New Updates On Postpartum Haemorrhage In Kenya

Preventing, Diagnosing, and Treating Postpartum Haemorrhage: A Practical Summary of WHO 2025 Recommendations

Introduction

Postpartum haemorrhage (PPH) remains the leading cause of maternal mortality globally, accounting for nearly one in five maternal deaths worldwide. The majority of these deaths are preventable through timely prevention, early diagnosis, and standardised treatment. Recognising persistent gaps in care, the World Health Organisation (WHO), in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM), released consolidated evidence-based guidelines in 2025 to harmonise global practice and accelerate reductions in maternal deaths.

This article summarises the key recommendations for the prevention, diagnosis, and treatment of postpartum haemorrhage, translating the guideline table into practical guidance for frontline health workers and health systems.

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Understanding Postpartum Haemorrhage

Postpartum haemorrhage is defined as excessive bleeding after childbirth, usually within the first 24 hours. While traditional definitions focused on volume alone, current guidance emphasizes objective blood loss measurement combined with maternal clinical signs, recognizing that women may deteriorate rapidly even at lower volumes of blood loss.

Because most women who develop PPH have no identifiable risk factors, every birth must be managed as potentially high risk, with preparedness for rapid response.

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Antenatal Interventions: Preventing PPH Before Birth

1. Prevention and Treatment of Anaemia

Anaemia significantly worsens outcomes when postpartum bleeding occurs. WHO therefore recommends:

• Full blood count testing as the preferred method to diagnose anaemia during pregnancy.
• Daily oral iron and folic acid supplementation (30–60 mg iron plus 400 μg folic acid) for all pregnant women.
• Intermittent iron–folic acid supplementation where daily dosing is poorly tolerated or anaemia prevalence is low.
• Intravenous iron therapy for women with moderate to severe iron-deficiency anaemia when oral iron is ineffective or not tolerated.

These interventions strengthen maternal reserves and reduce the severity of PPH-related complications.

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Intrapartum Interventions: Reducing Risk During Labour

To minimize trauma and bleeding during childbirth, the guidelines recommend:

• Perineal protection techniques (perineal massage, warm compresses, controlled delivery of the head) based on a woman’s preferences.
• Avoidance of routine episiotomy, which increases blood loss and perineal trauma.

These measures support physiological birth while reducing preventable bleeding.

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Postpartum Interventions: Preventing PPH After Birth

2. Universal Use of Uterotonics

The single most effective intervention for PPH prevention is the routine use of a quality-assured uterotonic during the third stage of labour. WHO recommends one of the following:

• Oxytocin 10 IU IM or IV – first-line choice where cold chain is reliable.
• Heat-stable carbetocin 100 μg IM or IV – preferred where cold chain cannot be guaranteed.
• Misoprostol 400–600 μg orally – effective alternative, including for community-based births.

Notably:

• Ergometrine, oxytocin–ergometrine combinations, and injectable prostaglandins are not recommended for PPH prevention.
• Sustained uterine massage is not recommended when prophylactic oxytocin has already been administered.

3. Community and Out-of-Facility Births

Where skilled birth attendants are unavailable:

• Community health workers may administer misoprostol.
• Antenatal distribution of misoprostol for self-administration is recommended only with targeted monitoring and evaluation.

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Diagnosis of Postpartum Haemorrhage: Early Detection Saves Lives

Timely diagnosis is critical. The guidelines strongly recommend:

• Routine objective measurement of blood loss for all births, using tools such as calibrated drapes.
• Initiation of treatment when:
• Blood loss is ≥500 mL, or
• Blood loss is ≥300 mL with abnormal vital signs (tachycardia, hypotension, shock index >1).
• Regular uterine tone assessment to identify uterine atony early.

The first two hours after birth are particularly high-risk and require close monitoring.

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First-Response Treatment of Postpartum Haemorrhage

Once PPH is identified, immediate standardized response is essential.

