PPH WHO 2025 - 2026 Update | New Definition + Management Changes | Dr. Zainab Vora

Added: 2026-05-08

[00:00:00]Hi friends. So in this particular video we're going to be talking about the postpartum hemorrhage update that was by WHO in 2025-26 guidelines, right? So there are some major changes which are very relevant for the exams and obs gynae is a subject where they do pick up updates and also this becomes a very important video for all of you. Earlier the definition of PPH that we used to study was that in a vaginal delivery if more than 500 ml blood loss is there or in a cesarean section more than 1 L is there. What was primary PPH that was happening within first 24 hours? So that 24 hours window has remained unchanged but what has changed is the number. So it's either 300 ml or more with any sort of clinical abnormality in the vitals or 500 ml blood loss. So 1000 is out of the window so more than 500 ml absolute figure or 300 ml with abnormal vitals which includes which of the following.

[00:01:00]So this is what is your potential question here. Any pulse more than 100 so tachycardia, shock index more than one. Do you remember what was shock index? We have studied this in surgery.

[00:01:10]Heart rate upon so as for as systolic BP. If it is heart rate upon MAP that would be modified shock index, right? So that is when it goes above one. So shock index more than one. Any BP which is less than 100 by 60, okay? So SBP less than 100 diastolic less than 60. So this is something which you need to remember. So 300 plus abnormal vitals or 400 as an absolute figure whichever is reached first of course and the first two hours remain very crucial after the delivery, right?

[00:01:44]So this is about the update here. Then what have they changed as far as active management of third stage of labor is concerned?

[00:01:52]First of all they have suggested that choose any one uterotonic and like always oxytocin remains the drug of choice. Same, 10 units either IM or IV infusion. Never give it as a bolus. So all of that remains unchanged. All right, so we will not give a bolus. They have also suggested you may use carbetocin which is the heat stable analog of oxytocin. That's 100 microgram. Do remember this. If you cannot refrigerate oxytocin you can use this, right? Misoprostol is something which can be used orally and that's the importance. This is very important for India, right? Where we may not have a cannula or somebody who knows how to inject or maybe a home delivery happening. So this is where they've added that in a low resource setting this can be administered by community health workers like say Asha or you know the patient can self-administer. So this is something which is super important that in an India rural setup we can implement misoprostol oral rather than not giving anything, right? So this is what is very very important.

[00:02:53]What they are saying do not use, right?

[00:02:55]So ergometrine, methylergometrine, oxytocin-ergometrine combination, injectable prostaglandins are not recommended. Tranexamic acid not recommended for prevention, right? So this is important though the question here because you have three here is of course all of the following are recommended as first line uterotonics except, right? So it's something which is very very obvious and can be asked from here. Then apart from that what else are they saying? Same things that controlled cord traction to be done if you have a skilled birth assistant only otherwise there's a risk of uterine inversion.

[00:03:29]Sustained uterine massage. This is a major change. They are saying no need to do a uterine massage in everybody if you have given oxytocin. So this has been removed, right? That you will not do uterine massage if you have already given a uterotonic and delayed cord clamping is preferred like always 1 to 3 minutes is what is the delayed cord clamp. So uterine massage has been removed so now AMTSL would be uterotonic, controlled cord traction and delayed cord clamping. All right, so this is about prevention. Now let's go to treatment. So here first of all they have created this bundle care bundle called as E-MOTIVE, okay? So what is E-MOTIVE? So that acronym can also be asked. E is early detection. So now the blood loss that we have you know defined the criteria which shouldn't just be estimated blood loss. It has to be measured with a calibrated drape. So there are drapes which will depending on how much they are soaked they can tell you how much is the blood loss. All right, so that's what you have to measure. If you're laying down such stringent criteria then we need to measure stringently as well, right? So that's first.

[00:04:40]Now uterine massage comes in as treatment not as prevention. So uterine massage is first like always how we have studied in the management. Then comes the role of uterotonic agents. Again oxytocin remains the first line that we have studied and now if failure now we can use ergometrine or a combination or misoprostol. Somehow in the guidelines they have not talked about carboprost, right? But so you want to remember that it's not been removed as such but it's not recommended as first line. So oxytocin-ergometrine combination or misoprostol. Tranexamic acid. This is a new change and I'm going to highlight it in green because this may be asked. So role of tranexamic acid has been brought upon just like we study in hemorrhagic shock, right? In trauma.

[00:05:28]It should be given early within the first three hours give tranexamic acid just like trauma, okay? IV fluids? Yes, crystalloids will be preferred over colloids, right? So that's something which is there. Examination and escalation. So rule out any trauma and escalate. So so far we have done a uterine massage, you have given the drugs, you know, and now if it doesn't resolve what are the measures? So these are escalation. Temporary measure is bimanual uterine compression or aortic compression or non-pneumatic anti-shock garments all of which we have studied in surgery, remember? Anti-shock garments.

[00:06:05]So these are the temporary measures but what is the preferred measure is balloon tamponade. Remember Bakri balloon? So that's what you will do.

[00:06:14]It's the first line. What they are saying is not recommended is uterine packing. Don't pack the uterus with gauze pieces. Further if uterine balloon tamponade doesn't work next step is uterine artery embolization followed by hemostatic sutures like B-Lynch followed by hysterectomy. So nothing really changes as far as the protocol steps were concerned. Start with massage, give pharmacotherapy, doesn't work directly go to balloon tamponade. After that devascularization and then you have surgery, right? So this is what is about the management, right? So this is very very important from exam point of view the updates in the WHO PPH management.

[00:06:54]So I hope this is helpful. Thank you so much.

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