By PPH Foundation

Postpartum haemorrhage (PPH) can progress from heavy bleeding to a life-threatening emergency within a short period, making timely escalation of care essential to saving mothers' lives. The World Health Organization's 2025 consolidated guidelines for PPH prevention, diagnosis and treatment emphasise early recognition, prompt first-response treatment and escalation when bleeding persists. The guidance highlights a critical principle in maternity care: recognising PPH is only the first step; healthcare providers must also know when a mother needs more advanced interventions to control bleeding and stabilise her condition.

Escalation of care refers to seeking additional clinical support or moving to more advanced treatment when the initial response is insufficient or the mother's condition deteriorates. Depending on the circumstances, this may involve calling a senior obstetrician, mobilising an emergency response team, preparing blood transfusion, transferring the woman to a higher level of care or proceeding to surgical intervention. These decisions must be guided by the amount of blood lost, the rate of bleeding, the woman's vital signs and her response to treatment.

Prof Anne Beatrice Kihara, an obstetrician and gynaecologist and President Emeritus of the International Federation of Gynecology and Obstetrics (FIGO), has emphasised the importance of readiness, recognition and response in PPH management. In a WHO announcement accompanying the 2025 guidelines, she stated: “These guidelines take a proactive approach of readiness, recognition and response. They are designed to ensure real-world impact – empowering health workers to deliver the right care, at the right time, and in a wide range of contexts.”

Her remarks reflect the importance of preparing maternity teams to recognise when routine measures are no longer sufficient and additional intervention is needed.

The WHO's 2025 guidelines recommend initiating first-response treatment when objectively measured blood loss reaches 500 ml or more, or when it reaches at least 300 ml alongside an abnormal haemodynamic sign, whichever occurs first within 24 hours after birth. These signs include a pulse rate above 100 beats per minute, systolic blood pressure below 100 mmHg, diastolic blood pressure below 60 mmHg or a shock index greater than one. Particular vigilance is required during the first two hours after delivery, although monitoring for bleeding must continue throughout the first 24 hours.

These thresholds are intended to trigger early assessment and treatment, not to delay action until a woman reaches a particular volume of blood loss. Clinical judgement remains essential, especially when bleeding is rapid or the woman's condition is worsening. A falling blood pressure, a persistently rapid pulse, altered consciousness, worsening weakness or continued heavy bleeding despite initial treatment may indicate serious deterioration requiring urgent escalation.

The E-MOTIVE trial, published in The New England Journal of Medicine in 2023, provides evidence for the value of early detection and coordinated treatment. Conducted across 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania, the trial involved 210,132 women who gave birth vaginally. It evaluated a package combining objective blood-loss measurement using calibrated drapes with a first-response treatment bundle comprising uterine massage, medicines to contract the uterus, tranexamic acid, intravenous fluids, examination and escalation of care.

The primary outcome, a composite of severe PPH, laparotomy for bleeding or maternal death from bleeding, occurred in 1.6% of women in hospitals implementing the intervention, compared with 4.3% in hospitals providing usual care. The findings demonstrate the value of systematic detection and timely, coordinated treatment, including clear pathways for further intervention when required.

Escalation is particularly important when bleeding continues despite first-response measures. Depending on the cause and severity, additional treatment may include blood products, procedures to control bleeding, surgery or transfer to a facility with the necessary capacity. These interventions should not be postponed while a mother deteriorates. Healthcare workers need clear protocols defining responsibilities, access to essential medicines and equipment, reliable communication systems and the ability to mobilise additional personnel quickly.

In facilities with limited resources, escalation may also require early coordination with referral hospitals, blood banks and transport services. Delays in arranging referral or obtaining blood can narrow the window for effective treatment. Preparedness therefore extends beyond the individual clinician to the entire maternity care system.

For families and communities, understanding the seriousness of heavy bleeding after childbirth is equally important. Excessive or increasing bleeding, faintness, difficulty breathing or sudden deterioration after delivery requires urgent medical attention. However, recognition of symptoms by families should complement, not replace, routine monitoring and clinical assessment by trained healthcare workers.

Preventing PPH-related deaths requires timely recognition, immediate treatment and decisive escalation when the first response is not enough. By strengthening clinical readiness and ensuring that maternity teams can access advanced care without unnecessary delay, health systems can improve the chances of survival for women experiencing this life-threatening complication.

References

1. World Health Organization. (2025). Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. Geneva: WHO. https://www.who.int/publications/i/item/9789240115637
2. World Health Organization. (2025, October 5). Global health agencies issue new recommendations to help end deaths from postpartum haemorrhage. https://www.who.int/news/item/05-10-2025-global-health-agencies-issue-new-recommendations-to-help-end-deaths-from-postpartum-haemorrhage
3. Gallos, I. D., Devall, A. J., Martin, J., et al. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage. The New England Journal of Medicine, 389(1), 11–21. https://doi.org/10.1056/NEJMoa2303966
4. World Health Organization. (2023). WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage. Geneva: WHO. https://www.who.int/publications/i/item/9789240085398
5. Image from Magnific