal
Change of proforma to include on-going
10.1 27/08/2021 Rosie Goodsell
assessment of blood loss
Jon Francis
Daisy Nirmal
Amendment of incorrect figure on
10.2 12/10/2021 Rosie Goodsell
flowchart
Jon Francis
In case of secondary postpartum
Daisy Nirmal
haemorrhage, retained products or
11 09/06/2022 Rosie Goodsell
anything of concern should be
Jon Francis
discussed with the consultant

This is a Controlled Document

Printed copies of this document may not be up to date. Please check the hospital intranet
for the latest version and destroy all previous versions.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 2 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Major Obstetric Haemorrhage on Delivery Suite Quick Reference

MLBU patients with EBL > 500ml should be discussed with Delivery Suite as they may
need urgent transfer for ongoing management (see section 2 below).

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 3 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Obstetric Haemorrhage Transfusion Flowchart

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 4 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Background

Obstetric haemorrhage remains one of the major causes of maternal death in both
developed and developing countries. The 2011–13 Confidential Enquiries into Maternal
Deaths and Morbidity report (1) identified 13 direct deaths due to obstetric haemorrhage in
the UK and Ireland: the report places obstetric haemorrhage as the second leading cause
of direct maternal deaths. The recommendations from the report focus on basic clinical
skills, with prompt recognition of the severity of a haemorrhage and emphasise
communication and teamwork in the management of these cases.

Antenatal anaemia should be investigated and treated appropriately as this may reduce
the morbidity associated with postpartum haemorrhage. (2) refer to The management of
anaemia in pregnancy guideline.

The management of women who refuse blood products presents a continuing challenge in
obstetric practice. These women should have an individual management plan documented
in the notes (refer to the existing departmental guideline on Obstetric haemorrhage in
women who refuse blood transfusion. Where appropriate, the RCOG “Care plan for
women in labour refusing a blood transfusion” should also be referred to.

The remit of this guideline is to inform practice in the event of Obstetric Haemorrhage. This
does not cover Management of Placenta Previa or suspected Accreta.

1. Antepartum Haemorrhage (APH)

The two most serious causes of APH are placenta praevia and placental abruption. It is
outside the remit of this guideline to discuss the predisposing factors and clinical features
of these conditions.

Placenta praevia leads to bleeding from a low-lying situated placenta. It is more common
pre-term, and the blood loss is typically ‘revealed’ and painless.

Placental abruption arises from premature detachment of a normally situated placenta

and complicates 0.5% - 1.8% of pregnancies, with serious maternal and fetal
consequences. It remains a significant cause of maternal mortality and morbidity. There
may be up to 60% perinatal mortality.

Complications of major APH:

 Hypovolaemia.
 DIC (Disseminated intravascular coagulation).
 Acute renal failure.
 ARDS (Acute respiratory distress syndrome).
 Fetal death.
 Postpartum haemorrhage.
 Maternal death.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 5 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

2. Post-Partum Haemorrhage (PPH)

Definition of PPH

Primary Postpartum haemorrhage (PPH) is the most common cause of Major

Obstetric haemorrhage. The traditional definition of primary PPH is the loss of 500 mL or
more of blood from the genital tract within 24 hours of the birth of a baby.

PPH can be minor (500–1000 mL) or major (more than 1000 mL). Major can be further
subdivided into moderate (1001–2000 mL) and severe (more than 2000 mL) (2).

Secondary PPH is defined as abnormal or excessive bleeding from the birth canal
Between 24 hours and 12 weeks postnatally. (3)

Principles of Management of Primary PPH

The midwife in charge and the first-line obstetric and anaesthetic staff should be alerted
when women present with minor PPH (blood loss 500–1000 mL) without clinical shock.
The aim being to recognise and arrest the bleeding before it becomes life-threatening. For
patients in the Midwifery-Led Birthing Unit (MLBU), if the Estimated Blood Loss (EBL) is
under 1000mLs, the bleeding has settled and the woman is stable and asymptomatic, it
may be appropriate to remain on MLBU, following discussion with the delivery suite Co-
ordinator. Where the EBL exceeds 1000mL, all women should be transferred to the
delivery suite.
(See MID34 Guideline for the Midwife-Led Birthing Unit (MLBU) Operational Guideline).

