Gestational context
After delivery
Maternal
- Loss measured, not estimated; shock index heart rate over systolic
- Loss measured, not estimated; shock index heart rate over systolic
- Fundus
- tone, height, and whether it is there at all
- Placenta and membranes inspected complete
- Placenta and membranes inspected complete
- Perineum, vagina and cervix examined for trauma; clotting checked
- Perineum, vagina and cervix examined for trauma; clotting checked
Fetal
- The baby is born; the fetal column becomes the neonatal team
- The baby is born; the fetal column becomes the neonatal team
- Cord gases if the birth was complicated
- Cord gases if the birth was complicated
- Skin to skin when the mother is stable
- Skin to skin when the mother is stable
- Feeding plan once the bleeding is controlled
- Feeding plan once the bleeding is controlled
The four Ts
| Cause | Share | Clues | First treatment |
|---|---|---|---|
| Tone (atony) | About 70 percent | Soft, boggy, high fundus; risk with long labour, oxytocin, multiple pregnancy, polyhydramnios, chorioamnionitis, magnesium | Fundal massage, empty the bladder, uterotonics in sequence |
| Trauma | About 20 percent | Firm uterus but continuing bleeding; lacerations of cervix, vagina, perineum; haematoma; uterine rupture or inversion | Examine under good light and analgesia; repair |
| Tissue | About 10 percent | Incomplete placenta on inspection; retained cotyledon or membranes | Manual removal or evacuation |
| Thrombin | About 1 percent | Oozing from every site; abruption, amniotic fluid embolism, HELLP, pre-existing coagulopathy, dilution after massive transfusion | Replace factors, fibrinogen, platelets; treat the cause |
Prevention
- Active management of the third stage: oxytocin 10 units intramuscularly (or intravenously) with delivery of the anterior shoulder or immediately after birth, delayed cord clamping, controlled cord traction after separation, and assessment of tone. This alone reduces PPH by about 60 percent.
- Risk assessment on admission: anaemia corrected antenatally, blood available for those at high risk, an intravenous line in labour when risk is high.
- Tranexamic acid within 3 hours of birth reduces death from bleeding (the WOMAN trial).
The sequence
- 1
Call, assess, resuscitate
Call for help early and name it a PPH. Two large cannulas, bloods (CBC, coagulation, fibrinogen, crossmatch), warmed crystalloid, oxygen, monitoring, a catheter to empty the bladder. Weigh the swabs; visual estimates undercount.
- 2
Find the cause
Feel the fundus. Soft: atony. Firm: look for trauma and check the placenta is complete. Everywhere: think thrombin.
- 3
Uterotonics in sequence
Oxytocin bolus then infusion; carboprost (not in asthma); ergometrine (not in hypertension); misoprostol as an adjunct. Tranexamic acid 1 g intravenously, repeated once if bleeding continues.
- 4
Mechanical and surgical
Bimanual compression while drugs work; intrauterine balloon tamponade; then theatre: compression sutures (B-Lynch), uterine artery ligation, interventional radiology embolisation where available, hysterectomy as the life-saving last step.
- 5
Massive transfusion
Activate the protocol early: red cells, plasma and platelets in ratio, fibrinogen concentrate or cryoprecipitate when fibrinogen falls under 2 g/L (it falls first in obstetric haemorrhage), calcium, warmth. Point-of-care coagulation testing where available.
- 6
Afterwards
Debrief the team and the patient; iron replacement; document the estimated loss and the timeline; plan for the next pregnancy.
Uterine inversion
A fundus that is not palpable, a mass at the introitus, shock out of proportion to the loss. Replace the uterus immediately by hand before a contraction ring forms, with tocolysis if needed; then uterotonics.
Watch it done
Team drill: recognition, the four Ts, uterotonics in sequence, bimanual compression.
On the modelFundus and cornuaBody and myometriumIsthmus and lower segmentPlacenta