Core First-Line Treatments

WHO recommends:

• Intravenous oxytocin as the first-line uterotonic.
• Additional uterotonics (ergometrine, oxytocin–ergometrine, or misoprostol) if bleeding persists.
• Uterine massage for treatment (distinct from prevention).
• Early intravenous tranexamic acid (TXA) within 3 hours of birth, in addition to standard care.
• Isotonic crystalloids for fluid resuscitation.

PPH Treatment Bundle

A standardized care bundle should include:

• Uterine massage
• Uterotonic administration
• Tranexamic acid
• IV fluids
• Genital tract examination
• Rapid escalation of care

This bundle approach improves survival by reducing delays and variation in care.

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Treatment of Refractory Postpartum Haemorrhage

When first-line measures fail, the following are recommended as temporizing or definitive interventions:

• Bimanual uterine compression
• External aortic compression
• Non-pneumatic anti-shock garment (NASG)
• Uterine balloon tamponade, provided strict safety criteria are met
• Surgical interventions when conservative measures fail
• Blood transfusion guided by clinical and laboratory assessment

Uterine packing with gauze is not recommended due to safety concerns.

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Supportive Care After PPH

Recovery does not end once bleeding stops. WHO recommends:

• Oral iron supplementation for 6–12 weeks postpartum in settings with high anaemia prevalence.
• Intravenous iron therapy for severe postpartum anaemia when rapid correction is required.

This reduces long-term morbidity and improves maternal well-being.

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Health System Interventions: Making PPH Care Sustainable

Effective PPH management requires strong systems. Recommended actions include:

• Use of formal PPH prevention and treatment protocols
• Clear referral pathways
• Simulation-based training for pre-service and in-service health workers
• Monitoring uterotonic use as a quality-of-care indicator

Health systems must ensure reliable supply chains, trained personnel, and functional referral mechanisms.

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Conclusion

Postpartum haemorrhage is a medical emergency that demands preparedness at every birth. The 2025 WHO consolidated guidelines provide a clear, evidence-based roadmap spanning antenatal care, childbirth, postpartum management, and health system strengthening. Consistent implementation of these recommendations—especially routine uterotonic use, objective blood loss measurement, early tranexamic acid administration, and standardized treatment bundles—can save thousands of mothers’ lives each year.

Ending preventable maternal deaths from PPH is not a question of knowledge, but of action, accountability, and system readiness.

Postpartum Haemorrhage (PPH) in Kenya

Practical Tables and Infographic Summaries Based on WHO 2025 Guidelines

Audience: County Health Management Teams (CHMTs), facility in-charges, clinicians, nurses, midwives, CHPs/CHEWs, implementing partners, and policy-makers.

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INFOGRAPHIC 1: WHY PPH MATTERS IN KENYA

Postpartum haemorrhage is:

• The leading cause of maternal death in Kenya
• Responsible for deaths in both facility and community births
• Often preventable with low-cost, high-impact interventions

Key message:
➡️ Every birth must be managed as a potential PPH risk.

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TABLE 1: ANTENATAL INTERVENTIONS (KENYA CONTEXT)

Intervention Area	WHO Recommendation	Practical Application in Kenya
Anaemia screening	Full blood count preferred; Hb testing acceptable	Use Hb meters in Level 2–4 facilities where CBC unavailable
Iron–folate supplementation	Daily iron (30–60 mg) + folic acid (400 μg)	Integrate into ANC clinics and community ANC outreaches
Intermittent iron	Weekly iron–folate where daily not tolerated	Useful in adolescents and women with side effects
IV iron therapy	For moderate–severe anaemia	Refer to Level 4–6 facilities with trained staff

County Action Point:
Ensure uninterrupted iron–folate supply through KEMSA and partner-supported last-mile delivery.

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INFOGRAPHIC 2: THE MOST IMPORTANT PREVENTION STEP

🩺 USE A UTEROTONIC FOR EVERY BIRTH

One woman. One birth. One uterotonic.

