BMJ 2017;358:j3875 doi: 10.1136/bmj.
j3875 (Published 2017 September 27)
Practice
CLINICAL UPDATES
Diagnosis and management of postpartum
haemorrhage
Edwin Chandraharan consultant obstetrician and gynaecologist, lead clinician of labour ward, and
1 2
honorary senior lecturer , Archana Krishna specialist registrar in obstetrics and gynaecology
1
St George’s University Hospitals NHS Foundation Trust, London SW17 0QT, UK; 2St George’s University of London, London, UK
Postpartum haemorrhage is a major cause of death during
pregnancy and early motherhood, accounting for 25% of
maternal deaths worldwide,1 and is the second leading direct
cause of maternal deaths in the UK.2 It is defined as blood loss
of more than 500 mL from the female genital tract after delivery
of the fetus (or >1000 mL after a caesarean section). Primary
postpartum haemorrhage occurs within the first 24 hours of
delivery, whereas secondary postpartum haemorrhage occurs
between 24 hours and 12 weeks after delivery and is less
common.1 For every maternal death due to postpartum
haemorrhage, there are at least 10 “near-misses.” Serious
maternal morbidities include multiorgan failure, multiple blood
transfusion, and peripartum hysterectomy.1 There have been
recent advances in the management of postpartum haemorrhage
secondary to coagulopathy and abnormal invasion of the
placenta.3
This review highlights the causes, diagnosis, and management
of postpartum haemorrhage and is aimed at those involved in
obstetric and postnatal care.
What are the mechanisms of and risk
factors for postpartum haemorrhage?
Atonic postpartum haemorrhage secondary to a poor tone of
the uterine muscle accounts for approximately 80% of all women
with excessive bleeding from the genital tract within 24 hours
of delivery.4 Women who have had prolonged labour, multiple
pregnancy, polyhydramnios, a large fetus, obesity, or pyrexia
during labour are all at increased risk.5 Rare causes of primary
postpartum haemorrhage include uterine inversion, placenta
percreta (fig 1⇓), as well as extra-genital bleeding. The
commonest cause of secondary postpartum haemorrhage is
endometritis.
It is estimated that over 85% of women who have a vaginal
birth will sustain some degree of perineal trauma, and, of these,
60-70% will need to be sutured.6 7 An episiotomy itself can
increase the risk of postpartum haemorrhage by up to fivefold.8
Correspondence to: E Chandraharan edchandi@yahoo.co.uk
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Page 1 of 6
PRACTICE
1
Emergency caesarean sections were associated with an
approximately threefold increase in postpartum haemorrhage
compared with elective caesarean sections or spontaneous
vaginal births.9
A population based, cohort nested, case-control study has
concluded that, after adjustment for all potential confounders,
intrapartum use of oxytocin was associated with a significantly
higher risk of severe postpartum haemorrhage (adjusted odds
ratio 1.8 (95% confidence interval 1.3 to 2.6)) in women who
did not receive prophylactic oxytocin after delivery; the odds
ratio for haemorrhage increased from 1 to 5 according to the
level of oxytocin exposure.10 It is postulated that this is due to
excessive uterine contractions and resultant lactic acidosis in
the uterine muscle as well as prolonged labour, when oxytocin
is used to augment labour.
How is primary postpartum haemorrhage
assessed and diagnosed?
Examination and resuscitation
Attempt to identify the cause in women who are bleeding
immediately after birth in parallel with resuscitation. The
infographic suggests an approach to management adapted from
the Royal College of Obstetricians and Gynaecologists
Green-top Guideline on postpartum haemorrhage.5
Further assessment
It is important to perform a systematic examination immediately
after birth11 so that specific treatments can be instituted (see
infographic).
Any delay in achieving haemostasis after birth can result in
major loss of maternal blood volume, leading to hypotension,
hypoxia, and acidosis. The blood flow to the uterus at term (that
is, >37 weeks of gestation) is approximately 1000 mL of blood
every minute, and a fetus at term receives about 200
mL/kg/minute from the placenta.12 Estimating the amount of
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BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 2017 September 27) Page 2 of 6

