Maternal & Newborn Atlas
About
Menu

PPH detection and first-response treatment bundle

A package for hospitals. Staff measure blood loss at vaginal births with a calibrated drape, and when heavy bleeding is detected they start a standard set of treatments straight away. The set covers uterine massage, a uterus-contracting medicine, tranexamic acid, fluids into a vein, a check for the source of bleeding and calling for more help. Staff training and feedback support the package.

Also called E-MOTIVE package · MOTIVE bundle

  • Intervention
  • In this atlas

Overview

Technical summary

The package combines objective blood-loss assessment with a calibrated drape, a first-response bundle (uterine massage, an oxytocic drug, tranexamic acid, intravenous fluids, examination of the genital tract and escalation of care) and an implementation strategy. WHO 2025 Recommendation 29 (Revalidated, Recommended) recommends it for all women having a vaginal birth. E-MOTIVE tested the whole package; the drape alone was not tested, and the effect cannot be assigned to any component. WHO says the supporting evidence comes largely from vaginal births in secondary-level facilities and that more research is needed before recommending bundle care at caesarean birth.

About this intervention

Type
Service
Mechanism
Early objective detection triggers a coordinated set of treatments, supported by training, audit and feedback and an emergency supply trolley or carry case (implementation strategy).

Claims and evidence

Context Patients having vaginal delivery in 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania (E-MOTIVE)

Recipient
Maternal
Population
Patients having a vaginal delivery in the study hospitals. Hospitals were randomly assigned to the package or to usual care. The abstract reports results among hospitals and patients with data, not for all randomised deliveries. The registry describes its research participants as health care providers attending vaginal births, a different basis from the paper.
Care setting
Secondary-level hospitals.
Geography
Kenya, Nigeria, South Africa and Tanzania.
Life stage
Childbirth and the first hours after birth
Gestational age
Not reported
Postnatal age
Not reported
Follow-up
Not stated in the abstract.
Eligibility: 1 inclusion criterion; 1 exclusion criterion
Included
  • Patients having a vaginal delivery in a participating hospital
Excluded
  • Other criteria are not stated in the abstract

  • Effect Interventional Certainty not assessed

    E-MOTIVE tested a package, not a single product. The package was a calibrated blood-collection drape for early detection, a bundle of first-response treatments, and a strategy to help hospitals use them. 80 secondary-level hospitals in Kenya, Nigeria, South Africa and Tanzania were randomly assigned to the package or to usual care. "Among hospitals and patients with data", severe bleeding (1000 mL or more), laparotomy for bleeding or death from bleeding occurred in 1.6% of patients with the package and 4.3% with usual care (risk ratio 0.40, 95% CI 0.32 to 0.50). Postpartum haemorrhage was detected in 93.1% against 51.1% (rate ratio 1.58, 1.41 to 1.76), and the bundle was used in 91.2% against 19.4% (rate ratio 4.94, 3.88 to 6.28).

    Applies to Maternal
    • Patients having a vaginal delivery in the study hospitals. Hospitals were randomly assigned to the package or to usual care. The abstract reports results among hospitals and patients with data, not for all randomised deliveries. The registry describes its research participants as health care providers attending vaginal births, a different basis from the paper.
    • Secondary-level hospitals.
    • Kenya, Nigeria, South Africa and Tanzania.
    • Childbirth and the first hours after birth
    • Gestational age Not reported
    • Postnatal age Not reported
    Follow-up Not stated in the abstract.
    Certainty method
    Not assessed
    Limitations
    The effect belongs to the whole package (drape, bundle and implementation strategy) and cannot be split by component, so none of it is credited to the drape or to tranexamic acid alone. Randomisation was by hospital. Only the NEJM abstract was read, because the full text returned HTTP 403 and was not retrieved another way, so analysis methods are not described. The percentages are results among hospitals and patients with data and are not counts of individual patients. The registry gives 99659 enrolled (actual), describes the research participants as health care providers attending vaginal births, and lists no masking; the paper reports 210,132 vaginal deliveries. These are different bases and are not reconciled. The primary outcome is a composite, so the abstract gives no separate effect on maternal death.
    Last checked
    2026-10-11
    Next evidence check due
    Not scheduled
    Sources and citations (4)

