Postpartum hemorrhage

Diagnostic approach

• ABCDE survey
• Targeted clinical evaluation, including pelvic examination
• Quantitative blood loss assessment
• CBC
• Coagulation studies, fibrinogen
• Type and screen, crossmatch
• Transabdominal and vaginal ultrasound

Red flag features

• Signs of hypovolemic shock
• Shock index > 0.9

Management checklist

• ABCDE approach
• IV fluid resuscitation
• Consult OB/GYN, anesthesia, ICU urgently
• Tranexamic acid (off-label)
• Bimanual uterine massage if uterine atony is suspected
• Oxytocin
• Identify and treat underlying cause
• Emergency blood transfusion as needed
• Continuous hemodynamic monitoring

4 Ts of PPH: Tone (uterine atony), Trauma (laceration, inversion), Tissue (retained placenta), Thrombin (coagulopathy)

Postpartum hemorrhage (PPH) is an obstetric emergency characterized by excessive bleeding after delivery. PPH is a leading cause of maternal mortality worldwide. Primary PPH is defined as a cumulative blood loss of ≥ 1000 mL or bleeding with signs of hypovolemia within 24 hours of delivery, while secondary PPH occurs between 24 hours and 12 weeks postpartum. The most common cause of primary PPH is uterine atony. Other common causes include obstetric injuries, retained placenta, and coagulation disorders. Secondary PPH is most commonly caused by, e.g., retained placenta and/or retained placental tissue, infection, subinvolution of the placental site, or coagulation disorders. Clinical manifestations include heavy vaginal bleeding and signs of hypovolemic shock, such as hypotension and tachycardia. Diagnosis is made through early recognition of excessive bleeding and a systematic physical examination to identify the underlying cause, sometimes confirmed with ultrasound. Initial management involves resuscitation (IV fluids, blood products) and administration of tranexamic acid. Cause-specific treatments include bimanual uterine massage and uterotonic agents like oxytocin for uterine atony, suturing lacerations, and removal of retained placental tissue. For refractory bleeding, invasive procedures (e.g., uterine artery embolization, hysterectomy) may be necessary.

Primary postpartum hemorrhage ^[1][2][3]

• Definition: bleeding leading to cumulative blood loss ≥ 1000 mL (including intrapartum blood loss) or signs of hypovolemia within 24 hours of delivery ^[1][2][4]
• Etiology: the "4 Ts" (See "Common causes of primary PPH" for details.)
  • Tone (i.e., uterine atony)
  • Trauma (e.g., laceration, uterine inversion)
  • Tissue (i.e., retained placenta or placental tissue)
  • Thrombin (i.e., bleeding diathesis)
• Management options include:
  • Uterotonic agents
  • Uterus-preserving hemostatic measures (e.g., balloon tamponade, packing, embolization)
  • Hysterectomy

Secondary postpartum hemorrhage ^[1][5]

• Definition: blood loss from 24 hours to 12 weeks postpartum ^[1]
• Etiology
  • Retained placenta or retained placental tissue
  • Infection (e.g., postpartum endometritis)
  • Subinvolution of the placental site
  • Inherited coagulation disorders (e.g., von Willebrand disease, hemophilia)
  • Uterine vascular disorders (e.g., arteriovenous malformations)
• Management includes hemostatic measures and cause-specific treatment, e.g.:
  • Removal of retained placental tissue
  • Empiric IV antibiotics for postpartum endometritis (e.g., clindamycin PLUS gentamicin)
  • Subinvolution of the placental site: uterotonic agents and surgery
  • Coagulation disorders: transfusion of blood products and administration of factor concentrates and other medications
  • Uterine arteriovenous malformations: uterine artery embolization

• Leading cause of maternal mortality worldwide ^[1][2]
• PPH complicates 1–10% of deliveries worldwide. ^[2]
• PPH causes 11% of maternal deaths in the US. ^[5]

Epidemiological data refers to the US, unless otherwise specified.

