💡 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
- 💉 Oxytocin 10 IU IV/IM routinely for 3rd stage management.
- 💊 Misoprostol (400–600 µg) if oxytocin unavailable.
- 🧪 Tranexamic Acid: early IV use if risk factors present.
- ✅ Active management of the third stage is standard. Early cord clamping ❌ not recommended.
- 🩺 Manual removal of placenta in theatre if not delivered promptly.
🚑 Management
- 🟢 Mild PPH (<1000 mL): Secure IV access, crystalloids, close monitoring.
- 🔴 Severe PPH (>1000 mL):
- Resuscitate: 🫁 O₂, 💉 IV access, 🛏️ lie flat.
- Infuse warmed IV fluids until blood available.
- Activate Massive Transfusion Protocol 📦 if unstable.
- Emergency O-negative blood if cross-match delayed.
- Blood component replacement:
- After 4 units RBC → give FFP 12–15 mL/kg.
- Cryoprecipitate if fibrinogen <2 g/L.
- Platelets if count <75 × 10⁹/L.
- Medical: Uterotonics 💊 (oxytocin infusion, ergometrine, carboprost, misoprostol).
- Mechanical/surgical: Balloon tamponade 🎈, uterine artery embolisation, hysterectomy ✂️ if uncontrolled.
📖 References
