Insight

The First 60 Minutes: Building a Reliable Response to Bleeding After Birth

Postpartum haemorrhage (PPH) remains one of the most serious complications of childbirth. It is a leading cause of preventable maternal mortality worldwide, and a major contributor to severe maternal morbidity in the UK.

Recent trials, including the E‑MOTIVE study led by teams at the University of Birmingham and the University of Oxford, have reinforced that the window for making a difference is narrow. Earlier, more accurate diagnosis of PPH at the bedside, followed by prompt, bundled treatment, is associated with reductions in severe PPH and life‑saving interventions. 

International guidance from WHO, FIGO and ICM now recommends routine, objective measurement of postpartum blood loss for all women following birth, with calibrated drapes highlighted as a practical method to support earlier detection and treatment.. For more information on the recommendations and their implications for practice, read our article Improving the Diagnosis of PPH.

Why the first 60 minutes matter

In the immediate period after birth, blood loss may appear modest at the bedside. The presence of expected postpartum bleeding can make it difficult to distinguish early PPH from normal blood loss. By the time a haemorrhage is obvious to the naked eye, the opportunity for simple, ward‑based interventions may already be closing.

Findings from E-MOTIVE and other related work have helped to clarify the link between timely diagnosis and outcomes. This evidence underpins a growing policy and clinical push (reflected in RCOG and NHS guidance) towards structured PPH pathways that emphasise early recognition, clear thresholds and team working.

The question for maternity services is not just how to treat PPH once diagnosed, but how to make the first 60 minutes after birth as reliable as possible.

Where recognition and response break down

Despite widespread awareness of the risks, visual estimates of blood loss remain a common point of weakness. Blood soaking into sheets and clothing, or pooling under a woman or birthing person, is hard to quantify accurately, particularly when staff are multitasking. 

Meanwhile, variation between sites adds another layer of complexity. Clinicians bring different training and levels of experience to assessing blood loss, which can influence when they act. Moreover, documentation of blood loss and escalation decisions may not always be aligned across wards, theatres, and recovery areas. 

These are systemic challenges. They arise where systems and processes rely too heavily on judgement and memory, and not enough on objective measurement, shared mental models and practice. Addressing them requires changes not only to tools, but to pathways and team behaviours.

Building a reliable first‑60‑minutes response

A more reliable response to bleeding after birth starts with changing how blood loss is measured. Calibrated PPH drapes offer a practical way to implement the recommendation for routine, objective quantification. Rather than estimating volume, blood is collected into a graduated pouch or funnel with clear volume markers. Placed on the bed or comfortably attached to the woman or birthing person, teams can monitor cumulative loss in real time.

Current international guidance recommends objective measurement of postpartum blood loss to support timely recognition and treatment of PPH. This allows midwives and doctors to see at a glance, whether blood loss is approaching or exceeding locally-agreed thresholds for concern.

Measurement alone, however, is not sufficient. A reliable response also depends on clear roles and escalation pathways. In a standardised PPH pathway, roles and responsibilities are clear, with regards to who’s watching for blood, who’s responsible for uterotonics, who is documenting and who is leading communication and escalation. Locally agreed thresholds, such as specific blood loss volumes, rate of loss or clinical signs, help teams decide when to move from observation to active intervention.

The third component of a reliable response is rehearsal. While policies are essential, they do not, on their own, guarantee consistent performance in high-pressure situations. Regular multidisciplinary drills and simulations, using the actual equipment found on the unit, help teams internalise the steps of their PPH pathway and build fluency in the first minutes of a haemorrhage.

Embedding standardisation across wards, shifts and sites

For many services, the challenge is not knowing what good looks like, but delivering it consistently. Embedding standardisation means making quantitative blood loss measurement the default rather than the exception, ensuring that PPH equipment is stocked and positioned consistently, and aligning documentation so that recognition times, escalation points and interventions can be audited across sites.

Standardising product choices can support this work. Consistency in equipment availability and familiarity can also support implementation, helping teams rehearse PPH pathways using the same equipment they will encounter in clinical practice. New staff and rotating trainees can build confidence more quickly when tools and pathways are familiar wherever they work.