• Excessive vaginal bleeding
• Possible clinical features of shock: hypotension, tachycardia, presyncope
• See also clinical features in:
  • Uterine atony
  • Uterine inversion
  • Retained placenta
  • Placenta accreta spectrum
  • Bleeding obstetric injuries
  • Subinvolution of placental implantation site

Signs of hypovolemia may not develop until > 25% of total blood volume is lost. ^[5]

Approach

• PPH is a clinical diagnosis.
• Diagnostic evaluation is indicated in a postpartum patient with either of the following: ^[1]
  • Excessive bleeding
  • Signs of hypovolemia

Do not delay urgent initial management of PPH to obtain diagnostic studies.

Clinical evaluation ^[1][2]

• Cumulative blood loss assessment ^[2][5][6]
• Physical examination (including speculum examination) of the perineum, vulva, vagina, cervix, and uterus to assess for potential causes, e.g.:
  • Uterine atony
  • Puerperal hematoma
  • Lacerations
  • Uterine inversion
  • Retained placenta or fetal membranes

Laboratory studies ^[5][7]

• CBC
• CMP
• Pretransfusion testing: type and screen, crossmatch
• Coagulation studies
• Consider thromboelastography for severe PPH (e.g., requiring massive transfusion).

Imaging ^[8]

Consider imaging for bleeding unresponsive to initial management of PPH. ^[8]

• Ultrasound
  • Modality: combined transabdominal and vaginal ultrasound with color Doppler
  • First-line imaging to evaluate for:
    • Retained placental tissue
    • Pelvic and/or uterine hematomas
    • Uterine vascular abnormalities
• CT abdomen and pelvis with IV contrast: Consider for hemodynamically stable patients to localize active hemorrhage.

Additional investigations

Further investigation is based on the underlying cause, e.g.:

• Uterine atony
• Uterine inversion
• Retained placenta
• Placenta accreta spectrum
• Bleeding obstetric injuries
• Subinvolution of placental implantation site

Initial management of PPH ^[1][2][3]

Pursue the following interventions for PPH in parallel.

• Resuscitation measures: ABCDE approach
  • Oxygen therapy, two large-bore IV access (≥ 16 gauge), and blood samples for laboratory testing
  • Immediate hemodynamic support, including IV fluid resuscitation; and emergency blood transfusion ^[2]
  • Nonpneumatic antishock garment
• Urgent consultations (e.g., OB/GYN, anesthesia, intensive care, interventional radiology)
• Focused gynecologic examination (including pelvic examination): to identify the cause of bleeding
• Tranexamic acid (off-label) : Administer as soon as possible and no more than 3 hours after delivery, regardless of the cause of PPH. ^[2][9]
• Immediate cause-specific management
  • Suspected uterine atony (most common cause)
    • Bimanual uterine massage
    • IM or IV oxytocin (See "Uterotonic agents" for details.) ^[1]
  • Immediate management of other causes, e.g.:
    • Bleeding obstetric injuries: laceration repair, hemostatic measures
    • Retained placenta causing primary PPH: manual removal of the placenta
    • Uterine inversion: Hold uterotonics and perform manual uterine repositioning.
    • Coagulation disorder: Manage acute hemorrhage in bleeding disorders (e.g., with blood products and coagulation factor concentrates).
• Monitoring
  • Hemodynamic monitoring: vital signs (including shock index), urine output, quantitative blood loss
  • Laboratory monitoring: CBC, CMP, INR, PTT, fibrinogen, thromboelastography, lactate

Suspect hemodynamic instability in patients with shock index > 0.9. ^[2]

While managing postpartum hemorrhage, ensure parallel neonatal care. Maternal resuscitation must not delay essential immediate care of the newborn.

