Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage

Published by WHO on Oct 3, 2025

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ISBN 978-92-4-011563-7 (electronic version) 

ISBN 978-92-4-011564-4 (print version)

 

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PICOS

PICO 10.1

Population
Pregnant women
Intervention
Test accuracy for diagnosing anaemia (Hb < 11 g/dL)
Comparator
Outcomes

PICO 10.1

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Hands off (poised)
Comparator
Hands on
Outcomes

PICO 10.1

Population
Women during third stage of labour (by mode of birth)
Intervention
Oxytocin
Comparator
Placebo or no treatment
Outcomes

PICO 10.1

Population
Women with postpartum haemorrhage
Intervention
Misoprostol
Comparator
Oxytocin /ergometrine
Outcomes

PICO 10.1

Population
Women with primary postpartum haemorrhage
Intervention
Bimanual uterine compression for postpartum haemorrhage treatment
Comparator
Outcomes

PICO 10.1

Population
Postpartum women
Intervention
Iron or iron and folic acid
Comparator
Placebo or control
Outcomes

PICO 10.1

Population
Women with postpartum haemorrhage
Intervention
Use of standard protocol
Comparator
No protocol
Outcomes

PICO 10.2

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Vocalisation
Comparator
Control
Outcomes

PICO 10.2

Population
Women during third stage of labour
Intervention
Carbetocin
Comparator
Placebo or no treatment
Outcomes

PICO 10.2

Population
Women with postpartum haemorrhage
Intervention
Adjunct Misoprostol
Comparator
Placebo
Outcomes

PICO 10.2

Population
Women with primary postpartum haemorrhage
Intervention
External aortic compression for postpartum haemorrhage treatment
Comparator
Outcomes

PICO 10.3

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Warm compress on the perineum
Comparator
Control (hands off or no warm compress)
Outcomes

PICO 10.3

Population
Women during third stage of labour
Intervention
Misoprostol
Comparator
Placebo or no treatment
Outcomes

PICO 10.3

Population
Women with postpartum haemorrhage
Intervention
Oxytocin
Comparator
Ergometrine
Outcomes

PICO 10.3

Population
Women with primary postpartum haemorrhage
Intervention
Non-pneumatic anti-shock garment for postpartum haemorrhage treatment
Comparator
Outcomes

PICO 10.4

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Massage of the perineum
Comparator
Control (hands off or usual care)
Outcomes

PICO 10.4

Population
Women with postpartum haemorrhage
Intervention
Oxytocin- Ergometrine IM (fixed dose combination)
Comparator
Oxytocin IV (any dose)
Outcomes

PICO 10.5

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Combined warm compress and massage
Comparator
Control
Outcomes

PICO 10.5

Population
Women with postpartum haemorrhage
Intervention
Oxytocin- Ergometrine IM (fixed dose combination)
Comparator
Oxytocin 10IU IM
Outcomes

PICO 10.6

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Combined warm compresses and massage
Comparator
Massage alone
Outcomes

PICO 10.6

Population
Women with postpartum haemorrhage
Intervention
Oxytocin- Ergometrine IM (fixed dose combination)
Comparator
Oxytocin IM (any dose)
Outcomes

PICO 10.7

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Ritgen's manoeuvre
Comparator
Standard care
Outcomes

PICO 10.7

Population
Women with postpartum haemorrhage
Intervention
Oxytocin-Ergometrine IM (fixed dose combination)
Comparator
Ergometrine IM (any dose)
Outcomes

PICO 10.8

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Primary delivery of posterior shoulder
Comparator
Primary delivery of anterior shoulder
Outcomes

PICO 10.8

Population
Women with postpartum haemorrhage during vaginal birth
Intervention
Carbetocin
Comparator
Oxytocin
Outcomes

PICO 10.9

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Massage of the perineum with enriched oil
Comparator
Liquid wax
Outcomes

PICO 10.9

Population
Women with postpartum haemorrhage during caesarean section
Intervention
Carbetocin
Comparator
Oxytocin
Outcomes

PICO 10.10

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Petroleum jelly on the perineum
Comparator
Control
Outcomes

PICO 10.10

Population
Women with postpartum haemorrhage
Intervention
Carbetocin
Comparator
Oxytocin-Ergometrine (fixed dose combination)
Outcomes

PICO 10.11

Population
Pregnant women in the second stage of labour having a spontaneous vaginal birth
Intervention
Perineal protection device
Comparator
Control
Outcomes

PICO 10.11

Population
Women with postpartum haemorrhage
Intervention
Intramuscular prostaglandins
Comparator
Injectable uterotonics
Outcomes

