Pregnancy · PPH Prevention
CMQCC PPH Risk Tool
Risk stratification for postpartum haemorrhage. Identifies women needing extra preparation (IV access, blood ready, theatre alerted). Active 3rd stage + tranexamic acid + QBL save lives. RCOG Green-top 52 / CMQCC California.
Last reviewed 2 June 2026
CMQCC PPH risk stratification
Antepartum / intrapartum PPH risk tier
High-risk factors — ANY ONE = high risk
Medium-risk factors — TWO OR MORE = medium risk
CMQCC PPH risk tier
LOW risk
Standard care: active third-stage management with prophylactic oxytocin, routine vital signs, QBL measurement.
0 high-risk · 0 medium-risk factor(s)
Educational tool only — not medical advice. CMQCC OB Hemorrhage Toolkit V3.0 is the gold-standard PPH risk stratification system, used in US hospitals certified by AIM and Joint Commission. Risk stratification at admission, on transfer to labour ward, post-delivery, and in PACU. Activation triggers a hemorrhage cart, blood-bank notification, and stage-based escalation pathway.
What does this mean?
PPH risk is not random — most cases are predictable from history, antenatal findings, and labour course. CMQCC’s three-bucket system (low/medium/high) lets units prepare BEFORE bleeding starts: high-risk women get a type-and-cross on admission, hemorrhage cart at bedside, second IV access, and active senior involvement; medium-risk get type-and-screen ready. The California Maternal Quality Care Collaborative (CMQCC) toolkit + structured drill programmes have measurably reduced severe maternal morbidity from PPH when adopted by hospital networks. Re-assess at each transition (booking, labour ward arrival, post-delivery, PACU) — risk changes as labour progresses (chorio, prolonged labour, instrumental delivery, atony all upgrade risk in real time). Even “low-risk” women still need active management of the third stage with prophylactic oxytocin — PPH happens to patients who weren’t flagged.
What is the CMQCC PPH risk tool?
Risk stratification for postpartum haemorrhage developed by California Maternal Quality Care Collaborative. Stratifies low / medium / high risk. Proactive preparation reduces severe PPH outcomes.
Risk factors
Antenatal:
- Previous PPH.
- Multiple pregnancy.
- Grand multiparity (≥4).
- BMI ≥40.
- Placenta praevia / accreta.
- Uterine fibroids.
- Pre-eclampsia / HELLP.
- Anticoagulation.
- Bleeding disorders.
Intrapartum:
- Prolonged labour.
- Induction + augmentation.
- Chorioamnionitis.
- General anaesthetic.
- Instrumental delivery.
- 3rd/4th degree tears.
Management by risk level
- Low risk: standard care; active 3rd stage; vigilance.
- Medium risk: IV access at admission; type + screen; cross-match available; active 3rd stage.
- High risk: two IV cannulae; cross-matched blood ready; obstetrician + anaesthetist aware; theatre alerted; appropriate consultant-led location; PPH “kit” (TXA, balloon, uterotonics).
Active 3rd stage management
- Prophylactic oxytocin 10 IU IM at anterior shoulder.
- Controlled cord traction.
- Uterine massage.
Reduces PPH ~60%.
Anaemia optimisation
- Target Hb ≥110 g/L by 36+ wk.
- Oral iron first-line (6-8 weeks effect).
- IV iron for persistent low or intolerance.
- Stores (ferritin) matter for recovery.
Placenta accreta / praevia
Highest-risk groups.
- Specialist centre delivery.
- Multidisciplinary team.
- Cell saver, blood products, interventional radiology.
- Plan 34-37 weeks usually.
- May need hysterectomy.
Tranexamic acid
Standard: within 3 hours of PPH onset (WOMAN trial — reduces deaths 19%). Prophylactic in selected very high-risk: emerging practice (TRAAP / TRAAP2 evidence modest).
Future pregnancies
- 10-20% recurrence (varies by cause).
- Correct anaemia preconception.
- Flag as high-risk at booking.
- Consultant-led delivery.
- Theatre + blood products ready.
Different scenarios
Scenario 1: First baby, no risk factors
Low risk. Standard care. Active 3rd stage.
Scenario 2: Previous PPH 1.5L, this pregnancy 36 wk
High risk. Consultant-led. Two IV cannulae. Cross-matched blood. Theatre alerted.
Scenario 3: BMI 42 + twins + induction
High risk multiple factors. Specialist consultant care; intensive preparation.
Scenario 4: Placenta accreta identified antenatally
Specialist centre at 34-37 wk planned. Multidisciplinary team. Cell saver + IR + likely hysterectomy.
