Active Management of the Third Stage of Labour, Postpartum Haemorrhage & PPH Management
A comprehensive and easy-to-understand guide for nursing and midwifery students on preventing, recognising and managing postpartum haemorrhage following childbirth.
The Third Stage of Labour
The third stage of labour begins immediately after the complete birth of the baby and ends when the placenta and fetal membranes have been completely expelled. Although it is usually much shorter than the first and second stages of labour, it is an extremely important period because failure of normal placental separation or adequate uterine contraction can result in severe maternal haemorrhage.
After the baby is born, the uterus continues to contract. These contractions reduce the surface area of the placental bed and cause the placenta to separate from the uterine wall. Retraction of the uterine muscle then compresses the maternal blood vessels that supplied the placenta. This physiological process acts as a form of living ligature and is the major mechanism by which bleeding is controlled after placental separation.
Why the Placenta Matters
The placenta is attached to the decidual surface of the uterus and receives a very large maternal blood supply. Following placental separation, the exposed placental bed contains numerous maternal vessels. Effective contraction and retraction of the myometrium compress these vessels.
If the uterus fails to contract effectively, these vessels remain relatively open and heavy bleeding may occur. This explains why uterine atony is the most common cause of primary postpartum haemorrhage.
Physiology of Placental Separation
Following delivery of the baby, powerful uterine contractions cause the placental implantation site to become progressively smaller. Because the placenta cannot contract to the same extent as the uterine wall, a cleavage plane develops between the placenta and the decidua. Blood may collect behind the separating placenta, assisting the separation process.
Signs of Placental Separation
- The uterus becomes firm and globular.
- The uterine fundus rises in the abdomen.
- The umbilical cord appears to lengthen.
- A sudden small gush of blood may occur.
After Separation
The separated placenta descends into the lower uterine segment and vagina before being delivered. The uterus should remain firmly contracted after placental delivery to maintain haemostasis.
Active Management of the Third Stage of Labour
Active management of the third stage of labour (AMTSL) refers to evidence-based interventions used around the time of placental delivery to reduce postpartum blood loss and the risk of postpartum haemorrhage. The most important component is the routine administration of an effective prophylactic uterotonic.
Steps in Active Management
Administer a Prophylactic Uterotonic
Administer the recommended uterotonic promptly after birth. Oxytocin is generally the preferred drug because it is effective and has a favourable adverse effect profile.
Delayed Umbilical Cord Clamping
In a stable mother and newborn, delayed cord clamping is generally performed approximately 1–3 minutes after birth while essential newborn care continues.
Controlled Cord Traction
When the uterus is contracted and placental separation has occurred, the trained attendant performs controlled cord traction while the other hand provides counter-pressure above the symphysis pubis to support the uterus.
Traction should be gentle and coordinated with uterine contraction. Forceful cord traction may cause cord avulsion or uterine inversion.
Deliver the Placenta and Membranes
As the placenta appears at the vulva, it is supported with both hands and gently rotated to assist delivery of the membranes without tearing them.
Inspect the Placenta
Examine the maternal surface, fetal surface, membranes and umbilical cord to ensure that the placenta is complete. Missing cotyledons or torn membranes may suggest retained placental tissue.
Assess Uterine Tone and Blood Loss
Palpate the uterus to ensure that it is firm and contracted. Assess vaginal bleeding and objectively quantify blood loss whenever possible.
Continue Maternal Observation
Monitor pulse, blood pressure, uterine tone, vaginal bleeding, consciousness and overall maternal condition during the immediate postpartum period.
Postpartum Haemorrhage
Postpartum haemorrhage (PPH) is excessive bleeding following childbirth and remains one of the most important causes of preventable maternal morbidity and mortality worldwide. Rapid recognition is essential because clinically significant blood loss can progress quickly.
Current WHO Trigger for Action
- Heavy ongoing bleeding or a constant trickle.
- Large blood clots.
- A soft or atonic uterus.
- Pulse greater than 100 beats/minute.
- Systolic blood pressure below 100 mmHg.
- Diastolic blood pressure below 60 mmHg.
- Shock index greater than 1.
- Other evidence of haemodynamic deterioration.
Primary and Secondary PPH
Primary PPH
Excessive postpartum bleeding occurring within the first 24 hours after birth. Uterine atony is the commonest cause.
