Women at risk of PPH must be managed carefully to minimise the likelihood of bleeding. When labour commences an intravenous cannula (size 14 or 16 gauge) is inserted and blood is taken for a full blood count (FBC) and confirmation of blood group. Serum is saved for ‘cross-matching’ blood should it become necessary to give the woman a blood transfusion. Prolonged labour, with its problems of dehydration and exhaustion, should be avoided. A Syntocinon (oxytocin) infusion should be started if labour progress is slow. The woman’s bladder should be kept empty by encouraging micturition or by catheterisation, as a full bladder may inhibit uterine muscle activity and add to the risk of atony.

Management of the 3rd stage should be discussed with the woman antenatally so that previous verbal consent can be given for any intervention, should it arise. She should be advised that the potential for PPH is greater with physiological management of the 3rd stage than it is with ‘active management’. It should be explained to her that the medical view is that it is safer to manage the 3rd stage of labour actively. In active management, an intramuscular injection of Syntocinon 10 IU or Syntometrine 1 ml, which contains Syntocinon 5 units and ergometrine 500 μg, is given with the birth of the anterior shoulder. The placenta is then delivered by controlled cord traction. An intravenous or intramuscular injection of Syntometrine 1 ml or ergometrine 500 μg would be prescribed if the woman starts to bleed, depending on what had been administered previously.

One intervention advocated by the RCOG (2007) is prophylactic radiology. This process involves inserting an arterial balloon into the blood vessels causing occlusion and embolisation to prevent major blood loss. This intervention should be used in the event of a PPH if the cause is secondary to:

• Atonic uterus following normal or prolonged labour, with or without caesarean section.

• Surgical complications or uterine tears at the time of caesarean section.

• Bleeding continues on the postnatal ward or in the postoperative recovery area following a normal delivery or a caesarean section.

• Bleeding following a hysterectomy.

Bimanual compression may be performed externally or internally. In external bimanual compression, one hand is dipped down as far as possible behind the uterus while the other is placed flat on the abdomen. The uterus is compressed between the two hands and pulled upwards in the abdomen. This ensures that the bleeding area of the placental site is compressed while the uterine veins are straightened out to allow free drainage, relieve congestion and decrease the bleeding (Lindsay 2004).

Internal bimanual compression is carried out if the mother is anaesthetised and still bleeding after manual removal of placenta. One hand is closed to form a fist, inserted into the anterior vaginal fornix and pushed up towards the body of the uterus. The other hand is placed on the abdominal wall behind the uterus and compresses the uterus downwards against the hand in the vagina. This applies compression to the placental site until the uterus is felt to contract (Fig. 45.1).

Once bleeding is controlled, an intravenous infusion containing Syntocinon (oxytocin) is started to maintain uterine contraction. If blood loss is excessive or if the woman had a low haemoglobin level before delivery, a blood transfusion may be necessary. There are approximately 4000 cases of obstetric haemorrhage a year. The majority will require a blood transfusion (RCOG 2009). Therefore it is important not to underestimate the amount of blood lost. Brant (1967) found that estimates of blood loss became more inaccurate as the amount lost increased. In the case of serious PPH, the obstetrician and anaesthetist will agree on the management of fluid replacement. It is recommended that each obstetric unit should have a protocol on managing PPH, which should be followed and ‘fire-drill’ scenarios conducted to train and update practitioners on the protocol (RCOG 2009). Group O rhesus-negative blood should be available on the labour ward for use in emergencies. Where large volumes of blood are to be transfused, blood-warming coils should be used. Appropriate personnel must be included and there should be early involvement of consultant obstetrician, anaesthetist, haematologist and blood bank (RCOG 2005).

If the uterus fails to contract even though oxytocic drugs have been used, a deep intramuscular injection of the prostanoid carboprost, which is 15-methyl-PGF _2α (Rang et al 2007), can be given in a dose of 250 μg and repeated at intervals of 1.5 h. Carboprost is contraindicated in women with cardiac, renal, pulmonary and hepatic disease as well as in acute pelvic inflammation. It should be used with care in women who have asthma, hypertension, diabetes, epilepsy, hypotension or hypertension (BNF 2008). Different maternity units, according to their guidelines, may use different methods for controlling bleeding. In continuing haemorrhage, internal iliac artery ligation and uterine packing may be needed and, if all fails, a hysterectomy may be performed to save the woman’s life. A systematic review by Mousa & Alfirevic (2007) argues that there is not enough robust evidence in which to alter the present treatment of primary PPH, which is the combined use of oxytocin and ergometrine with misoprostol. Further controlled trials are required to assess the effectiveness and safety of pharmacological, interventional radiology and surgical interventions used for the treatment of PPH (Mousa & Alfirevic 2007).

Once blood loss is controlled, the total loss is estimated remembering how difficult this can be and that estimates become less accurate as blood loss increases. Fluid intake is recorded, as is the hourly urine output. Central venous pressure measurement may be required, depending on the blood loss and the severity of the woman’s condition, which may require correct fluid replacement. Maternal pulse and blood pressure are recorded every 15 min to ensure her condition remains satisfactory. The uterine fundus is palpated frequently to ensure it remains contracted and the lochia are observed. All findings can be recorded using a modified early warning system (e.g. MEWS).

If the problem involves failure of blood coagulation, a haematologist should be involved. Fresh blood is usually the best treatment as it contains both platelets and coagulation factors but fresh frozen plasma, containing factors V and VIII and fibrinogen, can be used. This is guided by the results from the blood coagulation screen (RCOG 2007).