Management of refractory PPH ^[1][2][3]

• Imaging: : e.g., bedside ultrasound to assess the cause and extent of bleeding (See "Diagnostics for PPH" for details.)
• Mechanical hemostasis: Consider in patients with refractory PPH due to uterine atony after vaginal delivery. ^[2][3]
  • Bimanual uterine compression or external aortic compression (temporizing measures)
  • Uterine balloon tamponade
  • Uterine packing: not routinely recommended ^[3]
• Emergency preoperative evaluation: if surgical or interventional radiology intervention is planned
• Invasive procedures ^[2][3][10]
  • Uterine-sparing options: aim to control bleeding while preserving fertility
    • Uterine artery embolization: typically for hemodynamically stable patients
    • Ligation of uterine or internal iliac arteries
    • Uterine compression sutures (e.g., B-Lynch suture)
  • Hysterectomy: generally as last resort, except in placenta accreta spectrum ^[11][12]

Urgently consult a specialist (e.g., OB/GYN, interventional radiology) for invasive source control of bleeding refractory to conservative measures, as delays increase maternal morbidity and mortality. ^[2][3]

Ongoing management

• Hemodynamic monitoring as indicated
• Treatment of anemia
• Routine inpatient postpartum care (e.g., postpartum pain management)
• Postoperative management as indicated
• Postdelivery care of the newborn
• Rho (D) immunoglobulin, if indicated

The following subtypes are not comprehensive.

Definition

Uterine atony is a failure of the uterus to effectively contract after delivery of the placenta. ^[13]

Epidemiology

Uterine atony is the most common cause of primary PPH (70–80% of cases). ^[1]

Pathophysiology ^[13]

• Normally, the myometrium contracts and compresses the spiral arteries, which stops bleeding after delivery.
• Failure of the myometrium to effectively contract can lead to rapid and severe hemorrhage.

Risk factors ^[13][14]

• Overdistention of the uterus
  • Large for gestational age newborn (> 4000 g)
  • Multifetal gestation
  • Polyhydramnios
• Exhausted myometrium
  • Multiparity
  • Induced or augmented labor
  • Prolonged delivery
  • Prolonged oxytocin use ^[15]
• Anatomical abnormalities
  • Abnormal placental implantation
  • Myomas
• Instrumented vaginal delivery, genital tract trauma
• Infection (e.g., chorioamnionitis)
• Medications that lower contractions (e.g., anesthetics, MgSO₄)
• Maternal history and comorbidities
  • History of postpartum hemorrhage
  • Maternal hypertension, maternal diabetes

AEIOU are risk factors for uterine atony: Anatomic abnormalities, Exhausted myometrium, Infections, Overdistended Uterus

Clinical features ^[1]

• Vaginal bleeding within 24 hours of delivery
• Soft, enlarged (increased fundal height), boggy ascending uterus

Diagnosis ^[1][16]

Uterine atony is a clinical diagnosis.

• Empty the bladder and perform a bimanual pelvic examination.
• Rule out contributing or alternative causes of bleeding.
  • Speculum examination: to assess for birth injuries and retained placental tissue
  • Ultrasound: to assess for retained placental tissue

Treatment ^{[1][7][13][16]}

See "Management of PPH" for the comprehensive approach to all patients with PPH.

• Remove clots and perform bimanual uterine massage.
• Administer tranexamic acid (off-label) as soon as possible. ^[2][9]
• Start concomitant uterotonic agents.
  • First-line: oxytocin
    • IV oxytocin (preferred) ^[1][2][3]
    • If no IV access available, IM oxytocin ^[1][2][3]
    • PPH prevention doses of oxytocin differ (see "Active management of the third stage of labor").
  • Second-line ^[1]
    • Methylergonovine: contraindicated in hypertensive disorders of pregnancy ^[17]
    • Prostaglandin agonists (e.g., misoprostol) ^[5]
• If bleeding continues, see "Management of refractory PPH" for options, including:
  • Mechanical hemostasis (e.g., with balloon tamponade)
  • Uterine-sparing invasive procedures (e.g., uterine artery embolization)
  • Hysterectomy: last resort

Administer tranexamic acid concomitantly with uterotonic agents. ^[1][2][3]

Prevention

See "Active management of the third stage of labor."

