12.2 Active Management of the Third Stage of Labor & PPH

12.2 Active Management of the Third Stage of Labor & PPH

Core Obstetric Emergency Principle: Postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality in Kenya. In severe PPH, a parturient can exsanguinate in less than 30 minutes. Active Management of the Third Stage of Labor (AMTSL) must be practiced routinely for every single delivery, and the '4 Ts' algorithm must be executed systematically without delay the moment blood loss exceeds normal parameters.

The third stage of labor begins immediately after the delivery of the neonate and ends with the complete expulsion of the placenta and fetal membranes. Placental separation is achieved by strong myometrial contractions that dramatically reduce the surface area of the placental implantation site, shearing the placenta away from the decidua basalis. Once separated, sustained myometrial retraction compresses the tortuous maternal spiral arteries—a physiological phenomenon termed 'living ligatures'. When myometrial retraction fails, rapid and fatal hemorrhage ensues.

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1. The Three Core Steps of AMTSL

AMTSL is an evidence-based clinical package that significantly reduces the incidence of primary PPH by accelerating placental delivery and optimizing myometrial tone:

+---------------------------------------------------------------------------------------------------------+
|                         ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR (AMTSL)                           |
+---+---------------------------+-------------------------------------------------------------------------+
| # | STEP                      | CLINICAL PROTOCOL & TECHNIQUE                                           |
+---+---------------------------+-------------------------------------------------------------------------+
| 1 | Uterotonic Administration | Administer Oxytocin 10 IU IM within 1 minute of fetal delivery.         |
|   |                           | MANDATORY: Palpate maternal abdomen FIRST to rule out undiagnosed twin!|
|   |                           | Alternative: Misoprostol 400–600 mcg orally or Ergometrine 0.2 mg IM.   |
+---+---------------------------+-------------------------------------------------------------------------+
| 2 | Controlled Cord Traction  | Brandt-Andrews Maneuver:                                                |
|   | (CCT)                     | • Clamp cord close to perineum when pulsations cease.                   |
|   |                           | • Wait for a strong uterine contraction (globular, firm fundus).        |
|   |                           | • Apply gentle, steady downward cord traction with right hand.          |
|   |                           | • Concurrently push lower uterine segment UP & BACK with left hand      |
|   |                           |   placed suprapubically (counter-traction).                             |
|   |                           | • Gently twist placenta 360° upon exit to tease out intact membranes.   |
|   |                           | • STRICT RULE: Never pull without counter-traction or on relaxed uterus!|
+---+---------------------------+-------------------------------------------------------------------------+
| 3 | Uterine Fundal Massage    | • Immediately massage the uterine fundus vigorously through the         |
|   |                           |   anterior abdominal wall until firm and contracted ('cricket ball').   |
|   |                           | • Inspect placenta and membranes for completeness (cotyledons intact).  |
|   |                           | • Repeat fundal palpation & massage every 15 minutes for 2 hours.       |
|   |                           | • Teach the mother to palpate her own fundus to ensure persistent tone. |
+---+---------------------------+-------------------------------------------------------------------------+

Uterotonic Agents: Characteristics & Contraindications

• Oxytocin (First-Line Gold Standard): Dose: 10 IU Intramuscularly (IM). Mechanism: Activates G-protein coupled oxytocin receptors, causing rhythmic and sustained myometrial contractions. Onset: 2 to 3 minutes IM. Advantages: No hypertensive adverse effects; safe in pre-eclampsia, cardiac disease, and asthma. Requires cold chain storage (2°C to 8°C).
• Ergometrine / Methylergometrine: Dose: 0.2 mg IM. Mechanism: Ergot alkaloid producing prolonged, tetanic uterine smooth muscle spasms. Onset: 2 to 5 minutes IM. STRICT CONTRAINDICATION: Strictly contraindicated in gestational hypertension, pre-eclampsia, eclampsia, chronic hypertension, and cardiac disease due to potent peripheral vasoconstriction triggering acute hypertensive crisis, stroke, and pulmonary edema.
• Misoprostol: Dose: 400 to 600 mcg orally or sublingually. Mechanism: Synthetic prostaglandin E1 (PGE1) analogue. Excellent stability at room temperature (ideal for peripheral dispensaries without cold chain). Common side effects: Shivering, rigors, transient pyrexia (up to 40°C), and diarrhea.