    1. Supports Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage

      Publication · Massachusetts Medical Society (N Engl J Med 389(1):11-21) · Edition Abstract only, from PubMed (PMID 37158447). The version of record returned HTTP 403 on 2026-10-11 and was not retrieved by any other route. No PMC full text exists, so the analysis methods are not described in any record. · Published 2023-07-06 · doi: 10.1056/NEJMoa2303966

      Locator
      Abstract, METHODS: package and cluster design
      How it applies
      PubMed abstract; the full text was not retrieved.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      ac7a6b8ccd74b1e8eec860852401c1052be14e9cbe32a7f923b2be380a8662d0
      Reuse basis
      Bibliographic metadata and short factual extraction from the PubMed abstract. The abstract belongs to the publisher, so it is not committed; only its sha256 is kept.

    2. Supports Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage

      Publication · Massachusetts Medical Society (N Engl J Med 389(1):11-21) · Edition Abstract only, from PubMed (PMID 37158447). The version of record returned HTTP 403 on 2026-10-11 and was not retrieved by any other route. No PMC full text exists, so the analysis methods are not described in any record. · Published 2023-07-06 · doi: 10.1056/NEJMoa2303966

      Locator
      Abstract, RESULTS: primary outcome, detection and bundle use
      How it applies
      PubMed abstract; results among hospitals and patients with data.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      ac7a6b8ccd74b1e8eec860852401c1052be14e9cbe32a7f923b2be380a8662d0
      Reuse basis
      Bibliographic metadata and short factual extraction from the PubMed abstract. The abstract belongs to the publisher, so it is not committed; only its sha256 is kept.

    3. Background A Clinical Trial to Study the Effectiveness of a Care Bundle to Prevent Bleeding After a Woman Has Given Birth

      Registry · ClinicalTrials.gov · Edition API v2 JSON, fetched on 2026-10-11. The record has posted results, which were not read. · nct: NCT04341662

      Locator
      protocolSection.designModule: enrollment count and masking
      How it applies
      Registry JSON; a different basis from the paper.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      0a7a1ede0bc051836032b9f2016627544ebe5a0c0093f178b25e94a4ab1a6a8f
      Reuse basis
      Registry JSON. ClinicalTrials.gov terms of use have not been verified, so the bytes are not committed. Facts only. Public text is quote, following Ben's decision of 2026-10-13 (medical-atlas-core issue 2) that registries allow short quotations with attribution. This source's terms are unverified or reserve all rights, so any quotation stays short.

    4. Background A Clinical Trial to Study the Effectiveness of a Care Bundle to Prevent Bleeding After a Woman Has Given Birth

      Registry · ClinicalTrials.gov · Edition API v2 JSON, fetched on 2026-10-11. The record has posted results, which were not read. · nct: NCT04341662

      Locator
      protocolSection.descriptionModule.detailedDescription: research participants
      How it applies
      Registry wording on who the participants are.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      0a7a1ede0bc051836032b9f2016627544ebe5a0c0093f178b25e94a4ab1a6a8f
      Reuse basis
      Registry JSON. ClinicalTrials.gov terms of use have not been verified, so the bytes are not committed. Facts only. Public text is quote, following Ben's decision of 2026-10-13 (medical-atlas-core issue 2) that registries allow short quotations with attribution. This source's terms are unverified or reserve all rights, so any quotation stays short.

