Performing a uterine massage Side view of a uterine massage with underlying anatomy Uterine massage is a simple first line treatment as it helps the uterus to contract to reduce bleeding. Although the evidence around the effectiveness of uterine massage is inconclusive, it is common practice after the delivery of the placenta. Medication Intravenous oxytocin is the drug of choice for<unk>  hemorrhage. Ergotamine may also be used. Oxytocin helps the uterus to contract quickly and the contractions to last for longer. It is the first line treatment for PPH when its cause is the uterus not contracting well. A combination of syntocinon and ergometrine is commonly used as part of active management of the third stage of labour. This is called syntometrine. Syntocinon alone lowers the risk of PPH. Based on limited research available it is unclear whether syntocinon or syntometrine is most effective in preventing PPH but adverse effects are worse with syntometrine making syntocinon a more attractive option. Ergometrine also has to be kept cool and in a dark place so that it is safe to use. It may reduce the risk of PPH by improving the tone of the uterus when compared with no treatment, however it must be used with caution due to its effects of raising blood pressure and worsening pain. More research would be useful in determining the best doses of ergometrine and syntocinon. Oxytocin requires refrigeration, which may not always be available, particularly in low-resourced settings. When oxytocin is not available, misoprostol can be used. Misoprostol does not need to be kept at a certain temperature and research into its effectiveness in reducing blood loss appears promising when compared with a placebo in a setting where it is not appropriate to use oxytocin. Misoprostol can cause unpleasant side effects such as very high body temperatures and shivering. Lower doses of misoprostol appear to be safer and cause less side effects. Giving oxytocin in a solution of saline into the umbilical vein is a method of administering the drug directly to the placental bed and uterus. However quality of evidence around this technique is poor and it is not recommended for routine use in the management of the third stage. More research is needed to ascertain whether this is an effective way of administering uterotonic drugs. As a way of treating a retained placenta, this method is not harmful and has shown low certainty evidence of effectiveness. Carbetocin compared with oxytocin produced a reduction in women who needed uterine massage and further uterotonic drugs for women having caesarean sections. There was no difference in rates of PPH in women having caesarean sections or women having vaginal deliveries when given carbetocin. Carbetocin appears to cause less adverse effects. More research is needed to find the cost effectiveness of using carbetocin. Tranexamic acid, a clot stabilizing medication, may also be used to reduce bleeding and blood transfusions in low-risk patients, however evidence as of 2015 was not strong. A 2017 trial found that it decreased the risk of death from bleeding from 1.9% to 1.5% in women with<unk> . The benefit was greater when the medication was given within three hours. In some countries, such as Japan, methylergometrine and other herbal remedies are given following the delivery of the placenta to prevent severe bleeding more than a day after the birth. However, there is not enough evidence to suggest that these methods are effective. Surgery Surgery may be used if medical management fails or in case of cervical lacerations or tear or uterine rupture. Methods used may include uterine artery ligation, ovarian artery ligation, internal iliac artery ligation, selective arterial embolization, B-lynch suture, and hysterectomy. Bleeding caused by traumatic causes should be management by surgical repair. When there is bleeding due to uterine rupture a repair can be performed but most of the time a hysterectomy is needed. There is currently no reliable evidence from randomised clinical trials about the effectiveness or risks of mechanical and surgical methods of treating<unk> . Medical devices The World Health Organization recommends the use of a device called the non-pneumatic anti-shock garment (NASG) for use in delivery activities outside of a hospital setting, the aim being to improve shock in a mother with obstetrical bleeding long enough to reach a hospital. External aortic compression devices (EACD) may also be used. Uterine balloon tamponade (UBT) can improve<unk> . Inflating a Sengstaken–Blakemore tube in the uterus successfully treats atonic<unk>  hemorrhage refractory to medical management in approximately 80% of cases. Such procedure is relatively simple, inexpensive and has low surgical morbidity. A Bakri balloon is a balloon tamponade specifically constructed for uterine<unk>  hemorrhage. While effective, commercially available devices may be expensive for settings in which<unk>  hemorrhage is most common. Low-cost devices, such as the ESM-UBT, have been shown to be effective without the need for operative intervention. Protocol Protocols to manage<unk>  are recommended to ensure the rapid giving of blood products when needed. A detailed stepwise management protocol has been introduced by the California Maternity Quality Care Collaborative. It describes four stages of obstetrical hemorrhage after childbirth and its application reduces maternal mortality. * Stage 0: normal - treated with fundal massage and oxytocin. * Stage 1: more than normal bleeding - establish large-bore intravenous access, assemble personnel, increase oxytocin, consider use of methergine, perform fundal massage, prepare 2 units of packed red blood cells. * Stage 2: bleeding continues - check coagulation status, assemble response team, move to operating room, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy. * Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy. A Cochrane review suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) during the third stage of labour may reduce severe bleeding and anemia. However, the review also found that active management increased the patient's blood pressure, nausea, vomiting, and pain. In the active management group more patients returned to hospital with bleeding after discharge, and there was also a reduction in birthweight due to infants having a lower blood volume. The effects on the baby of early cord clamping was discussed in another review which found that delayed cord clamping improved iron stores longer term in the infants. Although they were more likely to need phototherapy (light therapy) to treat jaundice, the improved iron stores are expected to be worth increasing the practice of delayed cord clamping in healthy term babies. For preterm babies (babies born before 37 weeks) a review of the research found that delaying cord clamping may lead to fewer babies with bleeding in the brain, compared to early cord clamping. Another Cochrane review looking at the timing of the giving oxytocin as part of the active management found similar benefits with giving it before or after the expulsion of the placenta. There is no good quality evidence on how best to treat a secondary PPH (PPH occurring 24 hrs or more after the birth).
Postpartum bleeding
Antepartum bleeding
Early pregnancy bleeding
Obstetrical bleeding
Postcoital bleeding
Postpartum infections
Postpartum blues
Recurrent miscarriage