Making every minute count

PPH cannot always be predicted, making a reliable and timely response essential. By combining objective blood-loss measurement with clear escalation pathways, defined team roles and regular rehearsal, maternity teams can strengthen the way PPH is recognised and managed in the critical period after birth.

Maternity by Kimal works with services across the UK to support this shift. To learn more about how Maternity by Kimal’s products can support early accurate detection and management of PPH, visit our website or contact the team for more information.

Insight

Advancing Maternity Care for Every Birthing Person

For most women and birthing people, pregnancy and birth will not be life‑threatening. However, the latest maternal mortality figures from MBRRACE‑UK remind us that there is still work to do, particularly for those who face the greatest barriers to care.

Between 2022 and 2024, 12.8 women and birthing people died for every 100,000 births in the UK. That rate is 20% higher than it was in 2009–11, when the Government set an ambition to halve maternal mortality in England. Even when deaths related to COVID-19 are excluded, the rate remains 17% higher. 

At the same time, the data show that deaths are not evenly distributed: they are more likely to occur among Black and Asian women and birthing people, those living in the most deprived areas, and those with complex health or social needs.

What the latest maternal mortality data shows

The most recent MBRRACE‑UK maternal mortality data brief highlights several themes that are particularly relevant for frontline teams.

Patterns in causes and timing

Although overall numbers are small, the data show that direct obstetric complications such as thrombosis and thromboembolism remain leading causes of maternal death. Cardiac disease continues to feature prominently as an indirect cause. Mental health is also a key factor, especially after birth: suicide is now one of the leading causes of maternal death in the late postnatal period, and psychiatric conditions account for a significant proportion of deaths between six weeks and one year after the end of pregnancy.

Persistent inequalities

The brief also shows that some groups continue to face higher risks than others. Women and birthing people from Black ethnic backgrounds are several times more likely to die during or after pregnancy than those from White backgrounds. Those from Asian backgrounds also experience elevated risk. Meanwhile, people living in the most deprived areas have roughly double the maternal mortality rate of those in the least deprived areas. 

These patterns are not a reflection of a lack of commitment from staff. They point to the underlying impact of structural inequality and the challenges services face in reaching and supporting those whose lives are most complex. The question is how to respond in ways that are practical and grounded in day‑to‑day reality.

Practical steps towards more equitable, trauma‑informed care

Equitable, trauma‑informed care is not a new way of working for most teams. Rather, it is a way of making existing good practice more consistent and more responsive to those who need it most. There are several concrete steps services can take, even in the context of workforce and resource pressures.

Understand your own patterns and priorities

Each service will have its own unique challenges and opportunities, which can be uncovered through local data. Regularly reviewing serious incidents, near misses, unplanned readmissions and complaints can help teams see where risks are concentrated in their own population. Involving local partners like charities and lived experience groups in interpreting that data can make it more meaningful and helps identify practical priorities.

Design care around those at highest risk

Once those patterns are visible, care can be tailored more intentionally. That might mean prioritising ‘continuity of carer’ for women and birthing people with multiple disadvantages or building stronger outreach links with communities that have historically experienced poorer outcomes. 

Having clear, agreed routes into perinatal mental health, domestic abuse, cardiology and haematology services means staff know exactly who to contact and how quickly someone will be seen, so that when concerns arise they can get the right help in place without delay.

Embed trauma‑informed communication in everyday practice

Trauma‑informed communication is often most visible in the small moments, such as in how staff introduce themselves, explain procedures, ask about concerns and respond to distress. Simple habits can make a significant difference to whether care feels safe and respectful.

It also means asking about mental health and past trauma in a way that is sensitive and non‑judgemental, and revisiting these questions across pregnancy and the postnatal period, rather than treating them as a single tick‑box at booking. When people share difficult experiences or say they do not feel right, having clear routes to support builds trust.

Support staff to work in this way

Delivering equitable, trauma‑informed care is demanding, especially in busy services. Staff need space and support to learn new skills and to look after their own wellbeing. Regular team debriefs, access to psychological support and practical training can help sustain trauma‑informed practice over time.