Context Women having a vaginal birth, objective assessment with a first-response bundle (WHO 2025 Recommendation 29)

Recipient
Maternal
Population
All women having a vaginal birth. WHO says the supporting evidence comes largely from vaginal births in secondary-level facilities and that more research is needed to recommend bundle care at caesarean birth.
Care setting
Health facilities. The evidence is largely from secondary-level facilities; WHO says recognition and treatment are equally relevant in primary care, community and home settings.
Geography
Global (WHO guidance intended to inform national and subnational policy).
Life stage
Childbirth and the first hours after birth
Gestational age
Not reported
Postnatal age
Not reported
Follow-up
Not applicable (recommendation context)
Eligibility: 1 inclusion criterion; exclusion criteria not stated
Included
  • Any woman having a vaginal birth
Excluded
None stated

  • Recommendation Guidance Certainty not assessed

    WHO 2025 recommends a standardized and timely approach to managing postpartum haemorrhage for all women having a vaginal birth (Recommendation 29, category Recommended, Revalidated from the 2023 recommendation). The approach combines an objective assessment of blood loss with a treatment bundle supported by an implementation strategy. The first-line bundle includes rapid uterine massage, an oxytocic medicine and tranexamic acid, intravenous fluids, examination of the genital tract and escalation of care.

    Applies to Maternal
    • All women having a vaginal birth. WHO says the supporting evidence comes largely from vaginal births in secondary-level facilities and that more research is needed to recommend bundle care at caesarean birth.
    • Health facilities. The evidence is largely from secondary-level facilities; WHO says recognition and treatment are equally relevant in primary care, community and home settings.
    • Global (WHO guidance intended to inform national and subnational policy).
    • Childbirth and the first hours after birth
    • Gestational age Not reported
    • Postnatal age Not reported
    Follow-up Not applicable (recommendation context)
    Certainty method
    Not assessed
    Limitations
    The supporting evidence is largely from vaginal births in secondary-level facilities; WHO says more research is needed before recommending bundle care at caesarean birth, although each treatment is separately recommended. The trial behind this recommendation included multiple implementation and health system strengthening strategies, so the recommended package is more than the drape and the medicines. WHO says its evidence on measuring blood loss comes largely from trials using calibrated drapes. WHO 2025 labels each recommendation with one of four categories and a development status. These are not GRADE strength labels, so the claim certainty is left not assessed.
    Last checked
    2026-10-11
    Next evidence check due
    Not scheduled
    Sources and citations (4)

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

      Guideline · World Health Organization, co-published with the International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) · Edition First edition, 2025. The date is the who.int page date, 5 October 2025, which the atlas uses for WHO sources and decisions; the WHO IRIS record lists an issue date of 2025-09-26 for the same document. The web annexes with the evidence base and the implementation guide were not read. · Published 2025-10-05 · isbn: 978-92-4-011563-7

      Locator
      Recommendation 29: recommendation text and category
      How it applies
      WHO 2025 consolidated guideline, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      2049fb40dff7e97712c98cb58907ef662161627197a5e143ec50045abb1931de
      Reuse basis
      Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.

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

      Guideline · World Health Organization, co-published with the International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) · Edition First edition, 2025. The date is the who.int page date, 5 October 2025, which the atlas uses for WHO sources and decisions; the WHO IRIS record lists an issue date of 2025-09-26 for the same document. The web annexes with the evidence base and the implementation guide were not read. · Published 2025-10-05 · isbn: 978-92-4-011563-7

      Locator
      Recommendation 29, Remarks: implementation strategies, drape evidence, caesarean research need
      How it applies
      WHO 2025 consolidated guideline, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      2049fb40dff7e97712c98cb58907ef662161627197a5e143ec50045abb1931de
      Reuse basis
      Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.

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

      Guideline · World Health Organization, co-published with the International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) · Edition First edition, 2025. The date is the who.int page date, 5 October 2025, which the atlas uses for WHO sources and decisions; the WHO IRIS record lists an issue date of 2025-09-26 for the same document. The web annexes with the evidence base and the implementation guide were not read. · Published 2025-10-05 · isbn: 978-92-4-011563-7

      Locator
      Summary list of recommendations, footnote to Recommendation 29: integrated from the 2023 recommendations
      How it applies
      WHO 2025 consolidated guideline, CC BY-NC-SA 3.0 IGO; short quotation with attribution.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      2049fb40dff7e97712c98cb58907ef662161627197a5e143ec50045abb1931de
      Reuse basis
      Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.

