💡 Compared with expectant management, active management of the third stage of labour reduces the risk of postpartum haemorrhage (PPH).
⏱️ If the third stage of labour lasts more than 30 minutes, controlled cord traction (CCT) and IV/IM oxytocin (10 IU) should be used to manage retained placenta.
📘 About
- 🔗 CCT: Controlled cord traction to assist placental delivery.
- 🩸 Primary PPH: Blood loss >500 mL within 24 hrs of birth.
- ⚠️ Minor: 500–1000 mL
- 🚨 Major: >1000 mL
- 🕒 Secondary PPH: Excess bleeding between 24 hrs and 12 weeks postpartum.
🧾 Aetiology – The 4 Ts
- 🪢 Tone: Uterine atony (most common cause).
- 💔 Trauma: Vaginal, cervical, or uterine lacerations.
- 🧩 Tissue: Retained placental fragments or membranes.
- 🧬 Thrombin: Coagulopathies (DIC, thrombocytopenia).
⚠️ Risk Factors
- 💊 Anticoagulant use.
- 🩺 Underlying bleeding or clotting disorders.
- 👶 Multiple pregnancy, 🌊 polyhydramnios, ⏳ prolonged labour, or uterine overdistension.
🔍 Clinical Features
- Obvious (or concealed) per vaginal bleeding 🩸.
- Signs of shock: ⬇️ BP, ⬆️ HR, pallor, poor cap refill, oliguria.
- Soft, “boggy” uterus if atony is the cause.
🧪 Investigations
- 🧫 Bloods: FBC, U&E, LFTs, clotting profile.
- 🅰️🅱️ Group & cross-match blood urgently.
- 🛑 Catheterise & monitor hourly urine output.
🛡️ Prevention of PPH
- 💉 Oxytocin 10 IU IM or slow IV routinely for active management of the third stage of labour.
- 💊 Misoprostol if oxytocin is unavailable; commonly 400–600 micrograms orally/sublingually depending on local protocol.
- ✅ Active management of the third stage is standard: uterotonic drug, controlled cord traction where appropriate, and observation for bleeding.
- ❌ Early cord clamping is not routinely recommended.
- 🩺 Retained placenta: senior obstetric review and manual removal in theatre if the placenta is not delivered within local protocol timeframes or if bleeding occurs.
🩸 Treatment of Established PPH
- 🟢 PPH without shock / blood loss <1000 mL:
- 🚨 Call for help early and assess ABCs.
- 💉 Secure IV access, monitor observations, estimate ongoing blood loss and consider FBC, coagulation screen, group and save.
- 🔍 Treat the cause using the 4 Ts: tone, tissue, trauma, thrombin.
- 💆♀️ If uterine atony suspected: uterine massage and uterotonic treatment according to local protocol.
- 🧪 Tranexamic acid: 1 g IV over 10 minutes as soon as PPH is diagnosed. Repeat 1 g IV after at least 30 minutes if bleeding continues or restarts.
- 🔴 Major PPH / blood loss >1000 mL or haemodynamic instability:
- 🚨 Pull emergency buzzer / call obstetric, anaesthetic, midwifery, theatre, haematology and blood bank support.
- 🫁 Assess ABCs, give high-flow oxygen if shocked, lie flat, keep warm and monitor pulse, BP, SpO₂, urine output and mental state.
- 💉 Establish two large-bore IV cannulae and send FBC, U&E, coagulation screen including fibrinogen, group and save/crossmatch.
- 💧 Infuse warmed crystalloid while awaiting blood, but avoid excessive dilutional resuscitation.
- 📦 Activate the major haemorrhage protocol if unstable, ongoing heavy bleeding or blood loss is rapidly increasing.
- 🩸 Give crossmatched blood urgently if available; use emergency O-negative blood if crossmatch is delayed and the patient is unstable.
- 💉 Uterotonics: oxytocin 10 IU IM or slow IV, then additional agents according to local obstetric protocol, e.g. oxytocin infusion, ergometrine, carboprost or misoprostol.
- 🧪 Tranexamic acid: 1 g IV over 10 minutes as soon as possible once PPH is diagnosed. Repeat 1 g IV after at least 30 minutes if bleeding continues or restarts.
- 🔍 Treat the cause: tone, tissue, trauma, thrombin.
- Blood component replacement:
- Give RBC, FFP, platelets and cryoprecipitate/fibrinogen according to the major haemorrhage protocol and coagulation results.
- FFP: commonly 12–15 mL/kg during major obstetric haemorrhage, guided by protocol and coagulation tests.
- Cryoprecipitate or fibrinogen concentrate if fibrinogen <2 g/L.
- Platelets if platelet count <75 × 10⁹/L in ongoing major obstetric haemorrhage, or according to local haematology advice.
- Mechanical / surgical escalation: intrauterine balloon tamponade 🎈, examination under anaesthesia, repair of genital tract trauma, removal of retained tissue, uterine compression sutures, uterine or internal iliac artery ligation, uterine artery embolisation, or hysterectomy ✂️ if bleeding remains uncontrolled.
📖 References