Measures for minor PPH (blood loss 500–1000 mL) without clinical shock:
 Intravenous access (one 16-gauge cannula).
 Urgent venepuncture (20 mL) for:
a. Group and screen.
b. Full blood count.
c. Coagulation screen.
 Pulse, respiratory rate, temperature and blood pressure plus MEOWS score
recording every 15 minutes.
 Commence warmed crystalloid infusion.

Failure to recognise and adequately treat a primary PPH can quickly lead to Major
obstetric Haemorrhage.

Pregnant women can initially compensate well, and signs of hypovolaemia may occur late.
Whilst significant haemorrhage may be apparent from observed physiological disturbances,
young fit pregnant women compensate remarkably well. Whilst a tachycardia commonly
develops there can be a paradoxical bradycardia and hypotension is always a very late sign.
Therefore, ongoing bleeding should be acted on without delay. Fluid resuscitation and blood
transfusion should not be delayed because of false reassurance from a single haemoglobin
result; consider the whole clinical picture. (1)

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 6 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

The circulating blood volume increases in pregnancy to approximately 100mL/kg and so

responses to the estimated blood loss should take the woman’s stature into account. For
example, a woman of 70kg who loses 1500mLs of blood has lost about 20% of her circulating
volume, whilst in a woman who weighs 55kg this would comprise almost 30%.

Estimated blood volumes and proportionate losses according to body weight (1)
Weight 15% blood volume 30% blood volume 40% blood volume
Total blood volume*
loss loss loss
50kg 5000mLs 750mLs 1500mLs 2000mLs
55kg 5500mLs 825mLs 1650mLs 2200mLs
60kg 6000mLs 900mLs 1800mLs 2400mLs
65kg 6500mLs 975mLs 1950mLs 2600mLs
70kg 7000mLs 1050mLs 2100mLs 2800mLs

Aetiology of PPH (The four Ts-Tone, trauma, tissue, thrombin)

1. Atonic uterus (accounts for 75 - 90% of cases)
2. Genital tract trauma (20%of cases)
3. Retained products (10% of cases)
4. Clotting defect (1% of cases)

Risk factors for PPH

1. Multiple pregnancy/polyhydramnios (i.e. uterine over distension) (Tone).
2. Previous PPH (Tone).
3. Placental abruption (Thrombin).
4. Prolonged labour/precipitate labour (Tone).
5. Failure to progress in second stage (Tone).
6. Prolonged third stage of labour (Tissue).
7. Retained placenta (Tissue).
8. Placenta accreta (Tissue).
9. Chorioamnionitis (Tone,Thrombin).
10. Perineal laceration (Trauma).
11. High parity (P4 and above) (Tone).
12. General anaesthesia (Tone).
13. Second stage Caesarean section (Tissue).

Initial Management of APH and PPH

If managed inadequately or in an untimely manner, major APH and PPH will quickly lead to
sudden maternal collapse.

Immediate Management

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 7 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

The initial management of obstetric haemorrhage involves assessment and maternal

resuscitation followed by treating the cause of haemorrhage – and this is common to both
APH and PPH.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 8 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Actions should occur simultaneously:

 Communication.
 Resuscitation.
 Monitoring and investigation.
 Arrest bleeding.

Speed is of the essence, so clear lines of communication between the midwifery, obstetric,
anaesthetic and the blood transfusion staffs is essential. Where feasible it is important to
keep the patient and her birthing partner informed of what is happening and proposed
management.

1. Call for HELP, pull the emergency buzzer. On the Midwifery Led Birthing Unit
(MLBU) the emergency buzzer will sound on Blakeney Ward and staff from there
will attend.
2. Request 2222 call and ask for the emergency obstetric team. State clearly the
location of the emergency, its nature, i.e. APH/PPH, and the room number.
3. If situation occurs on the MLBU, the Delivery Suite co-ordinator should be
contacted immediately and provision for transfer should be made. Immediate
emergency measures as indicated below should be initiated whilst arrangements
are being made for transfer.
4. The massive blood transfusion protocol should be followed, and laboratory staff
alerted by ringing extension 2905 and use of the trigger phrase “I want to trigger
the Massive Blood Transfusion Protocol”. This is linked to the trust guideline for
Massive blood loss in adults. This will obtain: 5 units of PRC and 4 of FFP.
5. Ensure sufficient personnel are available to carry urgent blood samples to the
transfusion department and blood and blood products from there. This is a role for
which Midwifery Care Assistants (MCAs) have had specific training.
6. Inform the on-call consultant obstetrician and consultant anaesthetist where
appropriate for instance 40 % blood volume loss or ongoing bleeding.
7. Where possible, allocate a scribe. Use the Obstetric Emergency Record chart to
record events.

