Postpartum · Bleeding
Postpartum Haemorrhage (PPH) & QBL
Heavy bleeding after birth. 4 T's causes (Tone, Trauma, Tissue, Thrombin). Quantitative blood loss (QBL) saves lives. Tranexamic acid within 3 hours (WOMAN trial). RCOG Green-top 52.
Last reviewed 2 June 2026
QBL — quantitative blood loss / PPH
Postpartum hemorrhage threshold check
Delivery type
mL
Enter measured blood loss to interpret.
Educational tool only — not medical advice. ACOG CO 794 emphasises QUANTITATIVE (gravimetric + volumetric) over visual estimation — visual estimates underestimate blood loss by 30-50 %. Causes of PPH (4 Ts): Tone (uterine atony — most common), Trauma (laceration), Tissue (retained products), Thrombin (coagulopathy). TXA 1g IV within 3 hours of bleeding onset reduces death (WOMAN trial, Lancet 2017).
What does this mean?
Postpartum haemorrhage is the leading cause of maternal death worldwide. The shift to quantitative blood loss (QBL) matters because visual estimation underestimates by 30–50 %; gravimetric weighing of swabs and graduated drapes / suction containers triples accurate recognition. Causes (the 4 Ts): Tone (uterine atony, ~70 % of cases), Trauma (lacerations, ruptured uterus), Tissue (retained placenta, accreta), and Thrombin (coagulopathy / DIC). Bundle: uterine massage + oxytocin (preventive at delivery — AMTSL), then escalate to misoprostol, ergometrine, carboprost, intrauterine balloon, B-Lynch suture, embolisation, hysterectomy. The WOMAN trial (Lancet 2017) showed that tranexamic acid (TXA) 1 g IV within 3 hours of bleeding onset cuts death from PPH by ~30 % — give early, not late. Massive transfusion protocols (PRBC : FFP : PLT 1:1:1) mirror trauma resuscitation.
What is PPH?
- Bleeding ≥500 mL after vaginal birth.
- OR ≥1000 mL after C-section.
- OR any bleeding causing haemodynamic instability.
Primary PPH: within 24 hours. Secondary PPH: 24h-12 weeks. Severe (>1500 mL): ~1-2%.
Quantitative Blood Loss (QBL)
Measuring actual blood lost rather than visual estimation (estimates often 30-50% short). Methods: weighing sponges/drapes (1g = 1mL); calibrated drapes; suction measurement.
Successful CMQCC California programme reduced maternal mortality via QBL adoption. UK NHS increasingly using.
4 T’s causes
- Tone — uterine atony (70%, commonest).
- Trauma — tears, episiotomy, rupture (rare).
- Tissue — retained placenta or fragments.
- Thrombin — coagulopathy (rare, serious).
Risk factors
- Previous PPH.
- Multiple pregnancy.
- Polyhydramnios.
- Macrosomia.
- Placenta praevia / accreta.
- Pre-eclampsia.
- Obesity.
- Anaemia.
- Grand multiparity.
- Bleeding disorders.
Prevention — active management 3rd stage
- Oxytocin 10 IU IM at delivery of anterior shoulder.
- Controlled cord traction.
- Uterine massage.
- Anaemia correction antenatally.
- Reduces PPH ~60%.
Physiological 3rd stage is informed-choice option; slightly higher PPH risk.
Emergency treatment ladder
- Call for help.
- IV access (2 large bore); bloods + cross-match.
- Uterotonics: oxytocin → ergometrine → misoprostol → carboprost.
- Tranexamic acid 1g IV within 3h (WOMAN trial).
- Bimanual compression / massage.
- Balloon tamponade (Bakri).
- Theatre: B-Lynch suture, uterine artery embolisation, hysterectomy as last resort.
- Blood products as needed.
Tranexamic acid (WOMAN trial)
Anti-fibrinolytic. Stabilises clots. Given within 3 hours of PPH onset: reduces maternal deaths from bleeding by 19% (1/3 when given <3h). 1g IV; can repeat once at 30 min if continuing. Now standard globally.
Retained placenta
- Placenta not delivered within 30-60 min.
- Bladder empty.
- Oxytocin.
- Controlled cord traction.
- Manual removal in theatre if not delivering.
- Antibiotics prophylactically.
Placenta accreta: rare; very serious; sometimes needs hysterectomy; planned in advance if known.
Secondary PPH (24h-12 weeks)
- Retained products.
- Endometritis.
- Sub-involution.
- Rare AVM.
Call midwife / GP / A&E if heavy bleeding after discharge. Treatment: antibiotics + ergometrine; surgical evacuation if retained products.
Blood transfusion
- Haemodynamic instability.
- Hb <70 g/L symptomatic.
- Ongoing bleeding with intervention.
- Loss >1500 mL.
Cross-matched + Rh-compatible. Sometimes O-neg emergency.
