It is two in the morning in a district hospital labour room. A 24-year-old has just delivered her second baby. The placenta is out, but the bleeding has not stopped. The staff nurse looks at the pad and the sheet and says, “About 400 mL, doctor.” Her pulse is 110. Her haemoglobin at the last antenatal visit was 8 g/dL. This is an illustrative case, not a real patient.
The Postpartum Haemorrhage Pathway tells you what to do for her: which drug, at what dose, from which ampoule, and when to move her. It no longer tells you why. The trials, the study figures and the history used to sit in its Management and Evidence tabs. They have moved here, so that the tool stays quick at the bedside. By the end of this article you will know where each instruction came from, and how much weight it can bear.
Use this at the bedside
Open the tool: Postpartum Haemorrhage Pathway
Get the CDSS app: install the MEDiscuss CDSS on your phone
1. Measure the loss. Do not guess it
“About 400 mL” is a guess, and guesses run low. E-MOTIVE randomised 80 hospitals across four countries and 210,132 births (E-MOTIVE). The intervention was a calibrated drape to catch the bleed, a first-response bundle, and somebody making sure both were used. India was not one of the four countries.
Detection rose from 51.1 per cent to 93.1 per cent. Bundle use rose from 19.4 per cent to 91.2 per cent. Severe haemorrhage, laparotomy for bleeding or death from bleeding fell from 4.3 per cent to 1.6 per cent, a risk ratio of 0.40.
“So the drape stops the bleeding?” No. Nothing in a plastic drape treats anything. What it removes is the step where a clinician decides, by looking, that this is probably about 400 mL. Our nurse made exactly that step. The drape would have told her the number instead.
The rule of 30 has no source
Many of us were taught the rule of 30: a 30 per cent fall in haematocrit, 30 mmHg off the systolic, 30 beats added to the pulse, 30 per cent of the volume gone. Generations of Indian residents have been taught it. A search of the primary literature for the tool found no publication establishing or validating it, and the chapter that prints it most fully cites nothing. It is not being called wrong. It is being called untraceable, which is a different and more useful thing to know about a rule you are about to act on.
2. The shock index, and where its marks come from
The shock index is the pulse divided by the systolic pressure. In 233 women who had lost 1500 mL or more it beat either number alone, with an area under the curve of 0.75 for intensive care admission against 0.64 for systolic pressure (Nathan 2015). The working marks of 0.9, 1.4 and 1.7, which the tool still prints, come from a much larger series across low-resource settings.
Our patient has a pulse of 110. If her systolic is 100, her index is 1.1: above the mark at which she should be referred. And remember her haemoglobin of 8 g/dL. An anaemic woman is tachycardic before she loses a millilitre, so read the middle of the range with caution. The tool keeps that warning.
3. Tranexamic acid runs against a clock
Why does the tool ask how many minutes have passed since birth? Pooled patient-level data from 40,138 bleeding patients gives the single most useful number here (Gayet-Ageron 2018). Immediate tranexamic acid improved survival by more than 70 per cent. The benefit then fell by 10 per cent for every quarter of an hour of delay, until three hours. After that, none.
| Delay from birth | Of the survival benefit |
|---|---|
| Immediate | All of it |
| 30 minutes | About a fifth gone |
| 1 hour | About 40 per cent gone |
| 2 hours | About 80 per cent gone |
| Past 3 hours | None left |
Ten per cent a quarter of an hour is a rate a tool can compute and a tired reader cannot. That is why the engine takes the minutes since birth as an input rather than leaving the window to the reader.
“If it works so well, will it save her uterus too?” It will not. In the WOMAN trial, 20,060 women, death due to bleeding fell from 1.9 to 1.5 per cent, and to a risk ratio of 0.69 in those treated within three hours (WOMAN). Hysterectomy did not move at all: 3.6 per cent against 3.5. The trialists explain why, and it is worth carrying: the decision to operate was often taken at the same moment as randomisation, so the drug never had its chance at that outcome. Tranexamic acid stops her dying. It substitutes for nothing on the surgical ladder.