Remember – ABC
1. Airway maintenance, if pregnant left lateral tilt. Chin lift.
2. Breathing - Administer oxygen 10 -15 L/min via a face mask
3. Circulation - Ensure IV access -16-gauge intravenous cannulae x 2.
4. Take bloods for FBC, U&E clotting and X-match (4 units) and Kleihauer if Rh negative. All
patients should be given blood of their own blood group as soon as possible. If the blood
bank is informed of the urgency, ABO and Rh D compatible blood can usually be made
available on an emergency basis soon after receipt of the crossmatch sample. Additional
colloid will be necessary if more than 3 units have been given. Only use un-crossmatched
O Rh D negative blood if transfusion must be given immediately.
5. Initial fluid management. Rapid infusion of 2000 mL of warmed Hartmann’s solution.
6. The anaesthetist will normally supervise the management of fluid replacement.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 9 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

7. An indwelling bladder catheter should be inserted with hourly measurement output.

8. Strict fluid balance is essential, and a fluid balance chart should be initiated and carefully
maintained.
9. Postnatal women can be laid flat possibly with a head down tilt if there are signs of
hypovolaemia,
10. Regular haemoglobin and haematocrit assessment is helpful but restoration of
normovolaemia is first priority.
11. Fluid resuscitation and blood transfusion should not be delayed because of false
reassurance from a single haemoglobin result; consider the whole clinical picture (1)
12. Platelet counts and coagulation studies should be performed as a guide to the need for
replacement therapy with fresh frozen plasma, cryoprecipitate or platelet concentrates.
13. A plasma fibrinogen level of greater than 2 g/L should be maintained during ongoing PPH.
14. Give 4g Fibrinogen Concentrate after first 4 units of blood transfused BEFORE considering
FFP and/or cryoprecipitate. (see full Fibrinogen concentrate guideline here - Trustdocs ID:
17727)
15. Clinicians should consider the use of intravenous tranexamic acid 1.0 g IV, in addition to
Oxytocin at caesarean section to reduce blood loss in women at increased risk of PPH. (2)
16. In a woman who is bleeding and is likely to develop a coagulopathy or has evidence of a
coagulopathy, it is prudent to give blood components before coagulation indices
deteriorate and worsen the bleeding. (1)
17. Keep the patient warm.
18. If bleeding is ongoing after the first 4 units of blood have been transfused and fibrinogen
concentrate given, then the primary pack from the major obstetric haemorrhage protocol
should be used (5 units RBC as indicated, 4 units FFP).
19. Ensure appropriate blood product replacement. Up to 1000 mL of fresh frozen plasma
(FFP) and 10 units of cryoprecipitate (two packs) maybe given in the face of relentless
bleeding, while awaiting results of coagulation studies.
20. Correct acidosis, hypothermia (clotting is prolonged with hypothermia – active warming
measures should be considered) & hypocalcaemia.
21. Involve consultant haematologist if coagulation defect before surgical intervention.
22. Monitor BP, pulse, urine output, O2 saturation, respiratory rate continuously and
temperature every 15 minutes – Record on Mega chart. In cases of severe APH
commence CTG. MEOWs Scores must be attributed to each set of observations.
23. Invasive intravascular monitoring may be initiated by the anaesthetist.
24. Record keeping. Ensure records are up to date and complete following the event and that
all drugs are prescribed.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 10 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Continuing Management of APH

Having resuscitated the mother, the subsequent obstetric management depends on the
severity of the bleeding and the condition and gestation of the fetus.

Placenta praevia (fetus dead or alive): If delivery is deemed necessary, then caesarean
section is the only safe option. Senior obstetric and anaesthetic staff should be involved,
with a consultant obstetrician scrubbed in theatre and two anaesthetists (at least one a
consultant), as a minimum. A consultant gynaecologist should be aware the case is going
on in theatre (although do not need to be present). 4 units of blood should be available in
the fridge on delivery suite.