Skin-to-skin during PPH
When possible. If stable: baby on chest while team manages bleeding. Breastfeeding helps — oxytocin from feeding contracts uterus + reduces bleeding.
Emotional recovery
PPH traumatic. PTSD risk ~20-30%. Birth debrief at 4-6 weeks; perinatal mental health referral; counselling; CBT / EMDR. Partner often traumatised too.
Physical recovery 6-12 weeks slower; iron often needed. Birth Trauma Association, Sands, AIMS support.
Future pregnancies
- 10-20% recurrence.
- Correct anaemia pre-pregnancy.
- Consultant-led unit.
- IV access at admission.
- Active 3rd stage.
- Theatre + blood products available.
Different scenarios
Scenario 1: Vaginal birth, 600 mL loss, uterus boggy
Atony. Oxytocin bolus + massage. Tranexamic acid 1g. Stabilise.
Scenario 2: C-section, 1200 mL loss, atony despite oxytocin
Carboprost + ergometrine. Balloon tamponade. Theatre if not controlling.
Scenario 3: Day 7 postpartum, heavy bleeding + fever
Endometritis with retained products likely. A&E. IV antibiotics. Ultrasound + possible ERPC.
Scenario 4: Known placenta accreta antenatally
Planned C-section at specialist centre. Multidisciplinary team. Cell saver + blood ready. Possible hysterectomy.
Scenario 5: Previous severe PPH, this pregnancy 38 weeks
Consultant-led delivery. Iron stores optimised. IV access at admission. Active 3rd stage. Plan emergency response.
Care guidance — PPH
- Active 3rd stage reduces risk ~60%.
- QBL more accurate than visual estimate.
- Tranexamic acid within 3h saves lives.
- Tell midwife of any heavy bleeding postpartum.
- Iron supplementation if anaemic.
- Birth debrief 4-6 weeks if traumatic.
- Mental health support — PTSD common.
- Future pregnancies: consultant-led with planning.
Sources
- RCOG Green-top Guideline 52. Prevention and management of postpartum haemorrhage.
- WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality in women with PPH. Lancet 2017.
- CMQCC. California Maternal Quality Care Collaborative PPH toolkit.
- WHO. Recommendations on prevention and treatment of postpartum haemorrhage.
Recommended for this calculator
Frequently asked questions
What is PPH?
POSTPARTUM HAEMORRHAGE — bleeding ≥500 mL after vaginal birth OR ≥1000 mL after C-section, OR ANY bleeding causing haemodynamic instability. PRIMARY PPH: within 24 HOURS of birth (most common). SECONDARY PPH: 24 hours to 12 weeks postpartum. AFFECTS ~5-15% of births (mild); SEVERE (>1500 mL) ~1-2%. LEADING cause of maternal death globally. UK NHS: well-managed; deaths rare (~5 per year). RAPID recognition + response critical.
What's QBL?
QUANTITATIVE BLOOD LOSS — measuring actual blood volume lost rather than estimating visually. ACCURATE measurement reduces underestimation (visual estimates often 30-50% short). METHODS: (1) WEIGHING sponges, drapes, pads (1g blood = 1mL); (2) CALIBRATED drapes/collection systems; (3) SUCTION volume measurement; (4) ADDING ALL sources. SUCCESSFUL CMQCC programmes (California) reduced maternal mortality through QBL adoption. UK NHS increasingly adopting. PROMPTS earlier intervention; saves lives.
What causes PPH?
FOUR T's: (1) TONE — uterine atony (most common 70% — uterus doesn't contract after delivery; baby/placenta out + uterus relaxed); (2) TRAUMA — perineal/vaginal/cervical tears; episiotomy; uterine rupture (rare); (3) TISSUE — retained placenta or placental fragments; (4) THROMBIN — coagulopathy (clotting disorders) — rare but serious. ASSESSMENT identifies cause + guides treatment. SEQUENTIAL TREATMENT through the T's.
Who's at risk?
ANTENATAL risk factors: previous PPH; multiple pregnancy; polyhydramnios; macrosomia; placenta praevia / accreta; PE; obesity; anaemia; advanced maternal age; grand multiparity; maternal bleeding disorders; anticoagulants. INTRAPARTUM: prolonged labour; induction / augmentation; instrumental delivery; episiotomy; chorioamnionitis. POSTPARTUM: retained tissue. PROACTIVE PLANNING — risk-assessment at admission + during labour.
How is PPH prevented?
(1) ACTIVE MANAGEMENT THIRD STAGE: prophylactic UTEROTONIC (oxytocin 10 IU IM at delivery of anterior shoulder OR after birth) — reduces PPH risk ~60%; CONTROLLED cord traction; UTERINE MASSAGE; (2) ANEMIA correction antenatally — iron supplements; (3) IV ACCESS for high-risk women; (4) IDENTIFY high-risk + appropriate venue (consultant-led if very high risk); (5) PROMPT response if bleeding starts. SOME women choose physiological 3rd stage — informed decision; slightly higher PPH risk.