PICO 10.12

Population
Women with postpartum haemorrhage
Intervention
Carboprost
Comparator
Misoprostol (rectal)
Outcomes

PICO 10.13

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 600mcg (oral)
Comparator
No uterotonics or placebo
Outcomes

PICO 10.14

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 600mcg (sublingual)
Comparator
No uterotonics or placebo
Outcomes

PICO 10.15

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 400mcg (rectal)
Comparator
No uterotonics or placebo
Outcomes

PICO 10.16

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 200mcg (buccal)
Comparator
No uterotonics or placebo
Outcomes

PICO 10.17

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 600mcg (oral)
Comparator
Injectable uterotonics
Outcomes

PICO 10.18

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 400mcg (rectal)
Comparator
Injectable uterotonics
Outcomes

PICO 10.19

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 600mcg (rectal)
Comparator
Injectable uterotonics
Outcomes

PICO 10.20

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 800mcg (rectal)
Comparator
Injectable uterotonics
Outcomes

PICO 10.21

Population
Women with postpartum haemorrhage
Intervention
Misoprostol any dose (sublingual)
Comparator
Injectable uterotonics
Outcomes

PICO 10.22

Population
Women with postpartum haemorrhage
Intervention
Misoprostol 400mcg (rectal)
Comparator
Intramuscular prostaglandins
Outcomes

PICO 20.1

Population
Women during third stage of labour
Intervention
IV oxytocin
Comparator
IM oxytocin
Outcomes

PICO 20.1

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 300 ml or more alone
Comparator
500 ml or more
Outcomes

PICO 20.1

Population
Pregnant women
Intervention
Any supplements containing iron
Comparator
Same supplements without iron or no treatment/placebo (no iron or placebo)
Outcomes

PICO 20.1

Population
Women with postpartum haemorrhage
Intervention
Uterine massage (after placental delivery)
Comparator
No uterine massage
Outcomes

PICO 20.1

Population
Women with primary postpartum haemorrhage
Intervention
Condom-loaded Foley catheter intrauterine tamponade (saline filled) plus standard care (misoprostol)
Comparator
Standard care (misoprostol)
Outcomes

PICO 20.1

Population
Women with anaemia after birth
Intervention
Intravenous iron in addition to standard care
Comparator
Oral iron supplementation
Outcomes

PICO 20.1

Population
Women with postpartum haemorrhage
Intervention
Formal protocol for the referral
Comparator
No protocol
Outcomes

PICO 20.1

Population
Pregnant women in second stage of labour undergoing vaginal birth
Intervention
Policy of selective/restrictive
Comparator
Routine or liberal use of episiotomy
Outcomes

PICO 20.2

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 350 ml or more alone
Comparator
500 ml or more
Outcomes

PICO 20.2

Population
Women with postpartum haemorrhage
Intervention
Uterine massage before or after placental delivery
Comparator
No uterine massage
Outcomes

PICO 20.2

Population
Women with primary postpartum haemorrhage
Intervention
Latex balloon–loaded Nelson catheter intrauterine tamponade (air filled) plus stitch and standard care (uterine massage and uterotonics)
Comparator
Standard care (uterine massage and uterotonics)
Outcomes

PICO 20.3

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 400 ml or more alone
Comparator
500 ml or more
Outcomes

PICO 20.3

Population
Women with postpartum haemorrhage
Intervention
Uterine massage before placental delivery
Comparator
No uterine massage
Outcomes

PICO 20.3

Population
Women with primary postpartum haemorrhage
Intervention
Condom-loaded catheter intrauterine ballon tamponade
Comparator
Uterovaginal packing
Outcomes

PICO 20.4

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 450 ml or more alone
Comparator
500 ml or more
Outcomes

PICO 20.4

Population
Women with primary postpartum haemorrhage
Intervention
Bakri balloon tamponade
Comparator
Haemostatic square suturing to the lower segment of the uterus (Intrauterine tamponade)
Outcomes

PICO 20.5

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 300 ml or more, in combination with any other abnormal clinical markers
Comparator
500 ml or more
Outcomes

PICO 20.5

Population
Women with primary postpartum haemorrhage
Intervention
Bakri balloon intrauterine tamponade (saline field)
Comparator
Condom-loaded Foley catheter intrauterine tamponade (saline field)
Outcomes

PICO 20.6

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 350 ml or more in combination with any other abnormal clinical markers
Comparator
500 ml or more
Outcomes

PICO 20.6

Population
Women with primary postpartum haemorrhage
Intervention
Bakri balloon intrauterine tamponade (saline filled plus traction stitch)
Comparator
Bakri balloon intrauterine tamponade (saline filed) without stitch
Outcomes

PICO 20.7

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 400 ml or more in combination with any other abnormal clinical markers
Comparator
500 ml or more
Outcomes