Placental abruption:

Intrauterine death: Aim to deliver vaginally unless obstetric contraindication. Labour often
follows quickly. Perform amniotomy and augment with Oxytocin if indicated. Anticipate
PPH. Where an abruption results in fetal loss, a blood transfusion will usually be required.
Do not wait until the haemorrhage has been seen.

Live fetus: If signs of fetal compromise and viable gestation: perform a category “1”
Caesarean section under general anaesthetic.

If there is no fetal compromise, vaginal delivery may be appropriate. Discuss with

consultant on-call. Continuous electronic fetal heart rate monitoring is essential.

Continuing Management of PPH

Management of uterine atony

1. Anticipate the problem - those women with risk factors should already be on
Delivery Suite and have venous access and be receiving an Oxytocin infusion
post-partum of 30 units of Oxytocxin in 500 mL 0.9% normal saline at 166
mL/hour as per Trust Guideline for the Management of the Third Stage of Labour
including Retained Placenta Trustdocs ID: 818.
2. “Rub-up” the uterine fundus to stimulate uterine contraction, and consider removal
of vaginal/uterine clots. Consider Bi-manual compression.
3. Confirm that Syntometrine 5/500 IM was given in third stage - if not, do so. NB. In
pre-eclampsia or patients with a history of cardiac disease give 5 IU
Oxytocin by slow I.V. injection or 10 IU I.M.
4. Give 1g Tranexamic acid by slow I.V injection (~1mL/min). This is not a uterotonic,
so will not help uterine tone. However, it is an antifibrinolytic and has been shown
to reduce blood loss in this situation, especially if given early.
5. Repeat Syntometrine 5/500 (or Oxytocin if hypertensive or cardiac disease).
6. Commence infusion of 30 units of Oxytocin in 500 mL 0.9% normal saline at 166
mL/hour if not already in progress.
7. If ongoing bleeding at 30min or re-bleeding within 24 hours give a further 1g IV
Tranexamic Acid.
8. If the placenta is retained and uterus contracted, try controlled cord traction. If this
fails, arrange manual removal of placenta – see guideline for management of third
stage of labour.
Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)
Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 11 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

9. If atony persists, Carboprost (Hemabate), 250 mcg (1.0mL) may be given by deep
I.M. injection at the discretion of the Obstetric Registrar. If successful, further
doses (maximum of eight) may be required at 15-minute intervals, after discussion
with the on-call Consultant.
10. Misoprostol 800 mcg can be administered sub lingual.
11. Arrange urgent examination under anaesthesia if:
a. Significant haemorrhage continues despite a well contracted uterus.
b. Above measures fail to produce a tonic uterine contraction.
c. Bleeding is secondary to obvious genital tract trauma.
12. Consider Bakri Tamponade Balloon in selected cases
13. Consider B-Lynch brace suture in selected cases
14. Interventional radiology is available out of hours. If the bleeding persists, the
Obstetric Consultant can contact the Interventional Radiology Consultant on-call.
Trust Guideline for the Anaesthetic Management of Women with Known or
Suspected Abnormal Placentation requiring Interventional Radiology Trustdocs ID:
7504.
15. If bleeding is not responsive to the standard medical, surgical, radiological
treatment, rFVIIa may be considered. Discuss with consultant haematologist.
16. Cell salvage should be considered in selected cases after discussion with the
anaesthetist and the theatre staff (See also Trust guideline Joint Trust Guideline for
the Management of Intraoperative Cell Salvage in Obstetrics Trustdocs ID: 829).
17. Record keeping – procedures should be documented contemporaneously
throughout the event using the emergency PPH record chart by a scribe.
Documentation should include the persons present, tasks undertaken, drugs
given, and observations recorded including fluids given and urine output. Strict
fluid balance charts should be continued following the event with regular review by
the obstetrician.
18. If the emergency has occurred on the MLBU, the woman will be transferred to the
Delivery Suite following discussion with the co-ordinator and a transfer form
completed by the midwifery staff.
19. Communication: Document clear lines of communication between the consultant
obstetrician, consultant anaesthetist, haematologist, blood transfusion personnel,
Delivery Suite co-ordinator and senior midwife on MLBU.
20. Ensure the woman and her family are reassured throughout and are debriefed
after the event.