PRACTICE

What you need to know

• Postpartum haemorrhage remains the second leading direct cause of maternal deaths in the UK and the leading cause of maternal
mortality in the world
• Poor uterine tone accounts for about 80% of all cases of primary postpartum haemorrhage, whereas endometritis is the commonest
cause of secondary postpartum haemorrhage presenting up to 12 weeks after delivery
• Tranexamic acid is recommended for all women with atonic and traumatic postpartum haemorrhage as well as for ongoing haemorrhage
during a caesarean section
• Refer women with secondary postpartum haemorrhage after birth for ultrasonography to exclude retained products of conception or
endometritis
• Start broad spectrum antibiotics in women with secondary postpartum haemorrhage due to endometritis

Sources and selection criteria

We searched PubMed using the key words “postpartum haemorrhage,” “balloon tamponade,” “uterine compression suture,” “embolization,”
and “obstetric haemorrhage” from 1981 to 2016. We also considered review articles from 2001 to 2016 including systematic and narrative
reviews as well as the most recent Cochrane systematic review on treatment for primary postpartum haemorrhage.21 Priority was given to
randomised controlled trials and four large prospective series.

blood that has been actually lost in postpartum haemorrhage
visually is prone to error.13
An obstetric shock index (that is, pulse rate divided by systolic
blood pressure) of >1 has been shown to be associated with
substantial postpartum haemorrhage and the need for intensive
resuscitation and blood transfusion.14 15 In our clinical opinion,
an obstetric shock index of >1 would indicate the need for
immediate action to ensure haemodynamic stability.
A management algorithm called HAEMOSTASIS has been
proposed to aid a systematic and stepwise management of
postpartum haemorrhage (box 1),11 and a recent retrospective
observational study has suggested that the use of this algorithm
has helped improve outcomes and reduced the likelihood of
peripartum hysterectomy.16 “HAEMO” refers to the immediate
measures to be taken to arrest haemorrhage, while “STASIS”
represents the more advanced measures (box 1).
Intra-abdominal bleeding secondary to an extragenital cause
such as the rupture of the liver or spleen is uncommon, but may
be more likely in women with severe pre-eclampsia due to
rupture of the hepatic capsule. If a woman remains unresponsive
to treatment or if the amount of visible blood loss is less than
the observed haemodynamic instability, we recommend an
ultrasound scan to investigate a possible intra-abdominal cause.
How is postpartum haemorrhage
managed?
It is important to identify both antepartum and postpartum risk
factors that might predispose women to postpartum
bleeding—such as placenta praevia, uterine fibroids, and
retained placenta—as outlined in the infographic. Planning
ahead involves input from a multidisciplinary team to ensure
that experienced clinicians are present at the birth and there are
suitable blood products available.
Active management of the third stage of labour is the process
by which expulsion of the placenta and membranes is achieved
after delivery by uterine massage, controlled cord traction, and
the use of oxytocin as well as other drugs.
A randomised controlled trial showed that active management
of the third stage alone reduces the incidence of primary
postpartum haemorrhage by 70% compared with physiological
management alone.17 Clinical guidelines on postpartum
haemorrhage continue to recommend mechanical methods such
as bimanual compression or emptying the urinary bladder based
on consensus of professional opinion.5
What drugs are used in the medical
management of primary postpartum
haemorrhage?
Oxytocin is the most commonly used drug in the medical
management of postpartum haemorrhage. Other drugs are listed
in box 2.
The incidence of postpartum hypertension has been found to be
significantly lower in women who received carbetocin compared
with those who received syntometrine.23 Therefore, ergometrine
and syntometrine should be avoided in women with hypertension
and pre-eclampsia to avoid the risk of stroke.
Although, injectable prostaglandins (prostaglandin F2α and its
synthetic analogue carboprost tromethamine) have been used
as an adjunct to oxytocin in the management of atonic
postpartum haemorrhage, they have not been subjected to any
randomised controlled trials. Despite the lack of robust scientific
evidence, most clinical guidelines recommend the use of
injectable prostaglandins in the management algorithm, up to
eight doses 15 minutes apart of 250 μg given intramuscularly.5
Use prostaglandins with caution in patients with bronchial
asthma as it is not recommended as an intra-myometrial
injection.5
A recent Cochrane systematic review of 10 randomised
controlled trials reported that, compared with placebo, treatment
with tranexamic acid (1 g intravenous) reduced blood loss in
women with atonic postpartum haemorrhage,21 and therefore
tranexamic acid is recommended for atonic and traumatic
postpartum haemorrhage as well as ongoing haemorrhage during
a caesarean section.5
What is the role of a uterine tamponade
balloon?
A recent systematic review, which included 241 women, has
concluded that the insertion of a uterine tamponade balloon to
control bleeding is effective in 97% of cases of postpartum
haemorrhage.24 The authors suggested that it would be logical
to use this least invasive, easiest, and most rapid approach as
the first step in the management of intractable postpartum
haemorrhage after the failure of pharmacological treatment.
However, this systematic review did not include any randomised
controlled trials and therefore the conclusion should be
interpreted with caution.