PICO 20.7

Population
Women with postpartum haemorrhage unresponsive to first-response treatment
Intervention
Gauze packing (any)
Comparator
Uterine balloon tamponade (any)
Outcomes

PICO 20.8

Population
Women in the third stage of labour in all care settings
Intervention
Test accuracy of blood loss threshold of 450 ml or more in combination with any other abnormal clinical markers
Comparator
500 ml or more
Outcomes

PICO 30.1

Population
Women during third stage of labour
Intervention
Ergometrine
Comparator
Placebo or no Ergometrine
Outcomes

PICO 30.1

Population
Women with primary postpartum bleeding
Intervention
Standard care plus IV tranexamic acid
Comparator
Placebo or standard care alone
Outcomes

PICO 30.1

Population
Women with postpartum haemorrhage
Intervention
Artery embolization
Comparator
Standard care
Outcomes

PICO 30.1

Population
PPH
Intervention
Simulation for PPH treatment in training programs
Comparator
No simulation
Outcomes

PICO 30.2

Population
Women during third stage of labour
Intervention
Ergometrine plus Oxitocin
Comparator
Placebo or no Ergometrine plus Oxitocin
Outcomes

PICO 30.2

Population
Women with postpartum haemorrhage
Intervention
Surgical Interventions
Comparator
Standard care
Outcomes

PICO 30.2

Population
Pregnant women
Intervention
Any intermittent iron regimen (with or without other vitamins and minerals)
Comparator
Daily regimen (with same vitamins and minerals)
Outcomes

PICO 30.3

Population
Women during third stage of labour
Intervention
Injectable prostaglandins
Comparator
Placebo or no Injectable prostaglandins
Outcomes

PICO 30.3

Population
Women primary postpartum haemorrhage
Intervention
Standard care plus IV tranexamic acid (subgroup analysis)
Comparator
Placebo or standard care alone for the treatment of PPH (subgroup analysis)
Outcomes

PICO 30.4

Population
Women with primary postpartum haemorrhage
Intervention
Standard care plus IV tranexamic acid
Comparator
Placebo or standard care alone for the treatment of PPH
Outcomes

PICO 30.4

Population
Women primary postpartum haemorrhage
Intervention
Standard care plus IV tranexamic acid (subgroup analysis)
Comparator
Placebo or standard care alone for the treatment of PPH (subgroup analysis)
Outcomes

PICO 40.1

Population
Pregnant women
Intervention
Intravenous (IV) iron therapy
Comparator
Oral iron supplementation
Outcomes

PICO 40.1

Population
Pregnant women during the third stage of labour, and 24 hours after delivery, regardless of other aspects of the third stage of labour management, and mode of birth
Intervention
Direct estimation using calibrated drapes
Comparator
Visual estimation
Outcomes

PICO 40.1

Population
Women in third stage of labour
Intervention
Carbetocin
Comparator
Oxytocin
Outcomes

PICO 40.1

Population
Women with postpartum haemorrhage
Intervention
Colloid
Comparator
Crystalloid(add-oncolloid)
Outcomes

PICO 40.1

Population
Women with postpartum haemorrhage
Intervention
Cell salvage at birth in addition to standard care
Comparator
No cell salvage at birth or standard care alone
Outcomes

PICO 40.1

Population
PPH
Intervention
Monitoring the use of uterotonics
Comparator
No monitoring
Outcomes

PICO 40.2

Population
Pregnant women during the third stage of labour, and 24 hours after delivery, regardless of other aspects of the third stage of labour management, and mode of birth
Intervention
Direct estimation using calibrated drapes
Comparator
gravimetric technique
Outcomes

PICO 40.2

Population
Women in third stage of labour
Intervention
Misoprostol
Comparator
Oxytocin
Outcomes

PICO 40.2

Population
Women with postpartum haemorrhage
Intervention
Colloid
Comparator
Hypertonic crystalloid
Outcomes

PICO 40.3

Population
Pregnant women during the third stage of labour, and 24 hours after delivery, regardless of other aspects of the third stage of labour management, and mode of birth
Intervention
Two-set liquid collection bag
Comparator
Visual estimation
Outcomes

PICO 40.3

Population
Women in third stage of labour
Intervention
Injectable prostaglandins
Comparator
Oxytocin
Outcomes

PICO 40.3

Population
Women with postpartum haemorrhage
Intervention
Colloid and hypertonic crystalloid
Comparator
Isotonic crystalloid
Outcomes

PICO 40.4

Population
Women in third stage of labour
Intervention
Ergometrine
Comparator
Oxytocin
Outcomes