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TABLE 2: UTEROTONIC OPTIONS FOR PPH PREVENTION IN KENYA

Uterotonic	Dose & Route	When to Use	Kenyan Context
Oxytocin	10 IU IM/IV	First choice	Use in hospitals & health centres with cold chain
Heat-stable carbetocin	100 μg IM/IV	Where cold chain unreliable	Ideal for hard-to-reach counties
Misoprostol	400–600 μg oral	No injection or skilled staff	For community & home births

❌ Not recommended:

• Ergometrine
• Oxytocin–ergometrine combinations
• Injectable prostaglandins

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INFOGRAPHIC 3: COMMUNITY BIRTHS (KENYA REALITY)

If birth happens outside a facility:

• CHPs/CHEWs can administer oral misoprostol
• Antenatal misoprostol distribution allowed with monitoring
• Clear referral pathways must exist

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TABLE 3: DIAGNOSIS OF PPH – WHAT KENYAN FACILITIES SHOULD DO

Step	Recommendation	Facility-Level Practice
Blood loss measurement	Objective measurement for all births	Use calibrated drapes or standard containers
Early trigger	≥500 mL OR ≥300 mL + shock signs	Act within first 2 hours postpartum
Uterine tone	Routine uterine assessment	Include in post-delivery monitoring charts

County Indicator:
% of deliveries with documented blood loss measurement

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INFOGRAPHIC 4: FIRST 15 MINUTES SAVE LIVES

THE PPH FIRST-RESPONSE BUNDLE

1️⃣ Uterine massage
2️⃣ Uterotonic (oxytocin first-line)
3️⃣ Tranexamic acid (within 3 hours)
4️⃣ IV fluids (crystalloids)
5️⃣ Genital tract examination
6️⃣ Escalate care immediately

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TABLE 4: FIRST-RESPONSE TREATMENT OF PPH

Intervention	Status	Notes for Kenya
IV oxytocin	Recommended	First-line in all facilities
Additional uterotonics	Recommended	Use if bleeding persists
Tranexamic acid (TXA)	Strongly recommended	Stock in maternity & theatres
Uterine massage	Recommended	Treatment only (not prevention)
IV crystalloids	Recommended	Avoid colloids

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INFOGRAPHIC 5: WHEN BLEEDING DOES NOT STOP

REFRACTORY PPH = ACT FAST + REFER

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TABLE 5: MANAGEMENT OF REFRACTORY PPH

Intervention	Use in Kenya
Bimanual uterine compression	Immediate temporizing measure
External aortic compression	Useful in transit/referral
NASG	Ideal for Level 3–4 facilities & ambulances
Uterine balloon tamponade	Use only where surgery & blood available
Surgery	Refer urgently to Level 5–6
Blood transfusion	Protocol-based, timely

❌ Not recommended: Uterine gauze packing

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TABLE 6: POST-PPH SUPPORTIVE CARE

Intervention	Recommendation	Kenyan Practice
Oral iron	6–12 weeks postpartum	Integrate into PNC clinics
IV iron	Severe anaemia	Level 4+ facilities only

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INFOGRAPHIC 6: HEALTH SYSTEM ACTIONS FOR COUNTIES

STRONG SYSTEMS = FEWER DEATHS

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TABLE 7: COUNTY-LEVEL HEALTH SYSTEM INTERVENTIONS

Area	Required Action
Protocols	Display PPH protocols in all maternity units
Training	Simulation drills every 6–12 months
Referral	Clear, functional referral pathways
Monitoring	Track uterotonic use & PPH outcomes
Supplies	Ensure oxytocin, TXA, IV fluids always available

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CONCLUSION: WHAT THIS MEANS FOR KENYA

Postpartum haemorrhage deaths are largely preventable. For Kenya to achieve SDG 3.1 and national maternal mortality reduction targets:

• Every birth must receive a uterotonic
• Blood loss must be measured, not guessed
• Tranexamic acid must be used early
• Counties must institutionalize PPH bundles and drills

No woman should die giving life.