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Am Fam Physician. 2015;92(7):643

Obstetric hemorrhage is the leading cause of maternal morbidity and mortality, and rates are on the rise in the United States. A consensus bundle, with recommendations for reducing and managing obstetric hemorrhage and improving overall maternal care, has been published by the National Partnership for Maternal Safety. The partnership included the California Maternal Quality Care Collaborative, the American College of Obstetricians and Gynecologists, the Society for Obstetric Anesthesia and Perinatology, the American College of Nurse-Midwives, the American Association of Blood Banks, the Association of Women's Health, Obstetric and Neonatal Nurses, and the American Academy of Family Physicians.

Action Domains


A cart containing necessary supplies, including a checklist and instructions for placement of uterine tamponade balloons and uterine compression sutures, should be available in every birthing unit. Immediate access to hemorrhage medications also should be arranged. Putting together an emergency response team (e.g., blood bank, gynecologic surgery, other tertiary services) and transfusion protocols is critical for a rapid response. It is recommended that birthing units prepare staff for treating hemorrhages by using drills and follow-up discussions on areas for improvement.


Assessing hemorrhage risk should be ongoing at every stage of patient care. Cumulative blood loss measurement records should be kept throughout the birthing process, using quantitative measurements for more accurate monitoring. Active management of the third stage of labor, including oxytocin (Pitocin), uterine massage, and cord traction, is key to preventing obstetric hemorrhage. Oxytocin is the most effective medication for reducing the risk of postpartum hemorrhage; administration is recommended after all births.


If an obstetric hemorrhage occurs, there should be a detailed emergency management plan with instructions for diagnosis and evaluation. Each institution should design an emergency plan to meet its needs, adjusting the plan according to its capabilities. With each case of hemorrhage, it is important to assist patients and their families with reassurance, timely information, and other resources for support.


Establishing a system based on briefs (planning meetings), huddles (short meetings), and debriefs (informal feedback sessions after an event) will ensure an atmosphere conducive to learning, raise awareness in critical situations, and improve outcomes. Formal meetings should be scheduled as soon as possible after an incident of hemorrhage to discuss and identify improvements that may be needed. Reducing the number of obstetric hemorrhages that result in major blood loss is the primary objective of these recommendations. Outcomes should be monitored and reviewed as a way to track progress.

Guideline source: National Partnership for Maternal Safety

Evidence rating system used? No

Literature search described? No

Guideline developed by participants without relevant financial ties to industry? No

Published source: Obstet Gynecol. July 2015;126(1): 155–162

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at

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