Complications

• Anemia
• Hypovolemic shock
• Sheehan syndrome

Definition

• An obstetric emergency in which the uterine fundus collapses into the endometrial cavity, resulting in a complete or partial inversion of the uterus, usually following vaginal delivery

Epidemiology

• Uncommon complication of vaginal birth
• Morbidity and mortality occurs in ∼ 41% of cases. ^[18]

Classification ^[19]

Degree of inversion

• Partial uterine inversion: uterine fundus collapses into the endometrial cavity, without surpassing the cervix
• Complete uterine inversion: uterine fundus collapses into the endometrial cavity and descends through the cervix, but remains within the vaginal introitus
• Uterine prolapse: uterine fundus descends through the vaginal introitus

Time of onset

• Acute uterine inversion: uterine inversion occurring immediately after or within 24 hours of delivery
• Chronic uterine inversion: uterine inversion that has gone unnoticed or uncorrected, usually seen weeks or months after delivery

Etiology

• Puerperal inversion: uterine inversion following vaginal delivery (most common)
• Nonpuerperal inversion
  • Due to a submucous myomatous polyp arising from the fundus, creating a traction effect
  • Due to senile inversion of the uterus following high amputation of the cervix

Risk factors ^[1][7]

• Uncontrolled cord traction and/or excessive fundal pressure (Credé maneuver) during the third stage of labor
• Fetal macrosomia
• Previous uterine inversion
• Use of uterine muscle relaxants during the antepartum period (e.g., MgSO₄)
• Difficult removal of the placenta
• Nulliparity
• Uterine anomalies (e.g., relaxed lower uterine segment and cervix)
• Uterine leiomyoma
• Placenta accreta
• Retained placental tissue
• Prolonged delivery

Pathophysiology

• Partial uterine wall relaxation → prolapse of the uterine wall through the cervical orifice, and if simultaneous downward traction of the uterus is performed → inversion of the uterus

Clinical features

• Acute uterine inversion
  • Brisk postpartum hemorrhage
  • Lower abdominal pain
  • Round mass (inverted uterus) protruding from the cervix or vagina
  • Absent fundus (top of the uterus) at the periumbilical position during transabdominal palpation
  • Urinary retention
• Chronic uterine inversion
  • History of postpartum hemorrhage
  • Irregular bleeding
  • Asymptomatic, round vaginal mass
  • Vaginal discharge
  • Chronic pelvic pain

Diagnosis

• Clinical diagnosis: See “Clinical features.”
• Ultrasound
  • Confirms the diagnosis in uncertain cases
  • Hyperechoic mass in the vagina with central hypoechoic cavity

Treatment ^[1]

• General measures and immediate manual uterine repositioning should be performed.
• In case of chronic uterine inversion, surgical intervention is usually necessary.

General measures

• Start initial management of PPH, including IV fluid therapy and hemodynamic monitoring.
• Stop all uterotonic agents (e.g., oxytocin) in order to relax the uterus.
• If the placenta is still in situ, remove it only after successful repositioning of the uterus.

Manual uterine repositioning

• Technique ^[1][7]
  • Grasp the protruding uterus at the fundus with the thumb on the anterior surface and the four other fingers on the posterior surface.
  • Carefully push the uterus back toward the posterior fornix through the pelvic cavity until it is in the correct position.
• If repositioning is unsuccessful
  • Hemodynamically stable patients
    • Administer a uterine relaxant (e.g., MgSO₄, nitroglycerin, or terbutaline) and reattempt manual repositioning.
    • If ineffective: surgical repair
  • Hemodynamically unstable patients: surgical repair
• Following successful repositioning: oxytocin to induce placental extraction and prevent atony and reinversion

Complications

• Hypovolemic shock
• Neurogenic shock
• Maternal death

Definitions ^[20]

• Retained placenta: failure of placental detachment and/or expulsion, typically manifesting with a prolonged third stage of labor ^[20][21]
• Retained placental tissue: : a subtype of retained products of conception involving the persistence of placental fragments within the uterine cavity after delivery of the fetus

Retained placenta usually manifests as primary PPH with a prolonged third stage of labor; retained placental tissue can manifest as primary PPH or secondary PPH (i.e., delayed onset) based on the size of the fragments.

