- EBL <500 with on-going bleeding after vaginal delivery
- Deliver placenta and administer oxytocin 5-10 IU (I.M. or I.V.)
- Massage uterus, continuous bimanual compression
- Check for lacerations
- Check placenta for completeness
- Review patient history (prolonged labour? Previous uterine surgery?)
- Where is the rest of the team? (nursing, anesthesia, obstetrics, surgeon, blood bank, transport team, is the OR available?)
Situational awareness is the key component to the process. The index of suspicion rises as blood loss appears to be approaching the upper limit of normal. Simple, non invasive measures may be enough. A systematic mental review of the possible causes of PPH is essential with the 4 T’s acting as a memory guide.
During cesarean section Carbetocin 100ug over 1 min IV/IM shown to reduce uterine atony better than oxytocin but not in vaginal deliveries.