Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage

What this guideline says

GMJ summary

These consolidated guidelines present 51 evidence-based recommendations addressing postpartum haemorrhage (PPH), the leading cause of maternal death in most low-income countries. Developed jointly by WHO, FIGO and ICM, they integrate prevention strategies from pregnancy through the immediate postpartum period, diagnostic criteria and treatment protocols for both first-response and refractory PPH.

Key preventive measures include antenatal treatment of iron-deficiency anaemia, universal prophylactic uterotonic use (oxytocin 10 IU intramuscularly/intravenously, heat-stable carbetocin 100 μg, or misoprostol 400–600 μg orally), objective blood loss measurement and early detection. For diagnosis, the guidelines introduce new criteria: objectively measured blood loss ≥300 mL with abnormal haemodynamic signs or ≥500 mL, whichever occurs first. First-response treatment includes uterotonic agents, early tranexamic acid (within 3 hours), uterine massage and intravenous fluids delivered as a standardized bundle.

The guidelines explicitly do not recommend tranexamic acid for PPH prevention, ergometrine/methylergometrine for prophylaxis, or routine episiotomy. They emphasize health systems strengthening through formal protocols, simulation training and supply chain reliability for quality-assured medicines.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Diagnose PPH when objectively measured blood loss ≥300 mL with any abnormal haemodynamic sign (pulse >100 bpm, shock index >1, systolic BP <100 mmHg or diastolic BP <60 mmHg), or ≥500 mL, whichever occurs first within 24 hours after birth
2. Give prophylactic uterotonic to all women: oxytocin 10 IU IM/IV (preferred), carbetocin 100 μg IM/IV (heat-stable formulation where cold chain unreliable), or misoprostol 400–600 μg orally, administered within 1 minute of birth
3. For PPH treatment, give intravenous oxytocin plus tranexamic acid 1 g IV slowly within 3 hours of birth, uterine massage, isotonic crystalloids and examine genital tract
4. Do NOT use tranexamic acid for PPH prevention at vaginal or caesarean birth; reserve it for treatment only
5. Do NOT use ergometrine/methylergometrine or oxytocin-ergometrine combination for PPH prevention because of hypertension risk
6. Use intravenous iron therapy (not oral) for iron-deficiency anaemia in pregnancy when rapid correction needed or oral iron not tolerated, with monitoring for anaphylaxis (ferritin <30 mg/mL threshold)
7. Implement uterine balloon tamponade for atonic PPH unresponsive to first-line treatment only where immediate surgical backup and blood products available
8. Initiate blood transfusion based on continuous clinical and haematological assessment, not fixed thresholds alone

Summary of recommendations for prevention, diagnosis and treatment of postpartum haemorrhage

Table extracted from the guideline

Source: World Health Organization, Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• First consolidated PPH guidelines integrating antenatal, intrapartum and postpartum care; previously fragmented across 12 WHO documents (2012–2023)
• New diagnostic criteria introduced: blood loss ≥300 mL with abnormal haemodynamics OR ≥500 mL (replacing sole reliance on 500-mL threshold)
• Tranexamic acid explicitly NOT recommended for PPH prevention at vaginal or caesarean birth (despite previous interest); reserved for treatment only
• Ergometrine/methylergometrine and oxytocin-ergometrine combination no longer recommended for PPH prevention (previously context-specific options in 2018 WHO guidelines) because of hypertension risks
• Heat-stable carbetocin added as recommended uterotonic option for settings without reliable cold chain
• Intravenous iron therapy newly recommended for antenatal iron-deficiency anaemia when oral not tolerated or rapid correction needed
• Updated recommendation on techniques to reduce perineal trauma including perineal massage and warm compresses

From the guideline

Verbatim

“Oxytocin (10 IU, intramuscularly/intravenously) is the recommended uterotonic agent of choice for the prevention of postpartum haemorrhage for all births.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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