What's emergency treatment?
SEQUENTIAL: (1) CALL FOR HELP — emergency team. (2) IV ACCESS (2 large bore cannulae); BLOODS (FBC, coag, group/save, cross-match 4 units); (3) UTEROTONICS: OXYTOCIN bolus + infusion → ERGOMETRINE → MISOPROSTOL → CARBOPROST → TRANEXAMIC ACID (WOMAN TRIAL — gives anytime first 3 hours of bleeding, reduces mortality); (4) MASSAGE / BIMANUAL compression; (5) BALLOON TAMPONADE (Bakri); (6) THEATRE if not controlling — B-Lynch suture, uterine artery embolisation, hysterectomy as last resort; (7) BLOOD products as needed.
What's tranexamic acid?
ANTI-FIBRINOLYTIC drug that REDUCES bleeding by stabilising clots. WOMAN TRIAL (Lancet 2017, 20,060 women): given WITHIN 3 HOURS of PPH onset — REDUCED maternal deaths from bleeding by 19% (1/3 reduction when given <3 hours). NHS PROTOCOL: 1g IV within 3 hours of PPH onset; can repeat once at 30 minutes if continuing. SAFE — no major side effects. NOW STANDARD globally in PPH.
What about retained placenta?
PLACENTA not delivered within 30-60 MINUTES after baby. CAUSES bleeding. MANAGEMENT: (1) BLADDER empty (full bladder inhibits contractions); (2) OXYTOCIN; (3) CONTROLLED cord traction with active management; (4) MANUAL REMOVAL in theatre under anaesthesia if not delivering; (5) ANTIBIOTICS prophylactically; (6) PLACENTA ACCRETA (placenta grown into uterine wall): rare; very serious; sometimes needs hysterectomy; planned in advance if known. KEY: prompt management prevents major haemorrhage.
What about secondary PPH?
BLEEDING 24 HOURS-12 WEEKS postpartum. CAUSES: (1) RETAINED placental products; (2) INFECTION (endometritis); (3) Bleeding disorders; (4) SUB-INVOLUTION of uterus; (5) Rare: arteriovenous malformation. ASSESSMENT: ultrasound for retained products; high vaginal swab for infection; bloods. TREATMENT: IV antibiotics + ergometrine; surgical evacuation if retained products. CALL midwife / GP / A&E if heavy bleeding after discharge home.
When do I need a blood transfusion?
BLOOD TRANSFUSION CONSIDERED if: (1) HAEMODYNAMIC instability (BP drop, HR rise, dizziness); (2) HAEMOGLOBIN <70 g/L symptomatic; (3) ONGOING bleeding requiring intervention; (4) LARGE volume loss >1500 mL. TRANSFUSION: cross-matched + Rh-compatible blood; sometimes O-negative emergency blood. RECOVERY: monitoring, iron supplements + sometimes IV iron. RISKS minimal in modern NHS.
What about future pregnancies?
PREVIOUS PPH: 10-20% recurrence depending on cause. PLAN: (1) PRECONCEPTION discussion; (2) CORRECT anaemia before pregnancy; (3) Inform booking team — flag high-risk; (4) ANTENATAL care in consultant-led unit; (5) IV access at admission in labour; (6) ACTIVE THIRD STAGE; (7) Theatre + theatre staff prepared; (8) BLOOD products available. MOST SUBSEQUENT BIRTHS uncomplicated with planning.
Can I have skin-to-skin during PPH management?
WHEN POSSIBLE yes. BABY's needs continue. If you're stable: baby on chest while team manages bleeding. IF emergency intervention (theatre, sedation): partner / family hold baby. BREASTFEEDING start (skin-to-skin + early latch) — beneficial; oxytocin from feeding also contracts uterus + helps reduce bleeding! POSTPARTUM physical recovery slower if PPH; bonding can be supported via skin-to-skin when ready.
What about emotional recovery?
PPH TRAUMATIC. PTSD risk ~20-30% after severe PPH. SYMPTOMS: flashbacks; nightmares; avoidance of birth memories; difficulty bonding; anxiety; sleep disturbance. SUPPORT: birth debrief with midwife at 4-6 weeks; perinatal mental health team referral; counselling; CBT / EMDR. PARTNERS often traumatised too. PHYSICAL recovery: 6-12 weeks slower than uncomplicated birth; iron supplementation often needed. SUPPORT charities: Birth Trauma Association, Sands, AIMS.
How does this relate to other calculators on BumpBites?
Companion: /calculators/cmqcc-pph-risk for risk assessment; /calculators/anti-d-dosing; /calculators/maternal-sepsis (overlap); /calculators/lochia-tracker (postpartum bleeding); /calculators/hellp-classifier; /calculators/postpartum-mood-warning; /calculators/postpartum-thyroiditis.