Obstetrics and Gynaecology
Postpartum Haemorrhage and Third Stage Complications
Postpartum haemorrhage, the four Ts, retained placenta, accreta, uterine inversion and growth restriction for MBBS, mapped to NMC code OG16.
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Postpartum Haemorrhage and Third Stage Complications
Postpartum haemorrhage, the four Ts, retained placenta, accreta, uterine inversion and growth restriction for MBBS, mapped to NMC code OG16.
This chapter covers postpartum haemorrhage and the other complications of the third stage of labour. It sets out the definition and the four-T causes of haemorrhage, the stepwise medical and surgical management, and the recognition of retained placenta, placenta accreta spectrum and uterine inversion, along with growth restriction and its Doppler surveillance.
High-yield: Postpartum Haemorrhage and Third Stage Complications
- Primary postpartum haemorrhage is blood loss over 500 mL after vaginal delivery or over 1,000 mL after caesarean within 24 hours of birth.
- The commonest cause of postpartum haemorrhage is uterine atony, remembered with the four Ts: tone, trauma, tissue and thrombin.
- First-line management of atonic postpartum haemorrhage is uterine massage and uterotonics such as oxytocin, then ergometrine and prostaglandins.
- Carboprost, a prostaglandin, is avoided in asthmatics; ergometrine is avoided in hypertensive women.
- Persistent bleeding is managed by bimanual compression, balloon tamponade, and surgical steps such as brace sutures, uterine artery ligation and hysterectomy.
- Tranexamic acid given early reduces death from postpartum haemorrhage.
- Retained placenta is failure to deliver the placenta within about 30 minutes of birth and may need manual removal under anaesthesia.
- Placenta accreta spectrum is abnormal adherence of the placenta and is strongly linked to previous caesarean and placenta praevia.
- Uterine inversion is a rare emergency where the fundus turns inside out, often from mismanaged cord traction, causing shock.
- Immediate replacement of an inverted uterus and treatment of shock are priorities before the constriction ring forms.
- Intrauterine growth restriction is a foetus failing to reach its growth potential, diagnosed by serial biometry and Doppler.
- Umbilical artery Doppler surveillance guides the timing of delivery in growth-restricted foetuses.
- Absent or reversed end-diastolic flow in the umbilical artery is an ominous Doppler finding prompting delivery.
- Anticipation and active management of the third stage are the key preventive measures against postpartum haemorrhage.
The four Ts of postpartum haemorrhage
- **Tone:** Uterine atony, the commonest cause. Massage and uterotonics first.
- **Trauma:** Genital tract lacerations and uterine rupture.
- **Tissue:** Retained placental tissue or clots.
- **Thrombin:** Coagulation disorders. Give tranexamic acid early.
NMC competencies in this chapter
- **OG16.1:** Intrauterine growth restriction: diagnosis, Doppler surveillance and delivery timing
- **OG16.2:** Postpartum haemorrhage: recognition, resuscitation and stepwise control
- **OG16.3:** Third stage management, retained placenta, placenta accreta spectrum and uterine inversion
Frequently Asked Questions
What is the commonest cause of postpartum haemorrhage?
Uterine atony. The four Ts, tone, trauma, tissue and thrombin, summarise all causes, with atony (tone) being by far the most frequent.
How is atonic postpartum haemorrhage managed?
With uterine massage and uterotonics (oxytocin, then ergometrine and prostaglandins), tranexamic acid, bimanual compression, balloon tamponade and, if needed, surgical measures up to hysterectomy.
What causes uterine inversion and how is it treated?
It often follows mismanaged cord traction with the fundus turning inside out and causing shock. Immediate manual replacement and resuscitation are needed before a constriction ring forms.
How does Doppler help in growth restriction?
Umbilical artery Doppler tracks placental function, and absent or reversed end-diastolic flow is an ominous sign that prompts delivery to prevent foetal demise.
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