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BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 2017 September 27) Page 3 of 6

PRACTICE

Box 1: HAEMOSTASIS algorithm for management of postpartum haemorrhage16

H—Ask for help and hands on uterus (uterine massage)
A—Assess (that is, ABC) and resuscitate (that is, intravenous fluids)
E—Establish aetiology, ensure availability of blood, and ecbolics (drugs that induce contractions of the uterus, oxytocin or ergometrine)
M—Massage the uterus
O—Oxytocin infusion (10 U/hour) or intramuscular prostaglandins (250 μg)
S—Shift to theatre, with aortic compression, bimanual compression, or anti-shock garment (for low resource settings before transfer to a tertiary centre)
as appropriate
T—Tamponade by balloon or uterine packing after exclusion of retained tissue and trauma. Administer intravenous tranexamic acid (1 g)
A—Apply compression sutures on the uterus (B-Lynch or modified technique)
S—Systematic pelvic devascularisation (uterine, ovarian, quadruple. or internal iliac)
I—Interventional radiology and, if appropriate, uterine artery embolisation
S—Subtotal or total abdominal hysterectomy

Box 2: Drugs used in treatment of postpartum haemorrhage (source: BNF Online June 2017)
First line drugs
Oxytocin (octapeptide which is secreted by the supraoptic and paraventricular nuclei of the hypothalamus and is stored in the posterior pituitary
gland)
Mode of action—Myometrial contraction and retraction; increases basal uterine tone
Side effects—Nausea, vomiting, headache
Ergometrine (ergot alkaloid)
First line drug in developing countries
Mode of action—Arterial vasoconstriction and myometrial contraction
Side effects—Vomiting, headache, hypertension, chest pain, palpitations, bradycardia, Raynaud’s syndrome, pulmonary oedema18

Second line drugs

Tranexamic acid
Mode of action—Antifibrinolytic which prevents the breakdown of preformed blood clot and therefore stabilises the clot
Side effects—Hypotension, diarrhoea, thromboembolic events
Recent Cochrane review of 10 randomised controlled trials (RCTs) reported that blood losses >400 mL or >500 mL and >1000 mL were less
common in women who received tranexamic acid compared with placebo or no intervention (risk ratios 0.52 (95% confidence interval 0.42 to
0.63) and 0.40 (0.23 to 0.71), respectively)19
Misoprostol (prostaglandin analogue)20
Mode of action—Myometrial contraction
Side effects—Diarrhoea, rash, dizziness, vomiting21
Not found to be effective after administration of oxytocin21 and may increase adverse effects22
Prostaglandins F2α
Mode of action—Myometrial contraction
Side effects—Bronchospasm, cardiovascular system collapse, dyspnoea, hypertension, vomiting, pulmonary oedema
No robust evidence of effectiveness
Carbetocin (synthetic oxytocin analogue)
Mode of action—Myometrial contraction
Side effects—Diarrhoea, hypotension
Cochrane review of 11 RCTs concluded that use of carbetocin statistically significantly reduced the need for therapeutic uterotonics (risk ratio
0.62 (0.44 to 0.88) compared with oxytocin for women who underwent caesarean section but not for vaginal delivery.23 There was no robust
evidence to suggest that carbetocin was better than oxytocin in reducing postpartum haemorrhage, and its cost effectiveness remains unclear
Syntometrine (combination of 5 units of oxytocin and 0.5 mg of ergometrine)
Mode of action—Myometrial contraction
Side effects—Nausea, vomiting, diarrhoea
Cochrane review of 4 RCTs that compared carbetocin and syntometrine showed a lower mean blood loss in women who received carbetocin
(mean difference −48.84 mL (95% CI −94.82 to −2.85 mL)23