PICO 40.4

Population
Women with postpartum haemorrhage
Intervention
Supplemental albumin
Comparator
Control
Outcomes

PICO 40.5

Population
Women in third stage of labour
Intervention
Ergometrine plus Oxitocin
Comparator
Oxytocin
Outcomes

PICO 40.6

Population
Women in third stage of labour
Intervention
Misoprostol plus oxytocin
Comparator
Oxytocin
Outcomes

PICO 40.7

Population
Women in third stage of labour
Intervention
Misoprostol plus oxytocin
Comparator
Placebo or no misoprostol plus oxytocin
Outcomes

PICO 50.1

Population
Pregnant women for postpartum self-administration for PPH prevention
Intervention
Advance misoprostol distribution/provision
Comparator
Usual (or standard) care
Outcomes

PICO 50.1

Population
Postpartum women who experience PPH - vaginal birth
Intervention
Care bundle
Comparator
Usual care
Outcomes

PICO 50.1

Population
Women experiencing PPH following a vaginal or caesarean birth
Intervention
Fibrinogen concentrate
Comparator
Placebo or no fibrinogen concentrate
Outcomes

PICO 50.2

Population
Postpartum women who experience PPH - c-section
Intervention
Care bundle
Comparator
Usual care
Outcomes

PICO 50.2

Population
Women experiencing PPH following a vaginal or caesarean birth
Intervention
Cryoprecipitate
Comparator
No cryoprecipitate
Outcomes

PICO 60.1

Population
Advance misoprostol distribution to pregnant women for preventing and treating postpartum haemorrhage
Intervention
Advance misoprostol distribution/provision to pregnant women for postpartum self-administration
Comparator
usual (or standard) care for PPH prevention
Outcomes

PICO 60.1

Population
Women with retained placenta after vaginal birth
Intervention
Systemic uterotonic agents for retained placenta after vaginal birth
Comparator
placebo or no uterotonic agents
Outcomes

PICO 60.2

Population
Women with retained placenta after vaginal birth
Intervention
Intravenous carbetocin
Comparator
Sublingual misoprostol
Outcomes

PICO 70.1

Population
Women having a vaginal birth
Intervention
Administration of tranexamic acid in addition to standard care for the prevention of PPH
Comparator
administration of placebo or no tranexamic acid
Outcomes

PICO 70.1

Population
women undergoing manual removal of retained placenta after vaginal birth
Intervention
Prophylactic antibiotics
Comparator
No prophylactic antibiotics
Outcomes

PICO 70.2

Population
Women having a caesarean birth
Intervention
Administration of tranexamic acid in addition to standard care for the prevention of PPH
Comparator
administration of placebo or no tranexamic acid
Outcomes

PICO 80.1

Population
Women in third stage of labour
Intervention
Controlled cord traction
Comparator
No controlled cord traction
Outcomes

PICO 80.1

Population
Umbilical vein injection for management of retained placenta
Intervention
UVI with oxytocin solution
Comparator
expectant management
Outcomes

PICO 80.2

Population
Women in third stage of labour undergoing a caesarean section
Intervention
Manual removal of the placenta
Comparator
Controlled cord traction
Outcomes

PICO 80.2

Population
Umbilical vein injection for management of retained placenta
Intervention
UVI of oxytocin solution
Comparator
UVI of saline solution
Outcomes

PICO 80.3

Population
Umbilical vein injection for management of retained placenta
Intervention
UVI of oxytocin solution
Comparator
UVI of plasma expander
Outcomes

PICO 80.4

Population
Umbilical vein injection for management of retained placenta
Intervention
Prostaglandin solution
Comparator
oxytocin solution
Outcomes

PICO 80.5

Population
Umbilical vein injection for management of retained placenta
Intervention
Oxytocin solution
Comparator
ergometrine solution
Outcomes

PICO 80.6

Population
Umbilical vein injection for management of retained placenta
Intervention
Carbetocin solution
Comparator
oxytocin solution
Outcomes

PICO 100.1

Population
Women in third stage of labour
Intervention
Early cord clamping
Comparator
Late cord clamping
Outcomes

PICO 100.2

Population
Women in third stage of labour
Intervention
Early cord clamping
Comparator
Delayed cord clamping
Outcomes

PICO 110.1

Population
Women in third stage of labour
Intervention
Uterine massage before placental delivery
Comparator
No uterine massage
Outcomes

PICO 110.2

Population
Women in third stage of labour
Intervention
Uterine massage (before or after placental delivery)
Comparator
No uterine massage
Outcomes

PICO 110.3

Population
Women in third stage of labour
Intervention
Uterine massage (after delivery of the placenta for 1-2 hours and empty the clots)
Comparator
No uterine massage
Outcomes