All interventions included in the PPH treatment bundle are individually recommended for PPH treatment (see Recommendations 24–28).

• The examination of the genital tract involves a thorough inspection of the birth canal and surrounding areas to identify any sources of bleeding. This examination typically includes checking for lacerations, tears or haematomas in the vagina, perineum and cervix, assessment of the uterus to ensure it is contracting properly, and examination of the placenta and membranes to ensure there are no retained placental fragments.
• In the context of this recommendation, the GDG emphasizes the need for a consistent use and interpretation of the term bundle as a clinical care bundle for the treatment of PPH. This should not be misconstrued with the use of this term in other contexts.
• To ensure the maximal success of the PPH treatment bundle, early detection of PPH is a key and indissociable component of the first-response intervention. The available evidence on postpartum blood loss measurement is largely from trials that used calibrated drapes for women who had a vaginal birth (see Recommendation 21).
• Clinical judgement is important to guide PPH treatment decision-making. In a large trial, the treatment care bundle was initiated when measured blood loss was 500 mL or greater, or when measured blood loss was 300 mL or greater with early warning signs of excessive blood loss (see Recommendation 22 and corresponding remarks).
• The trial underlying this recommendation included multiple implementation and health system strengthening strategies, which helped to achieve high coverage in the consistent use of the treatment bundle (55). These included ensuring availability of required human resources, strengthened by dedicated research staff, regular health care facility-level audit and feedback, designated facility champions to oversee change, restocking of PPH trolleys or carry cases so that all necessary medicines and equipment were readily available in one place, and training for health workers.
• The PPH treatment bundle requires standardized and timely use of all included interventions. All bundle treatment interventions should ideally be initiated within the first 15 minutes after a diagnosis of PPH. However, health system readiness (e.g. availability of staff, equipment) varies across different settings. In the event that not all bundle interventions are available, available components should be initiated in a timely and standardized manner.
• In cases of refractory postpartum bleeding – where a woman has received all interventions within the PPH treatment bundle yet continues to bleed – prompt escalation to a higher-level health care facility or a senior clinical provider capable of providing further management is critical.
• The GDG acknowledges that the evidence supporting the treatment bundle is largely from trials on vaginal births, and does not have any clear evidence to refute that the findings would be different for a caesarean section. The individual PPH treatment interventions included in the PPH treatment bundle are also recommended by WHO for women undergoing a caesarean section. However, the group acknowledged that additional research is required to confidently recommend bundle care for caesarean section births.
• National, regional, subregional and district-level health systems must be strengthened so that sufficient resources are available, ensuring the sustainability of treatment bundle implementation. Adequate numbers of staff and availability of commodities are essential to achieve the benefits of treatment bundles. The supporting evidence has largely been generated from studies conducted in secondary-level health care facilities. However, prompt recognition and treatment of PPH for women who give birth in primary care settings, in the community or at home are equally relevant. Appropriate resources and health worker training integrated with setting-specific implementation strategies are necessary to facilitate this.
• Engagement with women and their communities is paramount to promote women’s human rights and agency in their health, and foster their participation in shared decision-making around PPH treatment.