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2. Postpartum Hemorrhage: Definition and Classification

• Clinical Definition: Blood loss of >= 500 mL following vaginal delivery, >= 1,000 mL following Cesarean delivery, or any volume of blood loss that causes signs of hemodynamic instability (tachycardia, tachypnea, hypotension, pallor, cold extremities, oliguria, or confusion).
• Primary PPH: Hemorrhage occurring within the first 24 hours after delivery. Accounts for over 90% of all PPH cases and the vast majority of maternal fatalities.
• Secondary PPH: Hemorrhage occurring between 24 hours and 6 weeks postpartum. Most commonly caused by retained placental fragments/cotyledons, secondary infection (endometritis), or delayed subinvolution of the placental site.

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3. Etiological Stratification: The '4 Ts' Framework

Whenever PPH is suspected or diagnosed, the clinician must systematically investigate the '4 Ts':

+---------------------------------------------------------------------------------------------------------+
|                                      THE '4 Ts' ETIOLOGY OF PPH                                         |
+----------+------------+-----------------------------------+---------------------------------------------+
| 'T' TYPE | FREQUENCY  | UNDERLYING PATHOLOGY & RISKS      | HALLMARK CLINICAL FINDINGS                  |
+----------+------------+-----------------------------------+---------------------------------------------+
| TONE     | 70% to 80% | Uterine Atony (failure of         | • Soft, flaccid, 'boggy' uterine fundus     |
|          |            | myometrium to contract & retract).| • Fundus elevated above umbilicus           |
|          |            | Risks: multiparity, polyhydramnios| • Massive dark blood and clots gush out     |
|          |            | twins, prolonged/precipitous labor|   upon abdominal massage                    |
+----------+------------+-----------------------------------+---------------------------------------------+
| TRAUMA   | ~20%       | Lacerations of perineum, vagina,  | • Uterus is ROCK-HARD and FIRMLY CONTRACTED |
|          |            | cervix, or lower uterine segment; | • Persistent continuous trickling or spurting|
|          |            | uterine rupture; inverted uterus  |   of bright red arterial blood              |
+----------+------------+-----------------------------------+---------------------------------------------+
| TISSUE   | ~10%       | Retained succenturiate lobe,      | • Incomplete placenta or missing cotyledons |
|          |            | retained cotyledons/membranes,    | • Uterus remains persistently subinvoluted  |
|          |            | morbidly adherent placenta accreta| • Continued intermittent atony and bleeding |
+----------+------------+-----------------------------------+---------------------------------------------+
| THROMBIN | ~1%        | Pre-existing coagulopathies, DIC  | • Blood fails to form clots in dry tube     |
|          |            | secondary to severe abruption,    | • Oozing from IV puncture sites, gums,      |
|          |            | eclampsia, or amniotic embolism   |   hematuria, petechiae                      |
+----------+------------+-----------------------------------+---------------------------------------------+

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4. Emergency Stepwise PPH Resuscitation Protocol

