Birth · Emergency
CMQCC PPH Risk Stratification
California Maternal Quality Care Collaborative (CMQCC) hemorrhage risk stratification — LOW / MEDIUM / HIGH tier based on patient characteristics. Activates a tiered response from active third-stage management (LOW) to dedicated nursing + immediate senior obstetric / anaesthetic availability (HIGH).
Last reviewed 25 May 2026
CMQCC PPH risk stratification
Antepartum / intrapartum PPH risk tier
High-risk factors — ANY ONE = high risk
Medium-risk factors — TWO OR MORE = medium risk
CMQCC PPH risk tier
LOW risk
Standard care: active third-stage management with prophylactic oxytocin, routine vital signs, QBL measurement.
0 high-risk · 0 medium-risk factor(s)
Educational tool only — not medical advice. CMQCC OB Hemorrhage Toolkit V3.0 is the gold-standard PPH risk stratification system, used in US hospitals certified by AIM and Joint Commission. Risk stratification at admission, on transfer to labour ward, post-delivery, and in PACU. Activation triggers a hemorrhage cart, blood-bank notification, and stage-based escalation pathway.
What does this mean?
PPH risk is not random — most cases are predictable from history, antenatal findings, and labour course. CMQCC’s three-bucket system (low/medium/high) lets units prepare BEFORE bleeding starts: high-risk women get a type-and-cross on admission, hemorrhage cart at bedside, second IV access, and active senior involvement; medium-risk get type-and-screen ready. The California Maternal Quality Care Collaborative (CMQCC) toolkit + structured drill programmes have measurably reduced severe maternal morbidity from PPH when adopted by hospital networks. Re-assess at each transition (booking, labour ward arrival, post-delivery, PACU) — risk changes as labour progresses (chorio, prolonged labour, instrumental delivery, atony all upgrade risk in real time). Even “low-risk” women still need active management of the third stage with prophylactic oxytocin — PPH happens to patients who weren’t flagged.
Introduction
The California Maternal Quality Care Collaborative (CMQCC) developed the most widely-used postpartum hemorrhage risk stratification tool in the US. Pre-stratifying patients into LOW / MEDIUM / HIGH tiers allows hospital teams to pre-position resources (blood products, surgical kit, nursing, escalation pathway) before bleeding actually starts. Implementation has reduced severe maternal morbidity by ~21 % in pilot hospitals.
The three tiers
HIGH risk — any 1 of:
- Placenta praevia / accreta spectrum.
- ≥ 4 prior caesarean deliveries.
- Haemoglobin < 8 g/dL on admission.
- Platelets < 70 × 10⁹/L.
- Active placental abruption / IUFD.
- Known coagulopathy.
MEDIUM risk — 2 or more of:
- 1-3 prior caesarean deliveries.
- Uterine fibroids.
- Chorioamnionitis.
- Magnesium sulphate use.
- BMI ≥ 40.
- Polyhydramnios.
- Grand multiparity (≥ 4).
- Previous PPH.
- Multiple pregnancy.
- Suspected macrosomia (EFW > 4 kg).
- Prolonged labour.
LOW risk:
Singleton, term, no prior CS, no other risk factors.
Tiered response
- LOW — standard active third-stage management with prophylactic oxytocin, routine QBL.
- MEDIUM — type-and-screen, IV access × 1, uterotonic kit at bedside, vigilant QBL.
- HIGH — type-and-crossmatch 2 units, IV × 2, dedicated nurse, bedside senior obstetric + anaesthetic, blood bank notified, balloon tamponade and TXA ready.
When to re-stratify
Risk stratification is performed at:
- Antenatal admission.
- Transfer to labour ward.
- Post-delivery.
- In PACU / recovery.
New factors during labour (chorioamnionitis, prolonged labour, instrumental delivery, cesarean, manual removal) can elevate someone to medium or high risk.
The stage-based response
- Stage 0 — routine active third-stage in every birth.
- Stage 1 — blood loss > 500 mL vaginal / > 1000 mL cesarean: hemorrhage cart, IV access, uterotonics, QBL.
- Stage 2 — bleeding > 1500 mL or signs of hypovolemia: transfuse, escalate uterotonics, balloon tamponade, OR/IR readiness.