** Notes:
 Oxytocin infusion is the recommended first line treatment for primary PPH.
When used following prophylactic uterotonics, misoprostol and oxytocin
infusion work similarly. Vaginal, sublingual or rectal misoprostol took 1.0–2.5
hours to increase uterine tone. Clinicians should be aware of this delay in the
clinical effect of misoprostol. Guidelines from WHO and the International
Federation of Gynecology and Obstetrics recommend that in the management
of PPH, misoprostol is administered sublingually. (2,5,6)

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 12 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

 The WOMAN trial published April 2017 recommends the early use of
tranexamic acid in PPH (7). This trial Randomised 20,060 women with PPH
(>500mL Normal Vaginal Delivery or >1000mL Caesarean Section) from
multiple centres (193 hospitals worldwide) to either placebo or 1g I.V.
tranexamic acid alongside usual care. A significant reduction in mortality
from bleeding was found especially if given early (Relative risk 0.69 p=0.008)
with no increase in adverse events including thromboembolic events. This
confirms previous smaller, underpowered studies with similar results (8).

Secondary PPH:

Following initial resuscitation, appropriate use of antimicrobial therapy should be initiated

when endometritis is suspected.
A pelvic USS may be helpful to exclude the presence of retained products of conception.
Surgical evacuation of retained products should be undertaken by an experienced clinician
(2).
All cases of secondary PPH should be discussed/reviewed by a consultant and a plan for
management should be written in the notes.

Debriefing

An opportunity to discuss the events surrounding the obstetric haemorrhage should be

offered to the woman (possibly with her birthing partner) at a mutually convenient time.

Follow-up for MOH:

1. All cases of unanticipated peripartum hysterectomy should be subsequently
discussed on monthly Clinical Governance Meetings.
2. Incident/Datix to be completed for all cases of Obstetric haemorrhage where blood
loss is more than 1.5 litres).

Auditing and Monitoring Compliance

The process for audit, multidisciplinary review of results and subsequent monitoring of
action plans is detailed in the monitoring compliance table appendix 1 and 2.

Auditable standards (adapted from RCOG):

1. The proportion of women who are screened for antenatal anaemia (100%).
2. The proportion of women who are offered uterotonics for the third stage of labour
(100%).
3. The proportion of women undergoing assessment of risk factors for PPH when they
present in labour (100%).
4. Appropriate documentation of management.
5. Incident reporting of blood loss more than 1.5 L (100%).

Expectations in relation to staff training

The expectations for staff training are those detailed in the Training Needs Analysis.

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 13 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Distribution list / dissemination method

This guideline has been ratified by the O&G Clinical Guideline Committee and has been
disseminated via the hospital intranet to all members of obstetric staff.

References / source documents

1. Saving Lives, Improving Mothers’ Care Lessons learned to inform future maternity
care from the UK and Ireland Confidential Enquiries into Maternal Deaths and
Morbidity 2009-2012 ,Dec 2014
2. Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 52.
Prevention and management of postpartum haemorrhage. Dec 2016 .RCOG Press:
London.
3. Alexander J, Thomas PW, Sanghera J. Treatments for secondary postpartum
haemorrhage. Cochrane Database Syst Rev 2002;(1):CD002867.
4. Blood transfusion in obstetrics. RCOG guideline No : 47 , July 2008
5. Tang J, Kapp N, Dragoman M, de Souza JP. WHO recommendations for
misoprostol use for obstetric and gynecologic indications. Int J Gynaecol Obstet
2013;121:186–9.
6. International Federation of Gynaecology and Obstetrics Treatment of Post-Partum
Haemorrhage with Misoprostol. FIGO Guideline Annotated Version. London: FIGO;
2012.
7. Effects 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. The Lancet, April
2017: DOI: http://dx.doi.org/10.1016/S0140-6736(17)30638-4
8. Tranexamic acid for the prevention and treatment of postpartum haemorrhage. Brit
J Anaes 2015:114 (4): 576-87 doi:10.1093/bja/aeu448

Other useful reading:

Use of blood and blood products in obstetric practice RCOG guideline No:47
Royal College of Obstetricians and Gynaecologists. Antepartum
Haemorrhage. Green-top Guideline No. 63. London: RCOG; 2011.
Royal College of Obstetricians and Gynaecologists. Placenta
Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and
Management. Green-top Guideline No. 27. London: RCOG; 2011

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 14 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Postpartum Haemorrhage (PPH) /

Massive Obstetric Haemorrhage
Proforma Patient Identifier Label
Date Time
dd/mm/yyyy 24 hours clock

Consultant

Person Print name Signature Designation Date dd/mm/yyyy

completing form
(scribe)
Print name Designation

Personnel
present

Lead: Helicopter
view
Date If transferring to theatre 2nd name band
dd/mm/yyyy Completed 
Time actioned as
Call for help Tick when actioned appropriate
24 hour clock
Emergency bell activated 
2222 call -ask for Obstetric Emergency team 
Airway
Check airway 
Breathing
Check breathing 
Oxygen 10 litres/minute 
Circulation
Lie flat 
1st 16G cannula 
Rapid infusion of 2L warmed Crystalloid

(Hartmanns)
FBC 
G&S 
Take bloods
urgently for Clotting 
Crossmatch 6 units 
Nominate Tick and complete as appropriate
Print name of
Designated person to liaise with Transfusion  designated person
Crossmatch 6 units 
Consider 2nd 16g cannula when EBL
>1000mLs 

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 15 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Postpartum Haemorrhage (PPH) / Massive

Obstetric Haemorrhage Proforma
Date Time
dd/mm/yyyy 24 hours clock Patient Identifier Label
Consultant
Person completing Print name Signature Designation Date dd/mm/yyyy
form (scribe)
Consider
If Massive Obstetric Haemorrhage (blood loss >1000mLs / continuing haemorrhage or clinical
concerns): Activate the Massive Blood Transfusion Protocol Trustdocs ID 852.
Contact x2905. State 'I wish to activate the Massive Obstetric Haemorrhage Protocol'
Inspect (Think
Tone Tissue Tick as applicable
Trauma
Thrombin)
Uterus is well
Yes  No  if no, consider uterotonics
contracted
Placenta and
membranes Yes  No  if no, consider EUA
complete
Genital tract any
Yes  No  if yes, consider repair
trauma?
Clotting defect
Yes  No  if yes, consider discussion with haematologist
suspected
Time actioned as appropriate
Monitor Tick as appropriate 24 hour clock
Maternal
observations on 
MEOWs chart
EBL ( Ongoing Time Weighed? Y/N
assessment – be  mLs
aware of  mLs
persistent  mLs
insidious loss  mLs
(trickling))  mLs
Treatment -
Time actioned as appropriate
ARREST THE Tick as applicable
24 hour clock
BLEEDING
Massage the
uterus, expel

clots, 'rub-up'
contraction
Urinary catheter 
Bimanual

compression
Time actioned as appropriate
Drugs Tick as applicable
24 hour clock
Syntometrine
5/500 IM (NB if
hypertensive or

cardiac disease
use Oxytocin 10
units IM)
Tranexamic acid

1g IV
Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)
Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 16 of 17
 Trust Guideline for the Management of: Major Obstetric Haemorrhage (MOH)

Oxytocin infusion
(30 iu Oxytocin in
500mL 0.9% 
sodium chloride
at 166mL/hr
Carboprost
(Hemabate)
250mcg IM every 
15 minutes up to
8 doses.
Repeat dose of

Syntometrine
Consider Theatre
Inform consultant 
Consider Blood Transfusion
Red cells 
O Neg (available in Delivery Suite blood fridge – consider in case of life threatening haemorrhage)
Incident form Tick as appropriate Time actioned as appropriate 24 hour clock
Incident form
Yes  No  If yes - Datix reference
completed

Clinical Guideline for: Management of Major Obstetric Haemorrhage (MOH)

Author/s: Daisy Nirmal, Consultant Obstetrician, Rosie Goodsell, Practice Development Midwife, Jon Francis, Consultant Anaesthetist,
Amanda Anderson, Practice Development Midwife, Sue Holland, Clinical Effectiveness Midwife
Approved by: Maternity Guidelines Committee Date approved: 09/06/2022 Review date: 09/06/2025
Available via Trust Docs Version: 11 Trust Docs ID: 852 Page 17 of 17