Key messages

• We found the combination of using a diagnosis with 1) birth-attendant clinical concern, or 2) 300 mL to 500 mL of drape-measured blood loss (blood is collected in a plastic drape with markings indicating the volume) with observations (e.g. heart rate, blood pressure, the tone of the womb, and flow of blood), or 3) 500 mL or more of drape-measured blood loss to diagnose postpartum haemorrhage (PPH), plus a treatment bundle, was more effective than using visual estimation for diagnosis plus usual care for treatment.

• When using the same treatment bundle for PPH treatment, using a diagnosis with 1) birth-attendant clinical concern, or 2) 300 mL to 500 mL of drape-measured blood loss with observations, or 3) 500 mL or more of drape-measured blood loss was more effective than a diagnosis using 1) birth-attendant clinical concern, or 2) 500 mL or more of drape-measured blood loss.

What is PPH?

PPH is commonly defined as blood loss of 500 mL or more in the first 24 hours after childbirth.

Why is this review important?

PPH is a common reason why mothers die in childbirth around the world. Reducing PPH harm requires a combination of accurate diagnosis and effective treatment. Our study aimed to determine which combinations are most effective.

What did we want to find out?

We aimed to find out which combinations of ways to diagnose and treat PPH are most effective.

What did we do?

We looked at relevant studies to find out which combinations of ways to diagnose and treat PPH are most effective. We included women having a normal or caesarean birth in any setting (community delivery units, hospitals, home births).

Examples of ways to diagnose PPH include the assessor: having clinical concern; looking at the blood loss and estimating the blood volume (visual estimation); measuring the volume of blood loss in a drape or tray with markings indicating the volume (volumetric method); measuring the blood loss in a drape along with observations (such as heart rate and blood pressure), and weighing blood loss using scales (gravimetric method).

Examples of ways to treat PPH include 'usual care' (normal hospital practice), and treatment 'bundles' with various treatments given at the same time, such as the MOTIVE bundle (M – Massage of the womb to help it contract, O – giving medicines like Oxytocin to contract the womb, T – giving Tranexamic acid (a medicine given to slow bleeding), IV – intravenous fluids: fluids given through a drip to help maintain blood pressure, E – Examination and Escalation: if bleeding does not stop, calling for help and considering other treatments).

What did we find out?

We found five studies involving 236,771 women.

We are confident that diagnosis using 1) birth-attendant clinical concern, or 2) 300 mL to 500 mL of drape-measured blood loss with observations, or 3) 500 mL or more of drape-measured blood loss, plus the MOTIVE bundle is more effective than visual estimation plus usual care in reducing PPH of 500 mL or more and PPH of 1000 mL or more, but probably makes little or no difference to the need for blood transfusion or other drug treatments, and the risk of mothers dying.

We are confident that diagnosis using 1) birth-attendant clinical concern, or 2) 500 mL or more of drape-measured blood loss, plus the MOTIVE bundle is more effective than visual estimation plus usual care for reducing PPH of 500 mL or more, but probably makes little or no difference to PPH of 1000 mL or more and the need for blood transfusion, and may make little or no difference to the risk of mothers dying. We are confident that it increases the need for additional drug treatments.

We are confident that diagnosis using 1) birth-attendant clinical concern, or 2) 300 mL to 500 mL of drape-measured blood loss with observations, or 3) 500 mL or more of drape-measured blood loss, plus the MOTIVE bundle is more effective than diagnosis using 1) birth-attendant clinical concern, or 2) 500 mL or more of drape-measured blood loss, plus the MOTIVE bundle in reducing PPH of 500 mL or more, PPH of 1000 mL or more, and the need for additional drug treatments. It probably makes little or no difference to the need for blood transfusion, and may make little or no difference to the risk of mothers dying.

Drape-based diagnosis plus usual care (E) (this is usual care in a European healthcare setting, which may be different to usual care in a low-income setting because of access to, for example, more effective treatments) versus visual estimation plus usual care (E) probably makes little or no difference to the need for blood transfusion.

We are confident that the gravimetric method-based diagnosis plus usual care versus drape-based diagnosis plus usual care is more effective in reducing PPH of 500 mL or more, but may make little or no difference to the need for blood transfusion.

Tray-based diagnosis plus usual care versus drape-based diagnosis plus usual care may make little or no difference in reducing PPH of 500 mL or more and PPH of 1000 mL or more.

Gravimetric method-based diagnosis plus usual care versus tray-based diagnosis plus usual care may make little or no difference in reducing PPH of 500 mL or more.

What are the limitations?

All our studies involved women giving birth normally and most were in hospitals. We would like more information about women giving birth by caesarean, and in other settings such as home births. We would also like more information about unwanted effects and women's experience of care.

How up to date is the evidence?

This evidence is current to 18 October 2024.