Postpartum haemorrhage

Key NICE recommendations on management

Refer to the full NICE guideline and your local drug formulary for further information when prescribing – including dose, contraindications, cautions, safety issues, adverse effects, drug interactions, and monitoring requirements. Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is 'off-label').

Active management of third stage of labour to reduce PPH risk

Women should be advised that active management of the third stage of labour is associated with a lower risk of a PPH or blood transfusion, compared with physiological management.

• Active management comprises: routine use of uterotonic drugs; clamping and cutting of the cord; and controlled cord traction after signs of separation of the placenta.

• For women who choose physiological management, a change to active management should be advised if haemorrhage occurs or if the placenta is not delivered within 1 hour of the birth of the baby.

For a woman who is having a vaginal birth and has chosen an active third stage, the choice of uterotonic for active management should be discussed. The following information should be included:

• Oxytocin plus ergometrine may be more effective than oxytocin alone at reducing the risk of PPH

• Oxytocin plus ergometrine is advised if the woman has risk factors for PPH

• Oxytocin plus ergometrine is more likely to lead to nausea and vomiting compared with oxytocin alone

  • Women having oxytocin plus ergometrine should be offered antiemetics (e.g., cyclizine)

For active management of the third stage after vaginal birth, one of the following options should be administered immediately after the birth of the baby and before the cord is clamped and cut:

• Oxytocin by intramuscular injection

• Oxytocin by slow intravenous injection (for women who have received oxytocin during labour)

• Oxytocin plus ergometrine by intramuscular injection.

For women who have had a caesarean birth, carbetocin by slow intravenous injection should be offered for prevention of PPH.

Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of labour.

Management of primary PPH

If (during the third stage of labour) there is PPH, a retained placenta or maternal collapse, or any other concerns about the woman’s wellbeing, carry out frequent observations to assess whether resuscitation is needed and transfer the woman to obstetric-led care. Take into account that multiple risk factors may increase the urgency of the transfer, particularly if they have a cumulative effect.

• Carry out transfer of care of women in labour as soon as possible after the decision to transfer has been made (and ensure the woman is monitored throughout transfer).

If a woman has a PPH:

• Call for help

• Immediate clinical treatment should be given:

  • Emptying of the bladder and

  • Uterine massage and

  • Uterotonic drugs and

  • Intravenous fluids and

  • Controlled cord traction if the placenta has not yet been delivered

• Continuously assess blood loss and the woman’s condition, and identify the source of bleeding

• Consider supplementary oxygen, targeting an oxygen saturation of 94 to 98% (starting at 15 L/min, using a non-rebreathing mask with reservoir bag)

• Arrange transfer to obstetric-led care.

A uterotonic should be administered as  first-line treatment for PPH, basing the choice of drug on which uterotonics have already been administered as part of active management of the third stage of labour. Further treatment for PPH should be offered if needed.

• See the NICE guideline for uterotonic drug options.

In addition to uterotonic drugs, tranexamic acid should be given (by slow intravenous injection). Repeat if necessary after at least 30 minutes for managing continuing PPH.

If the haemorrhage continues:

• Near-patient coagulation testing (if available) and administration of blood products (e.g., packed red cells and clotting products) should be considered

• Examination under anaesthetic should be performed, ensuring that the uterus is empty and repairing any trauma

• Balloon tamponade should be considered before surgical options. No particular surgical procedure can be recommended over any other for treating PPH.

Risk factors for PPH

Women with antenatal risk factors for PPH should be advised to give birth in an obstetric unit. Risk factors include:

• Previous PPH >1000 mL or requiring blood transfusion

• Placenta accreta spectrum

• Pre-eclampsia

• Maternal haemoglobin <85 g/L at onset of labour

• Body mass index (BMI) >35 kg/m²

• Grand multiparity (parity ≥4)

• Antepartum haemorrhage or placental abruption

• Overdistension of uterus (e.g., multiple pregnancy, polyhydramnios)

• Existing uterine abnormalities (e.g., fibroids)

• Low-lying placenta.

Assessment of risk factors for PPH should continue during labour, taking into account antenatal risk factors and any risk factors that have arisen during labour. These can include:

• Induction or augmentation of labour with oxytocin or prostaglandins

• Prolonged first or second stage of labour

• Sepsis

• Oxytocin use during labour

• Precipitate labour

• Birth with forceps or ventouse

• Caesarean birth

• Shoulder dystocia

• Delay in delivery of the placenta.

Be aware that taking a selective serotonin-reuptake inhibitor or serotonin-noradrenaline reuptake inhibitor in the month before birth may result in a small increased risk of PPH.

© NICE (2021) (2025) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.