4. The uterotonics, read at the ampoule
The tool keeps this table in two halves so that it fits a phone: the dose and ceiling in one, what to draw up in the other. Here it is whole, as the tool carried it on 3 November 2026. The doses are those of the ICMR workflow of December 2025 (ICMR 2025). Read the last column slowly. Two strengths of oxytocin and two of carboprost are sold in India, and that is where the error waits.
| Drug | Dose, route and interval | Ceiling | What to draw up |
|---|---|---|---|
| Oxytocin | 10 units intramuscularly if not already given after delivery. Then an infusion of 20 units in 500 mL of Ringer lactate or normal saline at 40 to 60 drops per minute. If bleeding is not controlled, 10 to 20 units per hour. Once controlled, 5 to 10 units per hour. An intravenous bolus of oxytocin must not be given. That prohibition is the workflow’s own, and it is the only instruction on the sheet written as one | Total oxytocin not to exceed 100 units in 24 hours | Read the ampoule. Both 5 units/mL and 10 units/mL circulate in India and both are on the community health centre essential medicines list, so 10 units is 2 mL of one and 1 mL of the other. Store cold. The Pfizer India label says only “store in a cold place”; the WHO-prequalified Indian product says 2 to 8 degrees |
| Methylergometrine | 0.2 mg intramuscularly, or intravenously slowly. Repeat after 15 minutes. The Novartis core data sheet gives the interval as every 2 to 4 hours up to five doses in 24 hours, which is not the same instruction. Both were read; the workflow’s interval is the one this tool uses | 5 doses, which is 1 mg | 0.2 mg in 1 mL, so one ampoule per dose. Refrigerate at 2 to 8 degrees, protect from light, and it may be kept 14 days out of the refrigerator but not above 25 degrees |
| Carboprost | 250 micrograms intramuscularly, repeated every 20 minutes. The Indian package insert for the same drug says the interval is about 90 minutes. The two agree on the ceiling and disagree on the interval by more than fourfold | 8 doses, which is 2 mg. The workflow and the package insert agree on this | Two strengths are marketed in India, and that is the error waiting to happen. The insert lists 125 micrograms in 0.5 mL, and 250 micrograms in 1 mL. So a 250 microgram dose is one ampoule of the second. Or two of the first. Store at 2 to 8 degrees, do not freeze |
| Misoprostol | 800 micrograms sublingually or per rectum. The rectal route is the workflow’s; WHO 2025 names the sublingual route for treatment and does not name the rectal one | No repeat dose and no ceiling is printed by any document read for this tool | 200 microgram tablets, so 800 micrograms is four tablets. Store below 30 degrees, in the blister |
| Carbetocin | Not a treatment drug. WHO 2025 gives heat-stable carbetocin 100 micrograms intramuscularly or intravenously for prevention, where the oxytocin cold chain cannot be maintained. It appears nowhere in either Indian document read here. WHO also discourages repeat dosing for treatment in a woman who has already had it for prophylaxis | Not applicable | A room-temperature-stable formulation has been marketed in India since 2021. The Indian vial strength and volume could not be verified from a manufacturer’s document, so none is printed |
5. Fluids: two documents, two answers
The national workflow says 3 mL of crystalloid for every 1 mL lost. WHO 2025 gives no ratio at all (WHO 2025). “Then which one is out of date?” Neither. This is a live disagreement and not staleness. The national workflow gives a ratio a resident can act on at three in the morning; the current international guideline deliberately refuses to give one and warns about the consequence of over-filling. The tool computes the ratio, attributes it, prints the caution beside it, and moves the caution to the top of the card when the woman has pre-eclampsia or heart disease.
6. Bimanual compression: why it works
The mechanism, from the FIGO 2022 recommendations: the hand in the vagina elevating the uterus stretches the uterine artery (FIGO 2022). That is why the compression must be firm, and why it must be held. It is a way of keeping the woman alive while the treatment is fetched.
7. External aortic compression: the study behind the warning
The tool warns that aortic compression fails in about a third of attempts, and that the femoral pulse is the only way to know. Where does that come from? Twenty parturients had the aorta compressed with a closed fist just above the umbilicus (Riley 1994). Leg blood pressure was completely obliterated in 55 per cent and significantly reduced in a further 10 per cent. Every woman in whom it worked also lost the femoral pulse. So feel for the pulse, not the blood pressure.