Epidemiology ^[20]

Retained placenta and/or retained placental fragments occur in 0.1–3% of vaginal deliveries.

Etiology ^[20]

• Uterine atony: Uterine contractions are insufficient to detach and/or expel the placenta.
• Placenta accreta spectrum: The placenta is abnormally attached to the uterus.
• Premature cervical closure: Placental expulsion is obstructed.

Risk factors ^[20][22]

• Prior cesarean delivery (most common)
• Prior history of retained placenta
• Placenta previa
• Placenta accreta spectrum
• Congenital uterine anomalies
• Prolonged use of uterotonic medication (e.g., oxytocin) ^[20]
• Preterm labor
• Assisted reproduction procedures (e.g., in vitro fertilization)

Clinical features ^[20]

• Retained placenta
  • Severe bleeding before placental delivery
  • Inability to deliver the placenta during the third stage of labor
• Retained placental tissue
  • Vaginal bleeding following placental delivery (may manifest as primary PPH or secondary PPH)
  • Speculum inspection: visualisation of placental fragments or fetal membranes within the uterus
  • Manual uterine exploration: detection of placental fragments or fetal membranes

A firmly palpable and contracted uterus makes uterine atony a less likely underlying cause. Consider an alternate etiology, e.g., premature cervical closure, or placenta accreta spectrum.

Diagnosis ^[1]

• Manual palpation and speculum examination
• Inspection of the placenta and fetal membranes
• Ultrasound for retained placental fragments ; ^[23][24][25]
  • Focal endometrial mass (most sensitive and specific finding)
  • Thickened endometrium ^[24][25]
  • Increased vascularity on color Doppler

Retained placental tissue is unlikely if the endometrial stripe appears completely normal on ultrasound (e.g., normal thickness, no masses, and no abnormal color Doppler flow.) ^[1]

Management ^[20]

Approach

• All patients: Begin initial management of PPH (e.g., hemodynamic support as needed).
• Primary PPH
  • Continue active management of the third stage of labor while preparing for placental removal.
  • Attempt manual removal of the placenta.
  • If unsuccessful, consult OB/GYN and proceed to operative management (e.g., suction curettage).
• Secondary PPH
  • Obtain an ultrasound to assist in decision-making. ^[25]
  • Completely normal findings: Manage conservatively and consider other causes of secondary PPH.
    • Positive or equivocal findings: Consider operative management.
  • Operative management options include:
    • Suction curettage
    • Hysteroscopic removal
• Any patient with persistent bleeding
  • Consult OB/GYN.
  • Proceed to management of refractory PPH (e.g., uterine balloon tamponade).
  • Persistent clinical suspicion for retained placental fragments and other causes of PPH ruled out: Consider manual or operative removal of placental tissue. ^[20]

Manual removal of placenta

• Indications: all patients with primary PPH caused by retained placenta or retained placental fragments
• Adjunctive premedication
  • Consider sublingual or IV nitroglycerin.
  • Consider prophylactic antibiotics.
• Technique
  • Keep fingers tightly together and use the edge of the hand to make a space between the placenta and the uterine wall to detach the placenta completely.
  • After placenta is detached, withdraw the hand from the uterus, bringing the placenta with it.
  • With the other hand, perform countertraction to the fundus by pushing it in the opposite direction of the hand that is removing the placenta.
• After removal: Administer a uterotonic agent.

Consider a clinical diagnosis of placenta accreta spectrum if manual placental removal is impossible, especially if the cleavage plane between the placenta and the myometrium is impalpable. ^[26]

The following section discusses bleeding genital tract injuries occurring as a complication of birth. For other etiologies (e.g., accidental or intentional trauma), see "Vulvar and vaginal injuries" and "Trauma in pregnant individuals." For nonbleeding injuries, see "Complications of normal labor and delivery." For fetal injuries, see "Birth traumas."

