Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock



      This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock.

      Target population

      All pregnant patients.

      Benefits, harms, and costs

      Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays.


      Medical literature, PubMed,, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols.

      Validation methods

      The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

      Intended Audience

      All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.


      • 1.
        An individualized risk assessment for postpartum hemorrhage should be documented in a checklist upon arrival to a labour unit and updated throughout labour and delivery (strong, high). The risk assessment should include a calculation of the maximum allowable blood loss (good practice point).
      • 2.
        Both antenatal and postnatal anemia should be identified and treated aggressively (strong, high).
      • 3.
        Quantitative blood loss measurement should replace estimated blood loss in all patients whenever possible (strong, moderate).
      • 4.
        Staging and management of postpartum hemorrhage should be based on quantitative blood loss (strong, high).
      • 5.
        Active management of the third stage of labour should be offered to all women (strong, high).
      • 6.
        Prophylactic intramuscular oxytocin can be used for patients at low risk for postpartum hemorrhage (strong, high).
      • 7.
        For patients at high risk of postpartum hemorrhage, prophylactic intravenous oxytocin should be used (conditional, moderate).
      • 8.
        When given intravenously, oxytocin can be given either as a rapid infusion (max rate 1 IU/min) for 4 minutes, followed by 7.5–15 IU/h or as a 3 IU intravenous rapid injection (strong, moderate)
      • 9.
        If there is inadequate response to oxytocin within 4 minutes, a second-line uterotonic should be administered (strong, high).
      • 10.
        Carbetocin can be considered as a first-line agent for postpartum hemorrhage prophylaxis at cesarean delivery (strong, moderate).
      • 11.
        Bimanual uterine compression and bladder emptying should be performed as first-line measures while waiting for pharmacologic agents to take effect (good practice point).
      • 12.
        Misoprostol (sublingual/oral) is an effective adjunct to prophylactic or therapeutic oxytocin in high-risk individuals (strong, high)
      • 13.
        Intramuscular ergotamine and intramuscular or intramyometrial carboprost, can both be used to treat active postpartum hemorrhage (strong, high).
      • 14.
        Rectal misoprostol is inferior to other routes (both in onset and in bioavailability) and should not be used (strong, moderate).
      • 15.
        Tranexamic acid can be used in all patients as an adjunct to uterotonics in the setting of postpartum hemorrhage, and can be used as a prophylactic agent in patients at high risk for postpartum hemorrhage (strong, high).
      • 16.
        Uterine tamponade is an effective tool and should be considered for ongoing mild to moderate bleeding (conditional, moderate).
      • 17.
        If the placenta has not been expelled spontaneously in the 30 minutes following delivery, measures should be taken to expedite delivery of the placenta (strong, high).
      • 18.
        When there is ongoing bleeding, examine the patient for the presence of clots, retained placental tissue, or genital tract lacerations (good practice point).
      • 19.
        In the case of uterine inversion, if immediate reversion is not possible, transfer the patient to an operating room for uterine relaxation and patient stabilization, as required (good practice point)
      • 20.
        If pharmacologic interventions have not controlled bleeding, surgical intervention should be undertaken promptly (strong, high)
      • 21.
        Compression sutures, ligation of uterine or internal iliac arteries, and uterine artery embolization are all effective interventions that can be considered; however, hysterectomy should not be delayed in an unstable patient (strong, high).
      • 22.
        Severe obstetrical hemorrhage should be managed by a multidisciplinary team consisting of obstetrics, anaesthesia, nursing, and transfusion medicine (strong, high).
      • 23.
        An obstetrical massive hemorrhage protocol, including defined roles and responsibilities of each team member, should be used (strong, moderate).
      • 24.
        Initial resuscitative and monitoring measures should include intravenous access × 2, electrocardiography, oxygen saturation, blood pressure, placement of an indwelling urethral catheter, euthermia, and volume replacement with balanced crystalloid (good practice point).
      • 25.
        Four units red blood cells should be given prior to other blood products in an actively bleeding patient who is approaching the maximum allowable blood loss, unless the patient has a coagulation defect (strong, moderate)
      • 26.
        Fibrinogen levels should be measured in every moderate to severe case of postpartum hemorrhage, and if <2 g/L, should be replaced accordingly (strong, high).
      • 27.
        A massive hemorrhage protocol with ratios of red blood cells to fresh frozen plasma to platelets of 1:1:1: or 2:1:1 can be used in the absence of timely lab results (strong, moderate).
      • 28.
        Simulation training with all members of the multidisciplinary team should occur on a regular basis, ideally by a trained facilitator (strong, high).



      CD (cesarean delivery), MABL (maximum allowable blood loss), MHP (massive hemorrhage protocol), PPH (postpartum hemorrhage), TXA (tranexamic acid)
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