8. Balloon tamponade: two numbers, both true
The observational evidence for balloon tamponade and the randomised evidence point in opposite directions.
- A systematic review of 91 studies and 4729 women puts pooled success at 85.9 per cent, and at 87.1 per cent where the cause is atony (Suarez 2020).
- The Indian series agree: bleeding stopped within ten minutes in 94 per cent of a Rajasthan cohort, mean fill 350 mL (Hasabe 2016), and a Chhattisgarh series reported 98 per cent in 60 women whose bleeding had already failed first-line treatment (Mishra 2019).
- The two randomised trials inside that same review showed no significant difference against no balloon at all. And a randomised trial in Benin and Mali found the composite of invasive surgery or death at 16 per cent with tamponade against 7 per cent without, with more loss above a litre in the tamponade arm (Dumont 2017).
“So does the balloon work or not?” The observational success rate and the randomised null are both real. The likeliest reconciliation is the one WHO names. Its remarks record problems in placement in the very trials the recommendation rests on, including delays in inserting the device. WHO also declines to rank improvised against purpose-designed devices, saying the evidence is insufficient, and notes that the trials it relied on used improvised devices with reported problems in placement. What the balloon does depends on how quickly and how well it is placed, and on what else is available when it fails. A balloon that takes fifteen minutes to assemble in a woman who needed a laparotomy has cost her fifteen minutes.
That is why the tool keeps the tamponade test. Bleeding controlled means no laparotomy. Bleeding continuing means go to theatre. You have the answer within a minute.
9. The anti-shock garment, and the Bihar pilot
The one Indian programme evaluation of this device found no effect. A pilot in two districts of Bihar trained staff and introduced the garment into public facilities, and concluded that even after training and appropriate introduction of the practice, the initiative did not make a difference to postpartum haemorrhage management in those facilities over six months (Sharma 2016). A device the national workflow now recommends for transport has, in Indian programme conditions, one published evaluation and it is negative.
Hold both. That is not a reason to leave it in the cupboard when the woman in front of you is shocked and the ambulance is an hour away. It is a reason not to treat its presence in a store room as a system that works. For the system, that finding is what an intervention looks like when it has been introduced rather than implemented, and it is why the WHO recommendation on the bundle insists on an implementation strategy and not merely on the bundle.
10. Where the surgical ladder came from
The idea of doing it in steps starts with AbdRabbo in 1994 (AbdRabbo 1994): five steps, each only if the last failed. Unilateral uterine vessel ligation, bilateral uterine vessel ligation, low uterine vessel ligation, unilateral ovarian vessel ligation, bilateral ovarian vessel ligation. It was the original stepwise devascularisation, in 103 women, effective in all of them with no hysterectomy.
The brace suture was first described in five cases in 1997, as an alternative to hysterectomy, and the paper’s title still ends in a question mark (B-Lynch 1997). The workflow’s order, compression sutures before ligation before hysterectomy, stands on these two papers.
11. The four Ts, roughly
Tone, the atonic uterus, about 70 per cent. Trauma, about 20 per cent. Tissue, about 10 per cent. Thrombin, about 1 per cent (Evensen 2017). Those figures sum to 101, and their source offers them as approximations rather than as an audit. Use the four Ts as a checklist afterwards. At the bedside the national sheet’s sequence is quicker: is the placenta out, and is the uterus soft?
Back to the labour room
Our patient’s loss was guessed, not measured, so the tool takes the guess with caution. Her shock index is above 0.9, so she is referred if blood and a theatre are not here tonight. She is anaemic, so her reserve is smaller than her observations suggest. Tranexamic acid goes in now, because every quarter of an hour costs a tenth of its benefit. Oxytocin runs as an infusion, never as a bolus, from an ampoule that somebody has read aloud. If she still bleeds, the balloon goes in quickly, and the tamponade test decides whether she goes to theatre. Each of those steps is a line in the tool. Now you know what stands behind each line.
Try this
A woman delivered at 11 at night. She starts bleeding heavily at half past midnight and reaches you at a quarter to one. Is tranexamic acid still worth giving, and how much of its benefit is left? Illustrative case.
