Introduction
Postpartum haemorrhage (PPH) remains a leading cause of direct maternal mortality in the UK. For clinicians, two key bodies provide authoritative guidance: the National Institute for Health and Care Excellence (NICE) and the Royal College of Obstetricians and Gynaecologists (RCOG). While complementary, their guidelines on the management of PPH have distinct characteristics. NICE's guideline (NG.219, published April 2023) is a comprehensive, evidence-based standard for the NHS in England and Wales. The RCOG's Green-top Guideline (No. 52, published December 2022, minor update April 2024) provides specialist, in-depth recommendations from a professional college perspective. This comparison aims to delineate the nuances between these two essential resources to aid clinical practice.
See how this translates to practice: Explore our Clinical governance features, visit the Patient Safety Hub, or review Clinical Safety & Assurance for enterprise rollout.
Diagnosis and Assessment
NICE (NG.219)
NICE adopts a pragmatic, quantitative approach. It defines primary PPH as a blood loss of 500 ml or more from the genital tract within 24 hours of birth. Major PPH is defined as a loss of 1000 ml or more, with a specific emphasis on objective measurement using quantitative or semi-quantitative methods (e.g., calibrated drapes, weighing swabs) rather than visual estimation alone.
- Focus: Standardisation of diagnosis across all maternity settings.
- Key Takeaway: Mandates moving beyond visual estimation to more accurate measurement to trigger guidelines promptly.
RCOG (GTG No. 52)
RCOG concurs with the 500/1000 ml definitions but places a stronger emphasis on the clinical condition of the woman. It explicitly states that the diagnosis of major PPH should be based on "any blood loss likely to cause haemodynamic instability," acknowledging that a woman with pre-existing anaemia may become unstable with a loss of less than 1000 ml.
- Focus: Clinical judgement and individualised patient assessment.
- Key Takeaway: The trigger for major PPH protocols is not just a volume number, but the physiological response to that loss.
Practical Difference: NICE drives a system-wide shift to objective measurement. RCOG provides the clinical rationale for this, reminding clinicians to treat the patient, not just the number.
Medical and Surgical Treatment
Pharmacological Management (First-line)
Both guidelines agree that Oxytocin is the first-line uterotonic drug for the treatment of PPH. NICE recommends 5 IU by slow IV injection or 10 IU by IM injection. RCOG provides more detail on administration, including the option of an IV infusion (40 IU in 500 ml crystalloid at 125 ml/hour) if bleeding continues after initial bolus.
Second-line Uterotonics
This is an area of significant alignment, with both recommending a rapid escalation to a second drug if oxytocin fails.
- NICE: Suggests Ergometrine (500 micrograms IM/IV), Oxytocin-Ergometrine (Syntometrine®) combination (if not already used for prophylaxis), or Carboprost (Hemabate®; 250 micrograms IM, repeated at 15-minute intervals up to 8 times).
- RCOG: Offers a similar sequence but provides a more detailed discussion on the contraindications (e.g., hypertension with ergometrine, asthma with carboprost) and practical considerations for administration.
Tranexamic Acid
Both guidelines strongly recommend early administration of Tranexamic Acid (1g IV over 10 minutes, with a second dose considered if bleeding continues after 30 minutes). NICE places it within the core "4 Ts" structure (Tone, Tissue, Trauma, Thrombin), while RCOG dedicates a specific section to its use, referencing the robust evidence from the WOMAN trial.
Intrauterine Balloon Tamponade (IBT)
This is a key area of practical difference.
- NICE: Recommends IBT as a next step after failure of first-line uterotonics, before proceeding to surgical interventions.
- RCOG: Positions IBT as a simultaneous or early step alongside pharmacological treatment, particularly in units where surgical expertise may not be immediately available. It is seen as a critical "holding measure" to stabilise the patient and potentially avoid surgery.
Practical Takeaway: RCOG encourages a lower threshold for deploying a balloon, viewing it as a bridge to definitive care, whereas NICE presents it as a more formal step within a sequential algorithm.
Surgical Interventions
Both guidelines cover compression sutures (e.g., B-Lynch), vascular ligation, and hysterectomy. RCOG provides more detailed technical descriptions and decision-making pathways for these procedures, reflecting its specialist surgical audience.
Special Situations
Morbidly Adherent Placenta (MAP)
- NICE: Briefly references MAP within the "Tissue" cause of PPH, advising senior input and consideration of hysterectomy if conservative measures fail.
- RCOG: Contains a comprehensive, dedicated section on the management of suspected and confirmed MAP, including the role of multidisciplinary team planning, interventional radiology, and conservative surgical options. This reflects its role as a specialist reference.
Peri-mortem Caesarean Section
RCOG includes specific guidance on peri-mortem caesarean section in the context of maternal collapse from PPH, a detail not covered in the NICE PPH guideline. This underscores RCOG's role in preparing for the most extreme obstetric emergencies.
Practical Clinical Flow: A Synthesis
A combined, practical approach for UK clinicians can be constructed:
- Call for Help & Resuscitate (A-B-C-D approach): Simultaneously measure blood loss quantitatively and assess clinical state. This satisfies both NICE and RCOG principles.
- Treat Cause (4 Ts):
- Tone: 1st-line: Oxytocin (IV/IM). 2nd-line: Escalate rapidly to Ergometrine or Carboprost.
- Thrombin: Administer Tranexamic Acid (1g IV) early.
- Trauma/Tissue: Examine for lacerations/retained products.
- Mechanical & Surgical: Consider Intrauterine Balloon Tamponade early (per RCOG philosophy), especially if bleeding persists or transfer is needed. If unavailable or ineffective, proceed to surgical interventions (compression sutures, etc.) with senior input.
- Major Haemorrhage Protocol (MHP): Activate the local MHP early. Transfuse blood products as per protocol and involve haematology early.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow if they differ?
Your local NHS Trust's protocol is paramount, as it will have been written to synthesise national guidance with local resources. Generally, these guidelines are complementary. Use the NICE algorithm for a standardised structure and the RCOG guideline for deeper clinical reasoning and specialist management options.
2. What is the single most important practical difference?
The timing of intrauterine balloon tamponade (IBT). RCOG advocates for its use earlier in the process as a stabilising measure, while NICE places it after second-line drugs. Discussing and practicing IBT insertion in local drills can clarify its role in your unit.
3. How should we monitor response to treatment beyond blood loss?
Both guidelines imply but RCOG explicitly emphasises monitoring for haemodynamic instability. Use frequent observations of heart rate, blood pressure, capillary refill time, and consciousness. Point-of-care testing for lactate or base deficit can provide an objective measure of shock.
4. Is there a difference in guidance for women who decline blood products?
NICE recommends discussing and documenting a management plan for women who decline blood products antenatally. RCOG provides more detailed advice on intraoperative cell salvage and pharmacological agents like recombinant Factor VIIa as alternatives, stressing the need for senior, multidisciplinary planning.
5. How do the guidelines address "minor" PPH (500-1000 ml)?
NICE is clear that any PPH (>500 ml) requires careful monitoring and treatment to prevent progression to major PPH. RCOG adds that even a "minor" PPH can be significant for an anaemic woman, reinforcing the need for individualised assessment and follow-up, including checking Hb levels.
Source Links
- NICE Guideline NG.219 (April 2023): Postpartum haemorrhage: NICE guideline
- RCOG Green-top Guideline No. 52 (Dec 2022, updated Apr 2024): Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No. 52)