Secondary PPH
Abnormal or excessive bleeding occurring after the first 24 hours in the later postpartum period. Causes may include retained products of conception, uterine infection, subinvolution or coagulation disorders.
Causes of PPH — Remember the 4 Ts
| Cause | Examples | Clinical Clue |
|---|---|---|
| Tone | Uterine atony, overdistended uterus, prolonged labour | Soft, enlarged or poorly contracted uterus with bleeding |
| Trauma | Cervical tear, vaginal tear, perineal trauma, uterine rupture, uterine inversion | Continued bleeding despite a firm, contracted uterus |
| Tissue | Retained placenta, retained placental fragments, abnormal placental adherence | Incomplete placenta or failure of placenta to separate |
| Thrombin | Disseminated intravascular coagulation, severe pre-eclampsia, placental abruption, inherited or acquired coagulation disorder | Persistent diffuse bleeding or oozing despite correction of obvious obstetric causes |
Risk Factors for Postpartum Haemorrhage
Uterine Overdistension
Multiple pregnancy, polyhydramnios and fetal macrosomia can overdistend the uterus and impair effective postpartum contraction.
Abnormal Labour
Prolonged labour, very rapid labour and prolonged exposure to uterotonic agents may be associated with postpartum uterine dysfunction.
Previous Obstetric History
Previous PPH, previous uterine surgery and abnormal placentation may increase risk.
Placental Factors
Placenta previa, placental abruption, retained placenta and placenta accreta spectrum are important considerations.
Maternal Factors
Anaemia, hypertensive disease, infection and coagulation abnormalities may increase the clinical consequences of haemorrhage.
Important Reminder
PPH can occur even when no risk factor has been identified. Every birth therefore requires preparedness for haemorrhage.
Recognition and Assessment of PPH
Visual estimation of blood loss may underestimate true haemorrhage. Where available, blood should therefore be measured objectively using a calibrated blood-collection drape and other appropriate quantitative methods.
Assess the Woman
- Level of consciousness
- Pulse rate
- Blood pressure
- Respiratory rate
- Skin colour and perfusion
- Oxygen saturation where available
- Urine output
Assess the Bleeding
- Quantify blood loss.
- Assess uterine tone.
- Look for clots and ongoing flow.
- Inspect the placenta for completeness.
- Examine the genital tract.
- Consider coagulation failure.
A shock index greater than 1 in a woman with postpartum bleeding should increase concern for haemodynamic compromise and the need for urgent treatment and escalation.
Management of Postpartum Haemorrhage
PPH management must be rapid, simultaneous and team-based. Do not wait for one intervention to fail before beginning all other appropriate components of the initial response.
Immediate General Measures
Call for Assistance
Activate the facility's obstetric haemorrhage response. Notify senior obstetric, anaesthetic, theatre, laboratory and blood-bank personnel as appropriate.
Assess ABC
Assess airway, breathing and circulation immediately while another team member begins haemorrhage-specific treatment.
Establish IV Access
Establish adequate large-bore intravenous access. Obtain blood for investigations including full blood count, blood group/crossmatch and coagulation studies according to facility protocol.
Resuscitate
Begin appropriate warmed isotonic crystalloid resuscitation while preparing blood and blood components when clinically required. Avoid delaying haemorrhage control while awaiting laboratory results.
Monitor Continuously
Reassess pulse, blood pressure, blood loss, uterine tone, consciousness, oxygenation and response to treatment.
Monitor Urine Output
Empty the bladder and catheterise when clinically appropriate to monitor urine output and reduce interference with effective uterine contraction.
The WHO MOTIVE PPH Treatment Bundle
Once PPH is diagnosed, current WHO recommendations support rapid initiation of the first-response treatment bundle. The interventions should be performed promptly and together rather than sequentially.