    4. Background WHO recommendations on the assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage

      Guideline · World Health Organization · Edition 2023. History and burden figures only: WHO integrated Recommendations 1 and 2 of this document into its 2025 consolidated guideline unchanged, as Recommendations 21 and 29, so the 2025 document carries the current decisions. · Published 2023-12-21 · isbn: 978-92-4-008539-8

      Locator
      Table 1, Recommendation 2: the same recommendation in 2023
      How it applies
      WHO 2023 recommendations, CC BY-NC-SA 3.0 IGO; history only.
      Retrieved
      Source effective date
      Not reported
      Source state
      Current
      Snapshot hash
      36364aa61f4e3b6dc00561e5a5d6aff380639230952bda6cab1db58d81c66ad8
      Reuse basis
      Licensed CC BY-NC-SA 3.0 IGO, as stated in the PDF and in the IRIS record. Only short quotations with attribution are used, and neither the PDF nor the pages are committed. The non-commercial and share-alike terms need a licensing decision before any text is adapted.

Guidance

Recommended: PPH detection and first-response treatment bundle

Applies to Maternal
  • All women having a vaginal birth. WHO says the supporting evidence comes largely from vaginal births in secondary-level facilities and that more research is needed to recommend bundle care at caesarean birth.
  • Health facilities. The evidence is largely from secondary-level facilities; WHO says recognition and treatment are equally relevant in primary care, community and home settings.
  • Global (WHO guidance intended to inform national and subnational policy).
  • Childbirth and the first hours after birth
  • Gestational age Not reported
  • Postnatal age Not reported
Follow-up Not applicable (recommendation context)
Issued by
World Health Organization
Guideline
Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage, edition First edition, 2025. The date is the who.int page date, 5 October 2025, which the atlas uses for WHO sources and decisions; the WHO IRIS record lists an issue date of 2025-09-26 for the same document. The web annexes with the evidence base and the implementation guide were not read.
Strength
Recommended (WHO 2025 consolidated PPH guideline. Each recommendation falls in one of four categories (Recommended, Not recommended, Recommended only in specific contexts, Recommended only in the context of rigorous research) and carries a development status (New, Updated, Revalidated or Edited). These are not GRADE strength labels. Recommendation 29 is Revalidated.)
Effective
2025-10-05 (The who.int page date, 5 October 2025 (2025-10-05), is the effective date under the atlas rule for WHO decisions. The WHO IRIS record lists an issue date of 2025-09-26. Both dates are kept.)
Jurisdiction
Global (WHO guidance intended to inform national and subnational policy). Co-published with FIGO and ICM.
Basis
WHO 2025 recommends a standardized and timely approach to managing postpartum haemorrhage for all women having a vaginal birth (Recommendation 29, category Recommended, Revalidated from the 2023 recommendation). The approach combines an objective assessment of blood loss with a treatment bundle supported by an implementation strategy. The first-line bundle includes rapid uterine massage, an oxytocic medicine and tranexamic acid, intravenous fluids, examination of the genital tract and escalation of care.

Limitations. The supporting evidence is largely from vaginal births in secondary-level facilities; WHO says more research is needed before recommending bundle care at caesarean birth, although each treatment is separately recommended. The trial behind this recommendation included multiple implementation and health system strengthening strategies, so the recommended package is more than the drape and the medicines. WHO says its evidence on measuring blood loss comes largely from trials using calibrated drapes. WHO 2025 labels each recommendation with one of four categories and a development status. These are not GRADE strength labels, so the claim certainty is left not assessed.

Clinical links

Each link reports what one cited claim says about one population. "Evaluated for" means studied, not shown to work. These links do not show that anything is effective or right for you.

Record details

Record id
maternal:pph-detection-and-first-response-bundle
Content hash
b1ec619c447dd7ca865e7aecb03b1a7e551c7e7274102d14204b59e9ede6c2d3