By PPH Foundation
A woman experiencing postpartum haemorrhage (PPH) may appear stable even as blood loss progresses towards a life-threatening emergency. This makes early recognition particularly important because visible signs of deterioration may not fully reflect the severity of bleeding. A 2023 randomized trial published in The New England Journal of Medicine found that delayed detection remains a major challenge in PPH management, with visual estimation of blood loss often underestimating the amount lost. The findings underscore why healthcare providers must assess blood loss objectively rather than rely on a woman's appearance alone.
During pregnancy, a woman's body undergoes physiological changes that help accommodate the demands of childbirth. These adaptations can allow her to compensate for blood loss initially, meaning that changes in blood pressure or other vital signs may not immediately reflect the extent of bleeding. However, as blood loss continues, the body's ability to maintain adequate circulation can become overwhelmed, resulting in shock, organ damage and, without prompt treatment, death.
According to the World Health Organization's 2025 consolidated guidelines on PPH prevention, diagnosis and treatment, early recognition and timely intervention are essential to reducing complications. The guidelines emphasise objective blood-loss measurement and clinical assessment to support prompt diagnosis and treatment.
Prof Moses Obimbo, a Professor at the University of Nairobi and the Project Lead of the EndPPH Initiative, highlights the importance of looking beyond a mother's outward appearance when assessing bleeding after childbirth.
“A mother may appear well even when she is losing a dangerous amount of blood. We cannot depend on appearance alone to determine whether she is safe. Objective measurement of blood loss, continuous assessment and prompt intervention are essential to preventing avoidable maternal deaths.”
Research from the E-MOTIVE trial demonstrates the impact of improving early detection and treatment. Conducted across 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania, the trial involved 210,132 women who gave birth vaginally. The intervention combined calibrated blood-collection drapes with a first-response treatment bundle that included uterine massage, medicines to contract the uterus, tranexamic acid, intravenous fluids, examination and escalation of care when needed.
Published in 2023, the study found that severe PPH, laparotomy for bleeding or maternal death from bleeding occurred in 1.6% of women in the intervention group, compared with 4.3% in the usual-care group. PPH was also detected in 93.1% of affected women in the intervention group, compared with 51.1% in the usual-care group. These findings demonstrate how systematic assessment and coordinated treatment can improve the detection and management of PPH.
The danger is not limited to bleeding that appears dramatic. Blood may collect where it is not immediately visible, and bleeding can continue while a woman is being monitored after delivery. Healthcare providers therefore need to consider the amount and rate of blood loss alongside uterine tone, pulse, blood pressure and other clinical observations. A woman who reports feeling faint or unusually weak, develops a rapid heartbeat or shows other signs of deterioration requires urgent assessment.
The WHO recommends initiating first-response treatment when objectively measured blood loss reaches 500 ml or more, or reaches at least 300 ml alongside an abnormal haemodynamic sign, whichever occurs first within 24 hours after birth. These thresholds support early action rather than waiting for a woman to become visibly unwell.
Preventing PPH-related deaths requires skilled birth attendants, reliable blood-loss measurement, appropriate medicines, access to blood transfusion when needed and timely escalation to emergency obstetric care. The period immediately after childbirth remains critical, and monitoring must continue even when delivery appears uncomplicated.
For health systems, the evidence is clear: early recognition must not depend on whether a mother looks ill. Consistent monitoring and prompt treatment can help close the gap between the onset of dangerous bleeding and the care needed to save her life.
References
- 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
- 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, 11–21. https://doi.org/10.1056/NEJMoa2303966
- 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-detail-redirect/9789240085398
- Image by prostooleh on Magnific</a>