Bibliographic information
GuidelineConsolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Antifibrinolytics for the prevention of postpartum haemorrhage. Tranexamic acid is not recommended for the prevention of postpartum haemorrhage at caesarean birth.
Not recommended
Notes and Remarks
- The GDG recognizes that this recommendation applies at the population level to all caesarean births and depends on the capacity to accurately assess blood loss and diagnose PPH. Future research may identify specific subpopulations that may benefit from prophylactic use of TXA before the onset of significant bleeding.
- For caesarean sections, PPH prophylaxis typically means administering TXA before the incision (preincision). However, some studies administered TXA after cord clamping to avoid fetal exposure, which could address some bleeding, aligning more with treatment than true prophylaxis.
- Clinical judgement should be used because individual woman needs and circumstances can vary. For certain high-risk women, benefits may outweigh the harms, and clinicians could consider using TXA to control bleeding even before the diagnostic criteria of PPH are met.
- Further, the GDG noted the increasing frequency of published reports on fatal and non-fatal medication errors regarding intrathecal administration of TXA. These reports seem to be concentrated in certain contexts where procured TXA is manufactured in ampoules that appear similar to bupivacaine ampoules. Consequently, care should be taken to ensure that TXA and bupivacaine are stored separately in the operating theatre. Additionally, TXA manufacturers are encouraged to improve product labelling and packaging to ensure they are easily distinguishable from bupivacaine (48).
- TXA remains recommended for treatment of PPH (Recommendation 27) and as part of the treatment bundle (Recommendation 29).
- TXA is not a uterotonic and should not be used as a substitute for uterotonics recommended for PPH prevention during caesarean birth (such as oxytocin).
- Where TXA is currently included in national guidelines or facility protocols for prophylaxis at caesarean birth, these policies should be reviewed in light of this recommendation. National programmes are encouraged to ensure that TXA is reserved for evidence-based indications to support safe, effective and equitable PPH care.