Scenario 5: PPH 1L treated, recovering
IV iron. Birth debrief. Mental health support. Future planning consultation.
Care guidance — PPH prevention
- Risk identification at booking + intrapartum.
- Anaemia correction antenatally.
- Active 3rd stage standard.
- QBL measurement.
- TXA within 3h of PPH.
- Multidisciplinary preparation high-risk.
- Birth debrief if traumatic.
- Mental health follow-up.
- Future pregnancies preconception planning.
Sources
- RCOG Green-top Guideline 52. Prevention and management of postpartum haemorrhage.
- CMQCC. California Maternal Quality Care Collaborative PPH toolkit.
- WOMAN Trial Collaborators. Tranexamic acid in PPH. Lancet 2017.
- TRAAP / TRAAP2 trials. Prophylactic tranexamic acid.
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Frequently asked questions
What is the CMQCC PPH risk tool?
RISK STRATIFICATION developed by California Maternal Quality Care Collaborative for ANTENATAL + INTRAPARTUM identification of women at risk of POSTPARTUM HAEMORRHAGE. STRATIFIES into LOW / MEDIUM / HIGH RISK based on history + clinical factors. PROACTIVE preparation reduces severe PPH outcomes. CALIFORNIA SUCCESS: reduced severe maternal morbidity from PPH significantly. INFLUENCES UK NHS practice + RCOG approaches.
What goes into the risk score?
ANTENATAL FACTORS: (1) PREVIOUS PPH; (2) MULTIPLE pregnancy; (3) GRAND MULTIPARITY (≥4); (4) BMI ≥40; (5) PLACENTA PRAEVIA / ACCRETA; (6) UTERINE FIBROIDS; (7) PRE-ECLAMPSIA / HELLP; (8) ANTICOAGULATION; (9) BLEEDING DISORDERS; (10) HAEMOGLOBINOPATHIES. INTRAPARTUM FACTORS: (1) PROLONGED LABOUR; (2) INDUCTION + augmentation; (3) CHORIOAMNIONITIS; (4) GENERAL anaesthetic; (5) INSTRUMENTAL delivery; (6) THIRD-DEGREE / 4th-degree tears. SCORE COMBINED → risk category.
What's the difference in management by risk?
(1) LOW RISK: standard care; active third stage management; vigilance. (2) MEDIUM RISK: IV access at admission; type + screen blood (cross-match available); recheck Hb; active 3rd stage standard. (3) HIGH RISK: TWO IV cannulae; cross-matched blood available; OBSTETRICIAN + ANAESTHETIST aware; theatre + neonatal team alerted; appropriate delivery location (consultant-led, level 3 unit); ACTIVE 3RD STAGE; consider PPH 'kit' ready (tranexamic acid, balloon, additional uterotonics). PROACTIVE preparation saves lives.
Should I be transferred to a specialist unit?
HIGH-RISK women: CONSULTANT-LED unit (with anaesthesia + theatre on-site 24/7) usually preferred. LEVEL 3 UNITS with high-dependency / ICU access for very high risk (e.g. placenta accreta, severe pre-eclampsia). MIDWIFE-LED / home birth: typically NOT recommended for high PPH risk. INFORMED CHOICE respected — but full information about risks of different birth settings. PLANNING in 3rd trimester essential.
What's active management of 3rd stage?
(1) PROPHYLACTIC UTEROTONIC at delivery of anterior shoulder OR within 1 min of birth: OXYTOCIN 10 IU IM (or 5 IU IV slow); (2) CONTROLLED CORD TRACTION after signs of placental separation; (3) UTERINE MASSAGE post-delivery. REDUCES PPH RISK ~60%. ALTERNATIVE: PHYSIOLOGICAL THIRD STAGE — woman's choice; spontaneous delivery; no uterotonic; cord clamping after pulsation stops; ~2-3x higher PPH risk. INFORMED CHOICE essential.
What if I'm anaemic before delivery?
OPTIMISE before delivery — ANAEMIA increases PPH consequence + recovery time. TARGET Hb ≥110 g/L (ideally ≥115) by 36+ weeks. SUPPLEMENTS: ORAL IRON (ferrous sulphate, ferrous fumarate) first-line; takes 6-8 weeks; SOME women intolerant (constipation, nausea); IV IRON (Monofer, Ferinject) for: persistent low Hb, intolerance, late presentation. STORES important — even when Hb normal, low ferritin matters for recovery.
What about placenta accreta / praevia?
