Obstetrics and Gynecology · MU Sofia

32. Bleeding in the third stage of labor and in the early postpartum period

Covers postpartum haemorrhage: its definitions, primary and secondary types, and the four Ts causes set out in a table with approximate shares. It describes bleeding in the third stage and retained placenta, then the stepwise management of primary haemorrhage, including drug sequence and surgical options. Uterine inversion and secondary haemorrhage are also addressed.

Inside: 4 sections · 1 table · 16 flashcards · 3 min

Topic 32 of 61 in the MU Sofia syllabus for Obstetrics and Gynecology (Medicine, Year 5). The free AceMed note covers it in 4 sections, about 345 words (3 min of reading), with 16 flashcards.

In this note

  1. Introduction
  2. Causes: the four Ts
  3. Bleeding in the third stage
  4. Management of primary PPH

Introduction

Postpartum haemorrhage (PPH) is blood loss ≥ 500 ml after vaginal birth or ≥ 1,000 ml after caesarean section, or any loss causing haemodynamic instability. Severe PPH is > 1,000 ml. Primary PPH occurs in the first 24 hours; secondary between 24 hours and 12 weeks. It is the leading cause of maternal death worldwide.

Bleeding in the third stage

  • The placenta separates by the central (Schultze) or marginal (Duncan) mechanism. Bleeding before the placenta is delivered usually means partial separation.
  • Retained placenta: not delivered 30 minutes after birth with active management (60 min with physiological management). Treatment: empty bladder, oxytocin, controlled cord traction, then manual removal under anaesthesia.
  • Check that the placenta and membranes are complete; a missing cotyledon or vessels running off the edge (succenturiate lobe) mean retained tissue.

Management of primary PPH

  1. Call for help; ABC, oxygen, two large-bore IV lines, bloods (crossmatch 4–6 units, FBC, coagulation, fibrinogen), warmed fluids, urinary catheter, record the loss (weigh).
  2. Rub up the uterus (fundal massage), bimanual compression; empty the bladder.
  3. Drugs in sequence: oxytocin 5–10 IU IV then infusion; ergometrine 0.5 mg IM/IV (not in hypertension); carboprost 250 µg IM every 15 min up to 8 doses (not in asthma); misoprostol 800 µg; tranexamic acid 1 g IV within 3 hours of birth (repeat once if bleeding continues).
  4. Examine for trauma and retained tissue in theatre; repair tears; manual removal of tissue.
  5. If bleeding continues: intrauterine balloon tamponade (Bakri), then surgery: B-Lynch compression suture, uterine or internal iliac artery ligation, interventional radiology (embolisation), and hysterectomy as the last resort.
  6. Replace blood and clotting factors: red cells, fresh frozen plasma, platelets, fibrinogen (keep fibrinogen > 2 g/L).

Uterine inversion

The fundus turns inside out, usually from traction on the cord with a fundal placenta. Shock is out of proportion to blood loss (vagal). Replace the uterus immediately by hand (Johnson manoeuvre) or hydrostatically (O'Sullivan), then give oxytocin.

Secondary PPH

Usually endometritis or retained products: antibiotics, then evacuation if tissue is retained.

Tone, Trauma, Tissue, Thrombin: a soft uterus is the usual cause, so massage and oxytocin come first, while you look for the other three.

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