Treatment Guideline Chart
Postpartum hemorrhage is defined traditionally as blood loss of ≥500 mL for vaginal delivery and ≥1000 mL for cesarean delivery, after completion of the 3rd stage of labor.
It may present as either early (primary) or late (secondary or delayed) postpartum hemorrhage.
Women with bleeding disorders have an increased risk of both early and late postpartum hemorrhage.

Postpartum%20hemorrhage Management

Management of 3rd Stage of Labor

Expectant Management

  • Best described as “hands off” approach, often termed as physiologic method
  • Placental separation without intervention
    • Either delivered spontaneously or aided by gravity
  • The cord is not clamped or cut until it has stopped pulsating
  • Change in shape of the uterine fundus

Active Management

  • Placenta and fetal membranes are delivered after uterine massage, controlled cord traction and use of uterotonic drugs
  • Clinical trials show that actively managed 3rd stage of labor has lower incidence of PPH, retained placenta and lower need for additional uterotonic drugs
  • The International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives jointly stated that active management of the 3rd stage of labor should be offered to women since it is proven to reduce the incidence of PPH, the quantity of blood loss and the use of blood transfusion
  • The World Health Organization (WHO) Reproductive Health Library and Cochrane database confirmed that active management is associated with reduced maternal blood loss, postpartum anemia and decreased need for blood transfusion
  • Active management of the 3rd stage of labor is practiced in many countries, but in others it may be reserved for women at high risk for PPH

Cord Clamping and Cutting

  • In active management of the 3rd stage of labor, the umbilical cord is clamped 1-3 minutes after birth and cut following delivery
  • It is not recommended to perform early cord clamping within <1 minute after birth unless newborn requires immediate resuscitation
  • Prompt clamping appears to shorten the 3rd stage of labor though there is no evidence that this decreases the risk of PPH
    • Delayed clamping has been shown to improve neonatal outcomes without increased PPH incidence

Controlled Cord Traction

  • Done by downward, gentle pulling on the cord once the uterus has contracted while simultaneously applying pressure on the uterus by pushing on the abdomen just above the pubic bone (counter traction)
  • Hastens separation of the placenta from the uterus and its subsequent delivery
  • If the placenta fails to descend within 30-40 seconds, do not continue to pull the cord
    • Wait until the uterus is well contracted again
  • Recommended for vaginal births if skilled personnel are available
    • It is crucial for personnel performing traction to have consistent training and guidelines due to the potential risk of uterine inversion, cord avulsion and partial placental detachment
  • For PPH prevention in women who delivered via cesarean section, controlled cord traction and IM or IV Oxytocin are recommended for placenta removal 

Patient Observation

  • Inspection of both the placenta and the lower genital tract
    • The placenta should be inspected for completeness
    • The lower genital tract thoroughly examined for lacerations
  • Ensure continued uterine contraction by fundal palpation and rub or massage as necessary
    • Uterus should be massaged immediately then every 15 minutes thereafter, repeated as needed during the first 2 hours
    • Ensure that the uterus does not relax after massage is stopped
  • Monitor patient for any sign of excessive bleeding

Patient Monitoring

Monitor Response to Treatment

  • Sensorium
  • Vital signs
  • Urine output
    • A urine output of >30 mL/hr is an objective sign of adequate renal perfusion
  • Complete blood count (CBC), coagulation status
    • Blood sample is drawn to assess hematologic and coagulation profile; may also assess electrolytes, metabolic profile and acid-base oxygenation status
  • Evaluate tissue perfusion
    • Measure serum lactate and base deficit 
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