- Stage 3 — refractory bleeding > 1500 mL: massive transfusion protocol, OR, possible hysterectomy.
Limitations
- Pre-stratification doesn’t catch all PPH cases — about 40 % of women who develop PPH have no identified risk factors.
- Risk factor checklists vary slightly between protocols (CMQCC, AWHONN, Joint Commission).
- Educational only; clinical decisions are made by the obstetric team in real-time.
Sources
- CMQCC. Improving Health Care Response to Obstetric Hemorrhage. California Maternal Quality Care Collaborative Toolkit V3.0. 2022.
- Main EK, et al. National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage. Obstet Gynecol 2015;126:155-62.
- Alliance for Innovation on Maternal Health (AIM). Obstetric Hemorrhage Patient Safety Bundle.
- Joint Commission. Provision of Care Standards for Maternal Safety.
- ACOG. Committee Opinion 794: Quantitative Blood Loss in Obstetric Hemorrhage.
Frequently asked questions
What is the CMQCC PPH risk score?
California Maternal Quality Care Collaborative (CMQCC) developed a risk-factor checklist that classifies pregnancies into LOW, MEDIUM, or HIGH PPH risk at admission, transfer to labour ward, after delivery, and in PACU. Each tier triggers a tiered response — for example, HIGH risk activates type-and-crossmatch of 2 units, dedicated nursing, and bedside availability of senior obstetrician and anaesthetist. Adopted nationally through AIM (Alliance for Innovation on Maternal Health) and the Joint Commission. Implementing the CMQCC protocol has reduced severe maternal morbidity by 21 % in pilot hospitals.
What triggers HIGH risk?
Any ONE of: placenta praevia / accreta spectrum, ≥ 4 prior caesarean deliveries, haemoglobin < 8 g/dL on admission, platelets < 70 × 10⁹/L, active placental abruption, known coagulopathy. HIGH-risk patients should deliver in a facility with full blood-bank, surgical, and ICU capability; have ≥ 2 large-bore IVs; have type-and-crossmatch of 2 units; have a dedicated nurse and immediate senior obstetric / anaesthetic availability.
What triggers MEDIUM risk?
Two or more of: 1-3 prior caesarean deliveries, uterine fibroids, chorioamnionitis, magnesium sulphate use, BMI ≥ 40, polyhydramnios, grand multiparity (parity ≥ 4), previous PPH, multiple pregnancy, suspected macrosomia, or prolonged labour. MEDIUM-risk: type-and-screen on admission, IV access × 1, active third-stage management, QBL monitoring, uterotonic kit at bedside.
What about emerging in-labour risk?
Risk stratification is re-evaluated at each transition: admission, on labour ward, post-delivery, in PACU. New risk factors (prolonged labour, chorioamnionitis developing intrapartum, instrumental delivery, cesarean, manual removal of placenta) can elevate someone from low to medium risk. The CMQCC checklist is designed as a living document for each patient.
What does the protocol actually involve?
Four stages. Stage 0: routine active management of third stage in every birth. Stage 1: blood loss > 500 mL vaginal / > 1000 mL cesarean — initiate hemorrhage cart, additional IV access, uterotonics, QBL. Stage 2: continued bleeding > 1500 mL or signs of hypovolemia — transfuse, escalate uterotonics, balloon tamponade, OR / IR readiness. Stage 3: blood loss > 1500 mL with refractory bleeding — massive transfusion protocol, OR, possible hysterectomy. The stages match the QBL thresholds.
Does CMQCC apply outside California?
Yes — widely adopted across the US through the AIM program; similar frameworks exist internationally (RCOG GTG 52 for UK PPH; FIGO PPH initiative). The CMQCC Toolkit V3.0 (2022) is freely downloadable and used as a template internationally.
How does this differ from MEOWS?
MEOWS (Maternal Early Obstetric Warning Score) is a TRACK-AND-TRIGGER system based on vital signs during the hospital stay. CMQCC PPH Risk is a PRE-STRATIFICATION system based on patient characteristics, performed at admission. They complement each other: MEOWS catches deterioration; CMQCC pre-positions resources for those most likely to need them.