[CG] Post partum haemorrhage: prediction and prevention

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Third Stage of Labour - Active Management

The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes.

Active management of the third stage involves a package of care comprising the following components in order to reduce the incidence of Post Partum Haemorrhage.

  • routine use of uterotonic drugs
  • delayed clamping and cutting of the cord
  • controlled cord traction after signs of separation of the placenta ( gush of blood, lengthening of cord, rising of fundus).

Physiological management of the third stage involves the following components

  • no routine use of uterotonic drugs
  • no clamping of the cord until pulsation has stopped ( unless clinical concerns re mother or baby)
  • delivery of the placenta by maternal effort

This policy is for active management of the third stage.

The PPH prophylaxis risk assessment should be carried out to identify patients at particular risk of PPH. This risk assessment should be carried out on admission to labour ward and following each vaginal assessment, as the risk of PPH can change during the labour process. The score should be documented with the vaginal examination findings and used to make a clinical plan for the patient to reduce the risk of PPH.

Postpartum Haemorrhage Vigilance (PPV): PPH prophylaxis risk assessment form

Active management of third stage of labour: A) vaginal delivery (flowchart)

Active management of third stage of labour: B) caesarean section (flowchart)

Clinicians should consider the use of intravenous tranexamic acid (1g IV), in addition to other uterotonic agents required, at caesarean section to reduce blood loss in women with 1 major risk factor or >3 minor risk factors for PPH.

References
  1. Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum haemorrhage. Green-Top Guideline No. 52. London: RCOG; 2016.
  2. Hall MH. Haemorrhage. In: Lewis G, editor. Why Mothers Die 2000–2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press; 2004. p. 86–93.
  3. McShane PM, Heyl PS, Epstein MF. Maternal and perinatal morbidity resulting from placenta previa. Obstet Gynecol 1985;65:176–82
  4. Sheiner E, Shoham-Vardi I, Hallak M, Hershkowitz R, Katz M, Mazor M. Placenta previa: obstetric risk factors and pregnancy outcome. J Matern Fetal Med 2001;10:414–9.
  5. Combs CA, Murphy EL, Laros RK Jr, Factors associated with postpartum haemorrhage with vaginal birth. Obstet Gynecol 1991;77: 69-76
  6. Kavle JA, Soltzfus RJ, Witter F, Teilsch JM, Khalfan SS, Caulfield LE, Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar Tanzania. J Health Popul Nutr 2008;26:232-40
  7. Simon L, Santi TM, Sacquin P, Hamza J, Pre-anaethestic assessment of coagulation abnormalities in obstetric patients. Br J Anaesth 1997;78:678-83
  8. de Lange NM, Lance MD, de Groot R, Beckers EA, Henskins YM, Scheepers HC, Obstetric haemorrhage and coagulation: an update. Obstet Gynecol Surv. 2012;67: 426-35.
  9. Scott-Pillai R, Spence D, Cardwell CR, Hunter A, Holmes VA. The impact of body mass index on maternal and neonatal outcomes: a retrospective study in a UK obstetric population 2004-2011. BJOG. 2013;8:932939.
  10. Nassar AM, Usta IM, Khalil AM, Melhem ZI, Nakad TI, Musa AAA, Fetal macrosomia (>4500kg) Perinatal Outcomes of 231 cases according to mode of delivery. J Perinatology. 2003;23:136-41
  11. Ononge S, Mirembe F, Wandabua J, Campbell OMR. Inicidence and risk factors for postpartum haemorrhage in Uganda. Reprod Health. 2016;13:38
  12. Royal College of Obstetricians and Gynaecologists. Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. Green-top Guideline No. 27. London: RCOG; 2011.
  13. Royal College of Obstetricians and Gynaecologists. Antepartum Haemorrhage. Green-top Guideline No. 63. London: RCOG; 2011.
  14. Marshall NE, Fu R, Guise JM. Impact of multiple caesarean deliveries on maternal morbidity. Am J Obstet Gyn. 2011. 205;262
  15. Nisenblat V, Barak S, Griness OB, Degani S, Ohel G, Gonen R. Maternal complications associated with multiple caesarean deliveries. Obstet Gynecol. 2006;108:21-6
  16. Das B, Clark S. Ch 44 Sepsis and postpartum haemorrhage. In: A textbook of postpartum hemorrhage: a comprehensive guide to evaluation, management and surgical intervention. Kirkmahoe: Sapiens Publishing; 2006. 

Last reviewed: 25 October 2017

Next review: 01 October 2022

Author(s): Dr Julie Murphy, Consultant Obstetrician RAH

Approved By: Obstetrics Clinical Governance Group