Overview of injuries

• Vulvar and vaginal lacerations
• Perineal laceration
• Puerperal hematoma (most commonly caused by iatrogenic injury during childbirth)
  • Vulvar hematoma: accumulation of blood in the vulvar soft tissue
  • Vaginal hematoma: accumulation of blood in the vaginal soft tissue
  • Postpartum retroperitoneal hematoma: accumulation of blood in the retroperitoneal space
• Cervical laceration
• Uterine rupture

Epidemiology

• Second most common cause of PPH (20% of cases) ^[27]
• Estimated incidence of puerperal hematoma ranges from 1:300 to 1:1500 deliveries.

Etiology ^[7][28][29]

• Iatrogenic injury (e.g., during assisted vaginal delivery or cesarean delivery)
  • Cervical laceration caused by forceps delivery ^[30]
  • Vaginal or perineal laceration caused by episiotomy
  • Uterine rupture associated with vaginal birth after cesarean delivery
  • Puerperal hematoma associated with assisted vaginal delivery
• Other
  • Macrosomia
  • Malpresentation of the fetus
  • Uncontrolled delivery
  • Prolonged second stage of labor
  • Primiparity
  • Coagulopathy
  • Hypertensive disease of pregnancy

Clinical features

• Features of hematoma or bleeding laceration of the female genital tract
  • Severe pain in the labia, pelvis and/or perineum ≤ 24 hours after delivery
  • Severe bleeding
  • Hypovolemic shock
  • Vaginal hematoma: protruding, tender, palpable vaginal mass
• Features of retroperitoneal hematoma
  • Pelvic pain
  • Signs and symptoms of hypovolemia (e.g., tachycardia, hypotension, diaphoresis, pale skin, dizziness)
• Features of uterine rupture

Search for obstetric injury in a postpartum patient with a sudden change in vital signs suggesting hypovolemic shock, even if there is no visible external bleeding. Occult bleeding into the peritoneal and retroperitoneal spaces is possible.

Treatment ^[1][7][29]

See also "Perineal lacerations" and "Uterine rupture."

• All patients
  • Begin initial management of PPH, including immediate hemodynamic support as needed.
  • Perform conservative mechanical hemostatic measures (e.g., applying pressure to wounds).
  • Repair visibly bleeding first or second-degree perineal lacerations and simple vulvar or vaginal lacerations.
  • Consult OB/GYN for:
    • Hemodynamic instability or hemorrhagic shock
    • Bleeding of unclear source
    • Bleeding refractory to conservative measures and simple laceration repair
    • 3rd- or 4th-degree perineal lacerations
    • Bleeding source near or involving the clitoris, urethra, or labia
    • Cervical laceration
• Options for persistent or refractory bleeding
  • Hemodynamically stable patients: angioembolization
  • Hemodynamically unstable patients: surgical management
    • Conservative surgical options include uterine artery ligation and uterine compression sutures (e.g., B-Lynch suture).
    • Hysterectomy for life-threatening PPH or if other treatments are unsuccessful
• Management of puerperal hematomas ^[28][31]
  • Optimal treatment depends on size, location, stability, expansion rate, and other patient factors.
  • Options include conservative management, surgical clot evacuation and repair, and angioembolization.

Prevention ^[29]

• Apply warm compresses to the perineum during the second stage of labor.
• Consider perineal massage and support.
• Avoid routine episiotomy.

