CTG response and postpartum haemorrhage

Primary Postpartum Haemorrhage (PPH)

Primary postpartum haemorrhage is defined as blood loss $\ge 500\text{ mL}$ following a vaginal birth or $\ge 1,000\text{ mL}$ following a caesarean section within 24 hours of delivery. Severe PPH is defined as blood loss $\ge 1,000\text{ mL}$ following any mode of birth.

The "4 Ts" Etiological Framework

1. Tone (70%): Uterine atony is the single most common cause. Risk factors include uterine overdistension (macrosomia, polyhydramnios, multiple pregnancy), prolonged labour, grand multiparity, chorioamnionitis, and tocolytic exposure.
2. Trauma (20%): Genital tract lacerations (perineal, vaginal, or cervical tears), broad ligament haematoma, uterine rupture, or uterine inversion.
3. Tissue (10%): Retained products of conception (cotyledons, succenturiate placental lobe, or morbidly adherent placenta accreta spectrum).
4. Thrombin (< 1%): Pre-existing coagulopathy (von Willebrand disease, immune thrombocytopenia) or acquired consumptive coagulopathy (DIC secondary to abruption, amniotic fluid embolism, sepsis, or massive transfusion).

Emergency Management Protocol for Primary PPH

• Step 1: Immediate Resuscitation and Multidisciplinary Escalation:
  • Call code obstetric emergency / haemorrhage team (senior obstetrician, anaesthetist, midwives, haematologist).
  • Airway, high-flow oxygen ($10\text{–}15\text{ L/min}$ via non-rebreather mask), and aggressive volume replacement.
  • Secure two wide-bore (14-gauge) intravenous cannulae; draw blood for FBC, coagulation profile (INR, APTT, fibrinogen), and crossmatch 4 to 6 units of packed red blood cells. Activate the institutional Massive Transfusion Protocol (MTP) if bleeding exceeds $1,000\text{ mL}$ with ongoing instability.
• Step 2: Physical and Mechanical Interventions:
  • Vigorous Fundal Uterine Massage: Continuous transabdominal rub of the fundus stimulates endogenous myometrial contraction.
  • Bimanual Uterine Compression: Insert a gloved fist into the anterior vaginal fornix, pressing against the anterior uterine wall, while the abdominal hand compresses the posterior uterine wall over the fundus.
  • Bladder Catheterisation: Insert an indwelling Foley catheter to completely empty the bladder; a distended bladder mechanically impedes uterine contractility.
  • Exploration: Inspect the lower genital tract using a lighted speculum to identify and suture lacerations; manually explore the uterine cavity to evacuate retained cotyledons and clot burden.
• Step 3: Pharmacological Uterotonics:
  1. Oxytocin: Use the local PPH regimen with a slow IV dose and appropriate infusion. Rapid large boluses can cause hypotension; treatment is given with resuscitation and assessment of tone, trauma, tissue and coagulation.
  2. Ergometrine: $0.25\text{ to }0.5\text{ mg}$ IM or slow IV. Produces sustained tetanic uterine smooth muscle contraction. Strict Contraindication: Hypertension, pre-eclampsia, or coronary artery disease (causes severe peripheral vasoconstriction and hypertensive crisis).
  3. Carboprost (PGF2$\alpha$): $250\text{ mcg}$ IM (or direct intramyometrial injection), repeatable every 15 minutes up to a maximum of 8 doses ($2\text{ mg}$). Strict Contraindication: Active or previous bronchial asthma (induces potent, life-threatening bronchospasm).
  4. Misoprostol (PGE1): $800\text{ to }1,000\text{ mcg}$ sublingually or rectally.
• Tranexamic acid: An antifibrinolytic, not a uterotonic. Give early in diagnosed PPH under the protocol, generally 1 g IV within three hours of birth, with a further 1 g if bleeding continues after 30 minutes or recurs within 24 hours. Give concurrently with haemorrhage control rather than waiting for every uterotonic to fail.
• Step 4: Tamponade and Surgical Haemostasis:
  • Intrauterine Balloon Tamponade (Bakri Balloon): Inserted into the uterine cavity and inflated with $300\text{ to }500\text{ mL}$ of warm sterile saline to provide uniform hydrostatic compression against bleeding uterine sinusoids. A "tamponade test" is positive if bleeding ceases via the drainage port.
  • Surgical Laparotomy: If balloon tamponade fails, proceed to surgical haemostatic brace sutures (B-Lynch suture), bilateral uterine artery ligation, internal iliac artery ligation, or interventional uterine artery embolisation.
  • Peripartum Hysterectomy: Final lifesaving intervention for unmanageable, catastrophic haemorrhage refractory to all conservative measures.

Life-Threatening Obstetric Emergencies

Shoulder Dystocia

• Definition: Failure of delivery of the fetal shoulders with gentle downward traction following delivery of the fetal head, caused by impaction of the anterior shoulder behind the maternal pubic symphysis.
• Diagnostic Hallmark: "Turtle Sign": The fetal head delivers and immediately retracts tightly against the maternal perineum. Fetal facial congestion and cyanosis develop rapidly.
• Cardinal Management Rules:
  • NEVER apply fundal pressure: Applying fundal pressure pushes the anterior shoulder more firmly behind the pubic bone, increases the risk of uterine rupture, and causes severe brachial plexus disruption.
  • Avoid excessive neck traction: Forceful traction on the fetal head tears the C5–C6 upper roots of the brachial plexus (Erb palsy).
• The HELPERR Management Algorithm:
  • H (Help): Call immediately for obstetric, paediatric, anaesthetic, and senior midwifery assistance. Direct the mother to stop pushing.
  • E (Episiotomy): Evaluate need for episiotomy. Episiotomy does not relieve the bony impaction, but facilitates vaginal access for internal rotational manoeuvres.
  • L (Legs — McRoberts Manoeuvre): Hyperflex and abduct the maternal hips, bringing the thighs tightly against the abdomen. McRoberts manoeuvre flattens the sacral promontory and rotates the symphysis pubis cephalad, successfully relieving up to 70% of shoulder dystocias.
  • P (Suprapubic Pressure): An assistant applies firm downward and lateral pressure immediately above the maternal pubic symphysis onto the posterior aspect of the anterior shoulder to adduct and dislodge it into the wider oblique pelvic diameter.
  • E (Enter Internal Manoeuvres): Insert fingers into the posterior vagina to execute the Rubin II manoeuvre (pressure on posterior surface of anterior shoulder) or Woods screw manoeuvre (rotate posterior shoulder $180^\circ$ by applying pressure to its anterior surface).
  • R (Remove the Posterior Arm): Reach into the sacral hollow, locate the fetal posterior elbow, flex the forearm across the chest, and sweep the hand out of the vagina, decreasing the biacromial diameter.
  • R (Roll to All-Fours — Gaskin Manoeuvre): Move patient onto hands and knees; changes pelvic geometry and uses gravity to assist disimpaction.
  • Last-resort techniques: Deliberate clavicular fracture, symphysiotomy, or Zavanelli manoeuvre (cephalic replacement into the vagina followed by emergency caesarean section).

Primary references (checked 7 October 2026): RANZCOG intrapartum surveillance; Queensland preterm birth guideline.