What are the surgical treatment options for
managing primary postpartum haemorrhage?
Some women may need examination under anaesthesia to repair
tears or trauma to the genital tract and the uterus, evacuation of
retained products, insertion of balloon for tamponade, or
drainage of a haematoma.25 Surgery may also be needed in case
of bleeding that is not responsive to volume resuscitation and
pharmacological treatment.
Some women may need an exploratory laparotomy in order to
insert compression sutures and to manage uncommon
extra-genital sources of bleeding such as rupture of splenic
artery aneurysm.26 27
Women who remain unresponsive to resuscitation despite
measures aimed at controlling the ongoing haemorrhage may
need a hysterectomy as a lifesaving measure.5 In centres where
blood and blood products are not readily available, hysterectomy
may be considered earlier to avoid dilutional coagulopathy
secondary to the excessive transfusion of intravenous fluids as
well as the loss of platelets, fibrinogen, and clotting factors (that
is, the “washout phenomenon”).

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BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 2017 September 27)
How is secondary postpartum
haemorrhage managed?
As secondary postpartum haemorrhage occurs anytime between
24 hours and 12 weeks after delivery (most commonly between
day 7 and day 14), it is important that clinicians working in
community health settings are able to diagnose and manage it
(see box 3).
History and assessment
Consider the possibility of retained products of conception or
endometritis in women with a history of manual removal of
placenta or prolonged rupture of membranes, prolonged labour,
or pyrexia during labour. Refer these women for an ultrasound
scan to exclude retained products of conception. Start broad
spectrum antibiotics in women with secondary postpartum
haemorrhage due to endometritis. Retained products of
conception may require surgical evacuation.5
What’s new in the management of
postpartum haemorrhage?
Tranexamic acid
The international, randomised, double blind, placebo controlled
WOMAN trial reported that tranexamic acid reduces death due
to bleeding in women with postpartum haemorrhage with no
adverse effects.27 This is consistent with the findings in surgery
and trauma (CRASH-2 trial).28 Therefore, based on the recent
WOMAN trial, tranexamic acid is recommended in the routine
management of postpartum haemorrhage unless there are
specific contra-indications.
Blood and blood products
A recent randomised controlled trial (PROPPR trial, 2015)
reported that initial infusion with plasma, platelets, and red
blood cells in a 1:1:1 ratio did not improve overall survival
compared with a 1:1:2 ratio in patients who had had or were at
risk of massive blood loss.29 However, in additional analyses,
more patients in the 1:1:1 group were reported to achieve
“anatomic” haemostasis (objective assessment by the surgeon
indicating that bleeding within the surgical field was controlled
and no further haemostatic interventions were anticipated), and
fewer patients may have died due to exsanguination by 24 hours.
A 1:1 transfusion ratio of plasma to red blood cells is
recommended, especially if bleeding is not under control.5 In
acute emergencies where group-specific cross-matched blood
is not readily available, consider O− “un-cross-matched” blood.
Abnormal invasion of the placenta
Abnormal and deep invasion of the placenta into the uterine
myometrium (fig 1⇓) is associated with serious maternal
morbidity and mortality secondary to massive obstetric
haemorrhage.30 It has traditionally been managed with
peripartum hysterectomy or intentional retention of placenta.
However, a new conservative surgical technique called the triple
P procedure has been described31 with good outcomes.32
Contributors: EC and AK designed the manuscript and AK performed
the literature search. EC and AK co-wrote the manuscript, and EC is
the guarantor and takes overall responsibility for the manuscript.
Competing interests: We have read and understood BMJ policy on
declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; externally peer reviewed.
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Page 4 of 6
PRACTICE
1 World Health Organization. WHO recommendations for the prevention and treatment of
postpartum haemorrhage. WHO, 2012. http://apps.who.int/iris/bitstream/10665/75411/1/
2
9789241548502_eng.pdf
Knight M, Tuffnell D, Kenyon S, Shakespeare J, Gray R, Kurinczuk JJ (eds) on behalf of
MBRRACE-UK. Saving lives, improving mothers’ care: Surveillance of maternal deaths
in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland
Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. National Perinatal
Epidemiology Unit, 2015.
3 Chandraharan E, Arulkumaran S. Massive postpartum haemorrhage and management
of coagulopathy. Obstetrics, Gynaecol Reprod Med 2007;358:119-22doi:10.1016/j.ogrm.
2007.02.004.
4 Arulkumaran S, Decruz B. Surgical management of severe postpartum haemorrhage.
Curr Obstet Gynaecol 1999;358:101-5doi:10.1016/S0957-5847(99)90008-2.
5 Mavrides E, Allard S, Chandraharan E, et al. Prevention and management of postpartum
haemorrhage: Green-top Guideline No 52. BJOG 2016;358:e106-49.pmid:27981719.