This is where specialist organisations can add real value. For example, Maternity by Kimal’s partner, Make Birth Better, is a UK‑based collective focused on reducing trauma in the perinatal period and supporting trauma‑informed change in services. MBB offers a wide variety of evidence‑informed training and resources that turn trauma‑informed principles into concrete, day‑to‑day skills for maternity teams.

Find out more

Insight

What OASI Litigation Teaches Us About Safer Maternity Care

Obstetric anal sphincter injuries (OASIs) are officially recorded in around 3 in 100 vaginal births in the UK, and in roughly 6 in 100 first‑time vaginal births. However, evidence also shows that some OASIs are missed or misclassified at the time of birth, meaning the true burden of injury may not always be reflected in routinely recorded figures.

The gap between what is recorded and what many women and birthing people experience is reflected in the costs of OASI‑related litigation. In a recent thematic review of claims in England, NHS Resolution identified 237 cases linked to OASI over a ten‑year period, with closed cases costing around £60 million once damages and associated expenses are included.

What the litigation tells us about OASI today

The OASI claims examined by NHS Resolution reveal a consistent pattern within NHS maternity services in England: when these tears are not recognised promptly, the delayed diagnosis has knock‑on effects for maternal outcomes and increases the likelihood of legal action. Here are the key findings. 

Missed tears and delayed diagnosis

In cases where damages were awarded, more than half of women and birthing people (58%) had a perineal tear that was initially graded as less severe than it really was. Many were later found to have sustained an OASI that had not been detected at the time of birth. 

The average delay from delivery to accurate diagnosis was approximately 294 days (close to ten months) with some women and birthing people waiting several years before the full extent of their injury was recognised.

Birth context 

Around six in ten had an instrumental delivery, most commonly with forceps. Episiotomy was performed in the majority of forceps births. Instrumental birth is often clinically necessary and can be life‑saving for mother or baby, but the claims data suggest that when forceps are used, the risk of severe perineal trauma increases.

The lasting toll

The symptoms described in the claims also underline the human cost of undiagnosed or poorly managed OASI. Faecal incontinence was the most frequently reported complaint, affecting roughly four in five women and birthing people in the cohort. Many also reported embarrassment, social withdrawal, strain on intimate relationships and difficulties returning to work or caring for their baby in the way they had hoped.

Priorities for safer maternity care 

The litigation picture makes it clear that while not all OASIs are preventable, earlier recognition and appropriate management may help reduce the risk of some of the longer-term consequences associated with missed injury. The report points towards several practical priorities for maternity services, all of which can help to reduce harm and future OASI‑related claims.

Safer assisted vaginal births 

Assisted vaginal births are a key point of risk for OASI, particularly when forceps are used. Regular, hands-on training in decision-making and instrumental technique can both reduce the likelihood and severity of OASI. 

Stronger supervision in complex deliveries

Many OASI claims involve births conducted by less experienced clinicians working with limited senior supervision. Ensuring visible consultant presence for complex or assisted births, alongside clear thresholds for escalation, makes it easier for teams to ask for help early. This support is particularly important when OASI risk is high, such as in rotational forceps deliveries.

Early diagnosis 

With missed or under‑graded tears a major driver of OASI claims, a consistent, structured perineal assessment after every vaginal birth is essential to detect OASI at the earliest opportunity. Research shows that digital rectal examination (DRE) can be unreliable, missing up to 80% of injuries. Instead, maternity teams should look to medical devices to support objective diagnosis. 

Conclusion

The OASI claims reviewed by NHS Resolution tell a consistent story: much of the litigation surrounding this injury is driven not by the tear itself, but by OASI that is missed or undergraded.

The findings reinforce the importance of giving clinicians the tools and confidence to identify OASI accurately at the earliest opportunity. Technologies such as ONIRY have the potential to complement clinical examination by providing an objective assessment at the bedside, supporting more informed decisions about appropriate care and repair.