Answer. Yes, at once. The clock runs from the birth, not from the start of the bleeding, so she is already an hour and three quarters into it. She sits between the 1 hour mark, about 40 per cent gone, and the 2 hour mark, about 80 per cent gone. What is left is lost at about a tenth for every further quarter of an hour. Had she reached you after 2 in the morning, past 3 hours from birth, none would be left, and WHO does not support its use beyond the window.
Take-home points
- Measure the loss with a calibrated drape where you can. A guess runs low, and the rule of 30 has no traceable source.
- Give tranexamic acid as early as possible: about a tenth of its benefit is lost for every quarter of an hour, and none is left after 3 hours from birth.
- Tranexamic acid prevents death from bleeding. It does not prevent hysterectomy.
- Read every uterotonic ampoule aloud. Two strengths of oxytocin and of carboprost are sold in India.
- Use the tamponade test: the balloon’s answer is worth as much as its pressure.
Use this at the bedside
Open the tool: Postpartum Haemorrhage Pathway
Get the CDSS app: install the MEDiscuss CDSS on your phone
Declaration: the author built and maintains the tool. It is free to use. The figures in this article are those the tool carried in its Management and Evidence tabs on 3 November 2026, each from the source named beside it.
References
- Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare. Standard Treatment Workflow: Postpartum Haemorrhage (PPH), ICD-11-JA43. December 2025.
- Ministry of Health and Family Welfare, Government of India, Maternal Health Division. Guidance Note on Prevention and Management of Postpartum Haemorrhage. December 2015.
- World Health Organization, International Federation of Gynecology and Obstetrics, International Confederation of Midwives. Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage. Geneva: World Health Organization; 2025. Published 5 October 2025.
- Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, et al. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet. 2022;157(Suppl 1):3-50.
- Mavrides E, Allard S, Chandraharan E, Collins P, Green L, Hunt BJ, et al. Prevention and management of postpartum haemorrhage: Green-top Guideline No. 52. BJOG. 2016;124(5):e106-e149.
- Gallos I, Devall A, Martin J, Middleton L, Beeson L, Galadanci H, et al. Randomized trial of early detection and treatment of postpartum hemorrhage. N Engl J Med. 2023;389(1):11-21.
- WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116.
- Gayet-Ageron A, Prieto-Merino D, Ker K, Shakur H, Ageron FX, Roberts I; Antifibrinolytic Trials Collaboration. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet. 2018;391(10116):125-132.
- Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, et al. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG. 2015;122(2):268-275.
- Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, Suarez-Rebling D, Eckardt M, Theron G, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis. Am J Obstet Gynecol. 2020;222(4):293.e1-293.e52.
- Dumont A, Bodin C, Hounkpatin B, Popowski T, Traore M, Perrin R, et al. Uterine balloon tamponade as an adjunct to misoprostol for the treatment of uncontrolled postpartum haemorrhage: a randomised controlled trial in Benin and Mali. BMJ Open. 2017;7(9):e016590.
- Hasabe R, Gupta K, Rathode P. Use of condom tamponade to manage massive obstetric hemorrhage at a tertiary center in Rajasthan. J Obstet Gynaecol India. 2016;66(Suppl 1):88-93.
- Mishra N, Gulabani K, Agrawal S, Shrivastava C. Efficacy and feasibility of Chhattisgarh balloon and conventional condom balloon tamponade: a 2-year prospective study. J Obstet Gynaecol India. 2019;69(Suppl 2):133-141.
- Sharma J, Negandhi P, Das AM, Sethy G, Neogi SB, Ali SH. Using nonpneumatic anti-shock garment for postpartum hemorrhage management and referral at the public health facilities: a pilot study in two districts of Bihar. Indian J Public Health. 2016;60(4):316-322.
- Evensen A, Anderson JM, Fontaine P. Postpartum hemorrhage: prevention and treatment. Am Fam Physician. 2017;95(7):442-449.
- Riley DP, Burgess RW. External abdominal aortic compression: a study of a resuscitation manoeuvre for postpartum haemorrhage. Anaesth Intensive Care. 1994;22(5):571-575.
- AbdRabbo SA. Stepwise uterine devascularization: a novel technique for management of uncontrolled postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol. 1994;171(3):694-700.
- B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104(3):372-375.
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