6 McCandlish R, Bowler U, van Asten H, et al. A randomised controlled trial of care of the
perineum during second stage of normal labour. Br J Obstet Gynaecol 1998;358:1262-72.
doi:10.1111/j.1471-0528.1998.tb10004.x pmid:9883917.
7 Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I. West Berkshire perineal
management trial. Br Med J (Clin Res Ed) 1984;358:587-90. doi:10.1136/bmj.289.6445.
587 pmid:6432201.
8 Combs CA, Murphy EL, Laros RK Jr. Factors associated with postpartum hemorrhage
with vaginal birth. Obstet Gynecol 1991;358:69-76.pmid:1984230.
9 Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric
haemorrhage in Scotland, 2003-05. BJOG 2007;358:1388-96. doi:10.1111/j.1471-0528.
2007.01533.x pmid:17949379.
10 Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C.
Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based,
cohort-nested case-control study. BMJ Open 2011;358:e000514. doi:10.1136/bmjopen-
2011-000514 pmid:22189353.
11 Chandraharan E, Arulkumaran S. Management algorithm for atonic postpartum
haemorrhage. J Paediatr Obstet Gynaecol 2005;358:106-12.
12 Ferrazzi E, Rigano S, Padoan A, Boito S, Pennati G, Galan HL. Uterine artery blood flow
volume in pregnant women with an abnormal pulsatility index of the uterine arteries
delivering normal or intrauterine growth restricted newborns. Placenta 2011;358:487-92.
doi:10.1016/j.placenta.2011.04.004 pmid:21531458.
13 Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at
obstetric haemorrhage using clinical reconstructions. BJOG 2006;358:919-24. doi:10.
1111/j.1471-0528.2006.01018.x pmid:16907938.
14 Le Bas A, Chandraharan E, Addei A, Arulkumaran S. Use of the “obstetric shock index”
as an adjunct in identifying significant blood loss in patients with massive postpartum
hemorrhage. Int J Gynaecol Obstet 2014;358:253-5. doi:10.1016/j.ijgo.2013.08.020 pmid:
24373705.
15 Nathan HL, El Ayadi A, Hezelgrave NL, et al. Shock index: an effective predictor of outcome
in postpartum haemorrhage?BJOG 2015;358:268-75. doi:10.1111/1471-0528.13206 pmid:
25546050.
16 Varatharajan L, Chandraharan E, Sutton J, Lowe V, Arulkumaran S. Outcome of the
management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”.
Int J Gynaecol Obstet 2011;358:152-4. doi:10.1016/j.ijgo.2010.11.021 pmid:21396642.
17 Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active
versus physiological management of third stage of labour. BMJ 1988;358:1295-300. doi:
10.1136/bmj.297.6659.1295 pmid:3144366.
18 Prata N, Bell S, Weidert K. Prevention of postpartum hemorrhage in low-resource settings:
current perspectives. Int J Womens Health 2013;358:737-52. doi:10.2147/IJWH.
S51661 pmid:24259988.
19 Novikova N, Hofmeyr GJ, Cluver C. Tranexamic acid for preventing postpartum
haemorrhage. Cochrane Database Syst Rev 2015;(6):CD007872. doi:10.1002/14651858.
CD007872.pub3. pmid:26079202.
20 Elati A, Weeks A. Misoprostol for the management of postpartum haemorrhage. BMJ
2011;358:d2877. doi:10.1136/bmj.d2877 pmid:21571915.
21 Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Z. Treatment for primary
postpartum haemorrhage. Cochrane Database Syst Rev 2014;(2):CD003249. doi:10.
1002/14651858.CD003249.pub3. pmid:24523225.
22 Quibel T, Ghout I, Goffinet F, et al. Groupe de Recherche en Obstétrique et Gynécologie
(GROG). Active management of the third stage of labor with a combination of oxytocin
and misoprostol to prevent postpartum hemorrhage: a randomized controlled trial. Obstet
Gynecol 2016;358:805-11. doi:10.1097/AOG.0000000000001626 pmid:27607864.
23 Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum haemorrhage.
Cochrane Database Syst Rev 2012;(2):CD005457. doi:10.1002/14651858.CD005457.
pub3. pmid:22336812.
24 Tindell K, Garfinkel R, Abu-Haydar E, et al. Uterine balloon tamponade for the treatment
of postpartum haemorrhage in resource-poor settings: a systematic review. BJOG
2013;358:5-14. doi:10.1111/j.1471-0528.2012.03454.x pmid:22882240.
25 Chandraharan E, Arulkumaran S. Surgical aspects of postpartum haemorrhage. Best
Pract Res Clin Obstet Gynaecol 2008;358:1089-102. doi:10.1016/j.bpobgyn.2008.08.
001 pmid:18790675.
26 Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative
management of postpartum hemorrhage: what to do when medical treatment fails. Obstet
Gynecol Surv 2007;358:540-7. doi:10.1097/01.ogx.0000271137.81361.93 pmid:17634155.
27 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;358:2105-16. doi:10.1016/S0140-6736(17)30638-4 pmid:28456509.
28 Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and
economic evaluation of the effects of tranexamic acid on death, vascular occlusive events
and transfusion requirement in bleeding trauma patients. Health Technol Assess
2013;358:1-79. doi:10.3310/hta17100 pmid:23477634.
29 Holcomb JB, Tilley BC, Baraniuk S, et al. PROPPR Study Group. Transfusion of plasma,
platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe
trauma: the PROPPR randomized clinical trial. JAMA 2015;358:471-82. doi:10.1001/jama.
2015.12 pmid:25647203.
30 Khong TY, Robertson WB. Placenta creta and placenta praevia creta. Placenta
1987;358:399-409. doi:10.1016/0143-4004(87)90067-1 pmid:3684969.
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BMJ 2017;358:j3875 doi: 10.1136/bmj.j3875 (Published 2017 September 27) Page 5 of 6