ONIRY is a bedside probe device that uses AI-powered detection to accurately and objectively detect OASI in just 60 seconds. Oniry improves OASI detection by up to 200%, helping clinicians make confident decisions in the moments when it matters most.

To learn more about how ONIRY can support OASI detection in your service, visit the:

ONIRY product page
Insight

Rethinking OASI Care Bundles for Inclusivity

Despite sustained clinical research, Obstetric anal sphincter injuries (OASI) remain among the most serious complications of vaginal birth. For many women and birthing people, the consequences extend far beyond the delivery room, with many experiencing long-term issues like faecal incontinence and chronic perineal pain.

As a result, the OASI care bundle has become a crucial element of perineal trauma prevention and management in the UK. Through the standardisation of key elements of care, maternity teams have been somewhat able to reduce the rates of severe perineal trauma and improve recognition and repair.

However, as discussed in a recent article in the British Journal of Midwifery, it may be time to further optimise the bundle. The OASI care bundle has improved outcomes overall, but it raises an important question: are those improvements being experienced equally across all patient groups?

Examining OASI through the lens of inclusive maternity care, it becomes clear that implementation matters just as much as evidence. An intervention can be effective overall and yet still fail women and birthing people who face language barriers, cultural stigma or structural disadvantage.

What the OASI care bundle gets right

The OASI care bundle, developed by the Royal College of Obstetricians and Gynaecologists and partners, provides an evidence‑based framework for OASI prevention and early recognition. While local variations exist, they typically bring together risk assessment, perineal protection techniques, guidance on mediolateral episiotomy, systematic post‑birth examination and stronger documentation, training and audit.

Observed together, these components have reduced unwarranted variation and given teams a shared standard of care. Not to mention, the bundles as a whole have helped to raise greater awareness of OASI among midwives, obstetricians and trainees, and contributed to better detection and timely repair.

Now we must consider how we need to evolve the bundle to ensure every woman and birthing person has an equal opportunity to benefit from it, regardless of language, ethnicity or background.

Who is being missed and why?

Emerging evidence suggests that OASI does not affect all groups equally. In the UK, OASI occurs in around 3 in 100 women having a vaginal birth, rising to around 6 in 100 women having their first vaginal birth. Recent research has also identified an association between non-English preferred language and severe perineal trauma.

The article suggests that language and communication are likely central components of this picture. In busy labour wards, crucial conversations about perineal protection, controlled pushing or consent for episiotomy and rectal examination can easily be compressed into a few hurried phrases, especially when interpreter support is limited. For women and birthing people who are not fluent in English, that can mean less opportunity to ask questions, express concerns or fully understand what is happening. When communication is constrained, it becomes harder to build trust, support informed choices and apply the OASI care bundle consistently.

Cultural stigma and structural barriers also play a role. In many communities, modesty norms and taboos around bowel function, sexual health and intimate examinations can make it difficult to talk openly about perineal trauma, incontinence or pelvic floor exercises. Misinformation and myths about “natural” birth may lead some to view recommended preventive measures with suspicion, particularly if messages from professionals are inconsistent. 

At the same time, practical challenges – from transport and childcare to digital exclusion – can limit access to antenatal education and postnatal follow‑up. Without addressing these factors, the OASI care bundle risks working best for those who already feel confident, informed and well served by the system, while others remain at greater risk of missed or under‑treated injuries.

Conclusion

Taken together, these insights suggest that the next phase of OASI improvement is less about adding new elements to the care bundle and more about making sure that every element is delivered in a way that is inclusive, understandable and equitable. That includes investing in culturally sensitive, multilingual information; strengthening interpreter pathways; building health literacy into routine contacts; and looking again at how we detect OASI, so that the quality of assessment does not depend on who happens to be on shift.

Tools such as Maternity by Kimal’s ONIRY can play a valuable part in this journey. By supporting more consistent, confident detection, they offer a way to reduce variation and give every woman and birthing person the same chance of timely diagnosis and repair, wherever they give birth.

To learn more about how ONIRY can support OASI detection in your service, visit the:

ONIRY product page