                             [DIAGNOSIS OF POSTPARTUM HEMORRHAGE]
                                 (Blood Loss >= 500 mL or Shock)
                                                │
                                                ▼
                   [ACTIVATE CODE RED / OBSTETRIC EMERGENCY CALL FOR HELP]
                        (Midwife, Clinical Officer, Nurse, Anesthetist)
                                                │
                     ┌──────────────────────────┴──────────────────────────┐
                     ▼                                                     ▼
        [RESUSCITATION & MONITORING]                             [PHYSICAL TONE ASSESSMENT]
  • High-flow Oxygen (6-8 L/min mask)                     • Immediate Vigorous Fundal Massage
  • Two wide-bore IV lines (14G or 16G)                   • External or Internal Bimanual Compression
  • Rapid IV Ringer's Lactate / Saline                    • Insert Foley Catheter with urometer
  • Blood draw: Crossmatch 4 units, FBC,                   (empties bladder & tracks hourly urine)
    bedside clotting test                                                  │
                     │                                                     │
                     └──────────────────────────┬──────────────────────────┘
                                                │
                                                ▼
                                  [PHARMACOLOGICAL MANAGEMENT]
  1. IV Oxytocin: 20 to 40 IU in 1L Saline at 40-60 drops/min (NEVER undiluted IV bolus)
  2. IV Tranexamic Acid (TXA): 1 g IV slowly over 10 min (give within 3 hrs of delivery)
  3. IM Ergometrine: 0.2 mg IM (if patient is NOT hypertensive)
  4. Misoprostol: 800 mcg sublingually or rectally
                                                │
                                                ▼
                             [DOES UTERUS CONTRACT & BLEEDING CEASE?]
                                 ├─── YES ──► Continue maintenance oxytocin infusion & close monitoring
                                 └─── NO  ──► PROCEED TO REFRACTORY ALGORITHM
                                                │
                                                ▼
                              [REFRACTORY ATONY: MECHANICAL CONTROL]
  • Condom-Catheter Uterine Balloon Tamponade (UBT) inflated with 300 to 500 mL warm sterile saline
  • External Aortic Compression while preparing operating theater
  • If Trauma suspected: Speculum examination and suture cervical/vaginal lacerations
                                                │
                                                ▼
                            [PERSISTENT BLEEDING: SURGICAL INTERVENTION]
  • Exploratory Laparotomy: B-Lynch uterine compression sutures
  • Bilateral Uterine Artery Ligation / Internal Iliac Ligation
  • Peripartum Hysterectomy (subtotal or total) as definitive life-saving measure

Bimanual Uterine Compression Techniques

• External Bimanual Compression: Place one hand across the posterior abdominal wall behind the fundus, pushing it forward, while the other hand presses firmly on the anterior abdominal wall over the lower segment, compressing the uterus between both hands.
• Internal Bimanual Compression: Clench one gloved hand into a fist and insert it into the anterior vaginal fornix, pushing up against the anterior uterine wall. Place the other hand externally on the maternal abdominal wall behind the posterior fundus, pulling the fundus down and firmly compressing the uterine body against the vaginal fist. Maintain until the uterus contracts or balloon tamponade is placed.

Intravenous Tranexamic Acid (TXA)

• Based on findings from the landmark global World Maternal Antifibrinolytic (WOMAN) trial, Tranexamic Acid (TXA) must be administered to all women with PPH within 3 hours of birth.
• Dose: 1 g IV (10 mL of 100 mg/mL solution) infused slowly over 10 minutes.
• If bleeding continues after 30 minutes, or restarts within 24 hours, a second 1 g IV dose is administered.
• Administration after 3 hours provides no clinical benefit and is not recommended.

Uterine Balloon Tamponade (UBT / Condom-Catheter System)

In Kenya and resource-limited settings, UBT is an indispensable, minimally invasive tool:

• Equipment: A sterile male latex condom tied tightly to a size 16–18 Fr Foley catheter with sterile silk or umbilical tape, connected to an IV infusion giving set and normal saline bag.
• Application: Under aseptic technique, insert the condom catheter into the uterine cavity up to the fundus. Infuse 300 to 500 mL of warm sterile saline by gravity or syringe until the balloon is palpably firm and resistance is met. Tamp the vagina with sterile gauze to prevent balloon extrusion. Keep in place for 12 to 24 hours under IV antibiotic coverage, then deflate gradually over 30 minutes before removal.

Acute Uterine Inversion Management

• Definition: The turning inside-out of the uterus, typically provoked by vigorous traction on the umbilical cord on a relaxed, non-contracted uterus.
• Signs: Severe neurogenic and hypovolemic shock out of proportion to external bleed, sudden absence of the abdominal fundus on palpation (a deep 'cup-like' depression felt), and a large, blue-purplish vascular mass visible at the introitus or in the vagina.
• Management: Immediate resuscitation, stop any oxytocin infusion (allows uterus to relax for repositioning), and perform the Johnson maneuver: Grasp the inverted fundus in the palm with fingers directed toward the posterior fornix and push the fundus steadily upward through the cervical ring toward the umbilicus. Once replaced, administer high-dose oxytocin to maintain contractility and prevent recurrence.