PRACTICE

Box 3: Tips for non-specialists

• Secondary postpartum haemorrhage occurs after the first 24 hours following childbirth and is most commonly due to endometritis or
retained products of conception
• Consider secondary postpartum haemorrhage in women who have excessive bleeding (that is, passage of clots or continuous bleeding)
which is more than the normal lochia after childbirth
• Check the woman’s temperature and exclude uterine tenderness, offensive vaginal discharge, or failure of uterine involution
• Refer to an obstetrician for an early clinical assessment and ultrasound scanning to exclude retained products of conception

Education into practice

• If a woman presents with vaginal bleeding up to 12 weeks after delivery in the community, do you palpate her abdomen for uterine
size, tone, and tenderness? The uterus should not be palpable per abdomen by day 14; a palpable uterus at this stage should make
you suspect endometritis or retained products of conception.
• How can you ensure that women who have a primary postpartum haemorrhage on their discharge summary receive specific follow-up
to assess their bleeding, their haemoglobin levels, and monitor oral iron supplementation? Do you have a local pathway in place to
support this, and if not, can you create one?

Educational resources
• Royal College of Obstetricians and Gynaecologists. Postpartum haemorrhage, prevention and management (Green-top Guideline
No 52). RCOG Press, 2016. www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/
• World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. WHO, 2012. http:
//apps.who.int/iris/bitstream/10665/75411/1/9789241548502_eng.pdf
• Hunt BJ, Allard S, Keeling D, et al. A practical guideline for the haematological management of major haemorrhage. Br J Haematol
2015;170:788-803. doi:10.1111/bjh.13580

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

31 Chandraharan E, Rao S, Belli AM, Arulkumaran S. The Triple-P procedure as a
conservative surgical alternative to peripartum hysterectomy for placenta percreta. Int J
Gynaecol Obstet 2012;358:191-4. doi:10.1016/j.ijgo.2011.12.005 pmid:22326782.
32 Teixidor Viñas M, Belli AM, Arulkumaran S, Chandraharan E. Prevention of postpartum
hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study
comparing outcomes before and after introduction of the Triple-P procedure. Ultrasound
Obstet Gynecol 2015;358:350-5. doi:10.1002/uog.14728 pmid:25402727.
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PRACTICE

Figure

Fig 1 Placenta percreta invading the uterine myometrium and the serosa

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