Definition

• A condition in which the uterus remains abnormally large following delivery because of the persistence of dilated uteroplacental vessels

Epidemiology

• Occurs most commonly in the second week postpartum
• Second most common cause of secondary postpartum hemorrhage (13% of affected individuals) ^[32]

Risk factors ^[23]

• Multiparity
• Cesarean delivery
• Uterine atony
• Endometritis
• Coagulopathy
• Retained products of conception

Clinical features

• Abnormal, severe uterine bleeding, most commonly during second week postpartum ^[33]
• Fever, chills
• Lower abdominal pain
• Signs of hypovolemia

Diagnostics ^[33]

• Ultrasound: hypoechoic tortuous vessels in the myometrium
• Pulsed wave Doppler: ↑ peak systemic velocity
• Histopathological examination (confirmatory test): large, dilated myometrial arteries with thickened walls and intravascular thrombosis

Treatment ^[34][35]

• Uterotonic agents (e.g., IV oxytocin)
• Surgical procedures (i.e., dilation and curettage or suction curettage)
• Severe bleeding: Uterine artery embolization, hysterectomy for patients with severe bleeding

Etiology

• Acquired
  • HELLP syndrome
  • Sepsis
  • Fetal death
• Inherited ^[36]
  • von Willebrand disease (vWD)
  • Hemophilia
  • Platelet dysfunction disorders
  • Coagulation factor deficiencies (e.g., factor XIII deficiency)

Clinical features

• Mucocutaneous bleeding (e.g., bruising, petechiae)
• GI bleeding
• Menorrhagia
• Features of the underlying condition (e.g., clinical features of sepsis, clinical features of HELLP syndrome)

Diagnosis

• Based on clinical features and laboratory studies
• CBC
• Coagulation panel, including PT, aPTT, fibrinogen, D-dimer, and other FDPs
• vWF antigen, vWF activity
• See “Diagnostic workup of bleeding disorders” for details.

Treatment

• Transfusion of blood products as needed (e.g., FFP, platelets)
• Replacement of specific coagulation factors (e.g., factor XI in hemophilia)
• Concentrates containing vWF and factor VIII (in vWD)
• Pharmacological therapy (e.g., desmopressin, antifibrinolytics)
• See “Treatment of hemophilia” and “Treatment of von Willebrand disease” for more information.

Risk assessment and preparation for delivery ^[1][2][5]

• Identify individuals at increased risk for PPH.
  • Screening for anemia and/or coagulopathy
  • Sonography to identify placenta accreta in patients with a history of cesarean delivery
• Prepare for initial management of PPH (e.g., IV access, pretransfusion testing, OB/GYN consultation).

Active management of the third stage of labor ^{[1][2][7][21]}

Active management refers to the following PPH prevention measures and is recommended for all patients in the third stage of labor. ^[21]

• Uterotonic agents
  • Administer IM or IV oxytocin to all patients following vaginal or cesarean delivery. ^{[1][2][3][37]}
  • Use an alternative uterotonic (e.g., misoprostol, methylergonovine) if oxytocin is not available.
• Controlled umbilical cord traction (Brandt-Andrews maneuver) ^[7][21]
  • Place one hand on the abdomen, securing the uterine fundus and preventing uterine inversion.
  • With the other hand, apply steady downward traction on the umbilical cord.
• External compression of the uterus and bimanual uterine massage: a manual technique to promote uterine contractions and to tamponade the vascular sinuses in the uterus ^[7]
  • Insert one hand into the anterior vaginal fornix and, with a clenched fist, exert pressure on the anterior wall of the uterus intravaginally.
  • Place the other hand on the abdomen overlying the uterine fundus and massage the uterus between both hands.
  • Credé maneuver ^[38]
    • The cranial part of the uterus is held with four fingers positioned on the posterior surface and the thumb on the anterior surface.
    • The pressure compresses the uterine vessels and aids in the expulsion of the placenta.

Avoid routine episiotomy and assisted vaginal delivery during active management of the third stage of labor.

• Anemia
• Hypovolemic shock
• Thromboembolism
• Sheehan syndrome
• Infection
• Maternal death
• Disseminated intravascular coagulation
• Fetal death (e.g., due to velamentous cord insertion)
• Abdominal compartment syndrome

We list the most important complications. The selection is not exhaustive.

• One-Minute Telegram 149-2026-2/3: TXA to keep postpartum hemorrhage away

Interested in the newest medical research, distilled down to just one minute? Sign up for the One-Minute Telegram in “Tips and links” below.