Prevention of postpartum hemorrhage

Antenatal Risk Assessment - Spotting Trouble Early

• Uterine Atony Risks (Most Common):
  • Overdistention: Multiple gestation, polyhydramnios, fetal macrosomia (>4 kg).
  • Uterine Muscle Fatigue: High parity (≥5), history of prolonged labor.
  • Structural/Functional: Uterine fibroids, prior uterine surgery, chorioamnionitis.
• Placental Abnormalities (Tissue):
  • History of retained placenta.
  • Placenta previa or low-lying placenta.
  • Suspected placenta accreta spectrum.
• Coagulopathy (Thrombin):
  • Pre-existing: von Willebrand disease, hemophilia carrier.
  • Acquired: Gestational thrombocytopenia, HELLP syndrome, ITP.

⭐ High-Yield: The single greatest risk factor for postpartum hemorrhage is a history of PPH in a prior pregnancy, which increases the risk by approximately 3-fold.

Intrapartum Management - Delivery Room Defense

Active Management of the Third Stage of Labor (AMTSL) is the standard of care to minimize postpartum blood loss.

• Uterotonic Administration:
  • Oxytocin (Pitocin) is the first-line agent.
  • Administer 10 units IM or a dilute IV infusion (10-40 units in 1L crystalloid) immediately after the delivery of the anterior shoulder.
• Controlled Cord Traction (CCT):
  • Apply gentle, steady traction on the cord while providing suprapubic counter-pressure (Brandt-Andrews maneuver).
  • Do NOT pull without signs of placental separation (gush of blood, cord lengthening, uterine fundus rises).
• Uterine Massage:
  • Perform immediately after placental delivery to stimulate firm contraction (globular, hard uterus).

⭐ The single most important intervention to reduce PPH risk by ~60% is the routine administration of a uterotonic agent, most commonly oxytocin, immediately after delivery.

Active Management of Third Stage (AMTSL) - The Golden Hour

Reduces PPH risk by over 60%. Key steps should be performed sequentially within the first hour post-delivery.

• Uterotonic Administration:
  • Oxytocin 10 units IM (or IV infusion) is standard. Given immediately after the delivery of the anterior shoulder.
• Controlled Cord Traction (CCT):
  • Apply gentle, steady downward traction on the umbilical cord while applying suprapubic counter-pressure (Brandt-Andrews maneuver).
  • ⚠️ Never pull on the cord without signs of placental separation (gush of blood, cord lengthening, globular uterus).
• Uterine Massage:
  • Performed immediately after placental delivery and repeated until the uterus is firm.

⭐ AMTSL is the single most effective intervention for preventing PPH from uterine atony.

High-Yield Points - ⚡ Biggest Takeaways

• Active Management of the Third Stage of Labor (AMTSL) is the most critical intervention for preventing postpartum hemorrhage.
• Key components include: prophylactic uterotonics (typically oxytocin), controlled cord traction, and uterine massage.
• Oxytocin is the first-line agent for PPH prophylaxis.
• Pre-labor identification and management of PPH risk factors (e.g., multiple gestation, macrosomia) is crucial.
• An empty bladder is essential for effective uterine contraction and involution.