Compared with expectant management, the active management of the third stage of labour is associated with a substantial reduction in the occurrence of PPH. If the third stage of labour lasts more than 30 minutes, CCT and IV/IM oxytocin (10 IU) should be used to manage the retained placenta.
- CCT: Controlled cord traction
- Primary PPH: loss of > 500 mls/blood within first 24 hrs after birth. Minor 500-1000mls Major > 1000 mls.
- Secondary PPH: Excess bleeding between 24 hrs and 12 weeks post natally.
Aetiology the 4 Ts
- Tone: uterine atony is commonest cause
- Trauma: vaginal or cervical lacerations
- Tissue: retained placental tissue
- Thrombin : clotting issues
- Bleeding disorders
- Frank PV bleeding
- Haemorrhagic shock: Hypotension, tachycardia pallor, Delayed capillary return, oliguria
- Monitor FBC, U&E, LFT, Clotting
- Group and cross match
- Consider Oxytocin to encourage uterine contraction usually 10 IU IV/IM
- Consider misoprostol where oxytocin is unavailable
- Consider IV Tranexamic acid if increased risk
- Early cord clamping not now advised
- If 3rd stage of labour delayed then manual removal of placenta
- Mild: IV access. IV crystalloid fluids. Monitor
- Severe: ABC, IV access, Oxygen. Lie flat.
- Infuse warm clear fluids until blood available
- Consider transfusion O rhesus negative if needed
- After 4 U red cells consider FFP 12-15 ml/Kg until haemostatic tests known
- Cryoprecipitate if low Fibrinogen. < 2g/L
- Platelets if count < 75 x 109/L
- Uterine artery embolisation
- Hysterectomy if bleeding fails to stop