Paradigm transformation in postpartum hemorrhage management: analysis of WHO consolidated 2025 guidelines

DOI

https://dx.doi.org/10.18565/aig.2025.334

Marshalov D.V., Kan N.E., Ketskalo M.V., Tyutyunnik V.L., Sholin I.Yu.
Academician V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, Moscow, Russia

Postpartum hemorrhage remains one of the leading causes of maternal mortality. Annually worldwide, postpartum hemorrhage occurs in 14 million women, resulting in 45,000 deaths (0.32%). In the Russian Federation in 2024, blood loss of over 1000 ml was recorded in 28% of cases of critical obstetric conditions, demonstrating a mortality rate of 0.34%.
The World Health Organization (WHO) consolidated 2025 guidelines represent a comprehensive revision of the approaches to managing this complication based on the analysis of complications in more than 300,000 women who have just given birth from 23 countries. A conceptual shift has been made in the diagnostic criteria for postpartum hemorrhage. Instead of an arbitrary threshold of 500 mL, new criteria have been proposed:
blood loss ≥300 mL in combination with signs of hemodynamic instability, or ≥500 mL regardless
of hemodynamic parameters. This reduces the time before diagnosis from 30 to 15 minutes and prevents underestimation of blood loss.
A clear hierarchy of uterotonics has been established. Oxytocin remains the first-line agent. In cases of inadequate storage conditions, thermostable carbetocin or misoprostol is recommended. Ergotamine is excluded from prophylaxis protocols due to the high risk of arterial hypertension and myocardial ischemia. Correction of anemia prior to delivery reduces its frequency in the postpartum period by 39% and reduces the need for blood transfusion by 30%.
In the treatment of bleeding that has already taken place, a comprehensive E-MOTIVE mnemonic approach is recommended: E – Escalation, M – Massage of the uterus, O – Oxytocin, T – Tranexamic acid, I – intravenous Infusion of crystalloids, V – Vaginal and genital tract examination, E – Escalation of care. It is important
to apply all components within 15 minutes of identifying the complication. Tranexamic acid must be administered no later than 3 hours after delivery; its prophylactic use is not recommended. The systemic aspects of implementing the guidelines include the requirement for objective measurement of blood loss volume, availability of medications, clear protocols, and staff training.
Conclusion: The 2025 recommendations demonstrate a transition from fragmented approaches to evidence-based systematic management of postpartum hemorrhage.

Authors’ contributions: Marshalov D.V., Sholin I.Yu. – developing the concept and design of the study, writing the text;
Sholin I.Yu. – collecting and processing the material; Kan N.E., Ketskalo M.V., Tyutyunnik V.L. – editing the text of the article. The authors approved the manuscript for publication and agreed to take responsibility for all aspects of the work, ensuring that any issues related to accuracy and integrity of any part of it will be properly reviewed and resolved.
Conflicts of interest: The authors declare that there are no conflicts of interest.
Funding: The study was conducted without sponsorship.
Generative artificial intelligence: Was not used.
For citation: Marshalov D.V., Kan N.E., Ketskalo M.V., Tyutyunnik V.L., Sholin I.Yu. Paradigm transformation in postpartum hemorrhage management: analysis of WHO consolidated 2025 guidelines.
Akusherstvo i Ginekologiya/Obstetrics and Gynecology. 2026; (3): 5-13 (in Russian)
https://dx.doi.org/10.18565/aig.2025.334

postpartum hemorrhage

diagnostic criteria

uterotonic drugs

treatment

prevention

anemia

iron deficiency

WHO clinical guidelines

Full text (in Russian)

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Received 17.11.2025

Accepted 10.02.2026

Dmitriy V. Marshalov, Dr. Med. Sci., Associate Professor, Leading Researcher at the National Medical Center for Anesthesiology and Resuscitation for Pregnant Women, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, 117997, Russia, Moscow,
Ac. Oparina str., 4, +7(495)531-44-44, marshald@mail.ru, d_marshalov@oparina4.ru, https://orcid.org/0000-0002-8774-0700
Natalia E. Kan, Professor, Dr. Med. Sci., Honored Scientist of the Russian Federation, Deputy Director General for Research – Director of the Institute of Obstetrics, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, 117997, Russia, Moscow,
Ac. Oparina str., 4, kan-med@mail.ru, Researcher ID: B-2370-2015, SPIN-code: 5378-8437, Authors ID: 624900, Scopus Author ID: 57008835600,
https://orcid.org/0000-0001-5087-5946
Mikhail V. Ketskalo, PhD, Director of the National Medical Center for Anesthesiology and Resuscitation for Pregnant Women, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, 117997, Russia, Moscow, Ac. Oparina str., 4, m_ketskalo@oparina4.ru,
https://orcid.org/0000-0001-6569-2106
Victor L. Tyutyunnik, Professor, Dr. Med. Sci., Leading Researcher at the Center for Scientific and Clinical Research, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, 117997, Russia, Moscow, Ac. Oparina str., 4, tioutiounnik@mail.ru,
Researcher ID: B-2364-2015, SPIN-code: 1963-1359, Authors ID: 213217, Scopus Author ID: 56190621500, https://orcid.org/0000-0002-5830-5099
Ivan Yu. Sholin, PhD, Senior Researcher at the National Medical Center for Anesthesiology and Resuscitation for Pregnant Women, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, 117997, Russia, Moscow, Ac. Oparina str., 4, i_sholin@oparina4.ru,
https://orcid.org/0000-0003-2770-2857
Corresponding author: Dmitriy V. Marshalov, marshald@mail.ru, d_marshalov@oparina4.ru

Paradigm transformation in postpartum hemorrhage management: analysis of WHO consolidated 2025 guidelines

Marshalov D.V., Kan N.E., Ketskalo M.V., Tyutyunnik V.L., Sholin I.Yu.

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