HIGHEST RISK groups. PLACENTA PRAEVIA: placenta covering cervix; bleeding antenatally + at delivery; planned C-section often. PLACENTA ACCRETA / INCRETA / PERCRETA: placenta grown into / through uterine wall; can cause massive haemorrhage at delivery; often need hysterectomy. RISK FACTORS: previous C-section (most common); previous uterine surgery; placenta praevia. PLANNED CARE: specialist centre; multidisciplinary team; cell saver; blood products + cross-match; possible interventional radiology / uterine artery embolisation. PLAN delivery 34-37 weeks usually.
What's tranexamic acid prophylaxis?
PROPHYLACTIC tranexamic acid (TXA) — given BEFORE or DURING delivery to prevent / reduce PPH. RCT EVIDENCE: TRAAP / TRAAP2 trials — tranexamic acid prophylaxis modest benefit; not yet standard universally. NICE / RCOG: standard ACTIVE MANAGEMENT remains primary. TXA STANDARDLY GIVEN AFTER PPH DIAGNOSED (within 3 hours per WOMAN trial). PROPHYLACTIC use in selected very high-risk women: emerging practice.
What other measures reduce PPH risk?
(1) ANAEMIA correction antenatally; (2) BIRTH PLAN includes PPH risk discussion + uterotonics; (3) APPROPRIATE delivery location; (4) ACTIVE 3rd stage management; (5) PROMPT recognition of bleeding (QBL — quantitative blood loss); (6) UTEROTONICS ready (oxytocin, ergometrine, carboprost, misoprostol); (7) TRANEXAMIC ACID within 3 hours of PPH; (8) IV ACCESS + blood products ready in high risk; (9) MULTIDISCIPLINARY team prepared; (10) EARLY ESCALATION + theatre access if not controlling.
Does my partner / birth partner have a role?
EMOTIONAL + practical support during birth + any complications. ADVOCATE for plan + preferences. INFORMED about PPH possibility — knowing reduces panic. PRACTICAL: holding baby if mum unwell; following team's instructions calmly. POSTPARTUM SUPPORT crucial — physical recovery + emotional processing slower after PPH. CONNECTION + bonding with baby supported.
What about emotional recovery from PPH?
PPH TRAUMATIC for women + partners. PTSD risk ~20-30% after severe PPH. SYMPTOMS: flashbacks; nightmares; avoidance; anxiety; bonding difficulties. SUPPORT: BIRTH DEBRIEF with midwife 4-6 weeks; PERINATAL mental health team referral; counselling; CBT / EMDR. PHYSICAL recovery 6-12 weeks slower; iron supplementation often needed. SUPPORT charities: Birth Trauma Association, Sands, AIMS.
Can high-risk women still have vaginal birth?
OFTEN YES with planning. HIGH PPH risk doesn't automatically mean C-section. C-section has different PPH risks. SHARED DECISION about: birth setting (consultant-led recommended); delivery method; analgesia (epidural for emergency access); 3rd stage management (active strongly recommended); IV access + blood products available. SOME conditions (placenta praevia, accreta) require C-section. OTHERS (high BMI, previous PPH): vaginal birth often appropriate.
What about future pregnancies?
PREVIOUS PPH: 10-20% recurrence (varies by cause). PRECONCEPTION: (1) Correct anaemia; (2) Optimise BMI if possible; (3) Treat underlying conditions; (4) Discuss with consultant. NEXT PREGNANCY: flag as high-risk at booking; intensive antenatal anaemia monitoring; consultant-led delivery; active 3rd stage; theatre + blood products ready. MOST subsequent births uncomplicated with planning.
What's the difference between CMQCC + RCOG approach?
(1) CMQCC: California developed; risk stratification + bundles; QBL emphasis; reduced PPH-related mortality. (2) RCOG GREEN-TOP 52: UK guidance; similar principles but slightly different specifics; risk identification + escalation pathways; tranexamic acid emphasis post-WOMAN trial. (3) BOTH emphasise: PREVENTION (active 3rd stage), PROMPT RECOGNITION (QBL), RAPID INTERVENTION (uterotonics, TXA, surgery if needed). UK NHS practice broadly aligned with international best practice.
How does this relate to other calculators on BumpBites?
Companion: /calculators/pph-qbl; /calculators/anti-d-dosing; /calculators/kleihauer-betke; /calculators/maternal-sepsis; /calculators/hellp-classifier; /calculators/lochia-tracker; /calculators/postpartum-mood-warning; /calculators/vte-prophylaxis-pregnancy.