Medicines Used in PPH Management
| Medicine | Role | Important Clinical Point |
|---|---|---|
| Oxytocin | First-line uterotonic for prevention and treatment of uterine-atony-related PPH. | IV oxytocin is the preferred uterotonic for treatment when available. Administration regimen should follow the local PPH protocol. |
| Ergometrine / Methylergometrine | Alternative or additional uterotonic where clinically appropriate. | Avoid or use extreme caution in women with hypertension, pre-eclampsia or significant cardiovascular disease. |
| Misoprostol | Prostaglandin uterotonic that may be used when oxytocin is unavailable or bleeding does not respond adequately. | WHO guidance includes 800 micrograms sublingually as a treatment option in appropriate circumstances. |
| Other Prostaglandin Uterotonics | May be used depending on availability and local obstetric protocol. | Consider relevant contraindications, particularly respiratory and cardiovascular disease. |
| Tranexamic Acid (TXA) | Antifibrinolytic medicine that reduces breakdown of formed blood clot. | Give early for clinically diagnosed PPH, ideally as soon as possible and within 3 hours of birth. |
Management According to the 4 Ts
1. TONE — Uterine Atony
If the uterus is soft and poorly contracted, begin uterine massage and administer appropriate uterotonic therapy while continuing the rest of the PPH bundle.
- Massage the uterus.
- Empty the bladder.
- Administer oxytocin or appropriate uterotonic therapy.
- Give tranexamic acid as part of the PPH treatment bundle.
- Continue fluid and blood-product resuscitation as needed.
- Consider bimanual uterine compression when bleeding persists.
- Escalate to uterine balloon tamponade or operative management when required.
2. TRAUMA — Genital Tract Injury
Persistent bleeding with a firm uterus should raise suspicion of genital tract trauma.
- Inspect the perineum, vagina and cervix.
- Identify and repair significant lacerations.
- Assess for expanding haematoma.
- Consider uterine rupture in the appropriate clinical setting.
- Manage uterine inversion as an immediate obstetric emergency.
3. TISSUE — Retained Placenta or Placental Tissue
Examine the placenta carefully. If placental tissue is retained, the uterus may remain poorly contracted and bleeding may continue.
- Assess whether the placenta has been completely delivered.
- Look for missing cotyledons or abnormal membranes.
- Escalate for manual removal when clinically indicated.
- Provide appropriate analgesia or anaesthesia.
- If placenta accreta spectrum is suspected, avoid forceful removal and obtain senior obstetric assistance.
4. THROMBIN — Coagulation Disorder
Consider a coagulation abnormality when bleeding is diffuse, there is persistent oozing, or haemorrhage is disproportionate to the identified mechanical cause.
- Send urgent coagulation investigations where available.
- Activate the major haemorrhage/transfusion protocol when indicated.
- Replace red cells and haemostatic blood components as required.
- Correct hypothermia, acidosis and significant coagulopathy.
- Continue treatment of the underlying obstetric cause.
Mechanical and Temporising Measures
When uterine atony does not respond rapidly to initial treatment, mechanical measures may help reduce blood loss while definitive management is organised.
Bimanual Uterine Compression
A trained clinician may compress the uterus between an internal vaginal hand and an external abdominal hand as a temporary measure while additional treatment is provided.
External Aortic Compression
In catastrophic bleeding, external aortic compression may be used by appropriately trained providers as a temporary life-saving measure while definitive care, blood products or transfer are being arranged.
When Bleeding Continues — Escalation of Care
Persistent haemorrhage despite first-line treatment requires rapid escalation. The exact intervention depends on the cause of bleeding, resources available, the woman's condition and the experience of the clinical team.
Uterine Balloon Tamponade
Uterine balloon tamponade may be considered for persistent PPH due to uterine atony when standard first-line treatment has failed and appropriate surgical and blood-transfusion backup is available.
Operative Conservative Measures
Depending on clinical circumstances, operative measures can include uterine compression sutures and surgical control of uterine or pelvic vessels.
Interventional Radiology
Uterine artery embolisation may be considered in suitable facilities when the patient is sufficiently stable and expertise is immediately available.
Hysterectomy
Life-saving hysterectomy may be required when haemorrhage remains uncontrolled despite appropriate conservative treatment. Definitive surgery should not be delayed until irreversible shock has developed.
Nursing and Midwifery Responsibilities During PPH
Rapid Recognition
Detect abnormal blood loss, uterine atony and changes in vital signs early and activate the emergency response without delay.
Team Coordination
Call appropriate personnel, clearly communicate estimated or measured blood loss and assist with the facility's haemorrhage protocol.
Medication Administration
Prepare and administer prescribed uterotonics, tranexamic acid and other emergency medicines safely according to the approved PPH protocol.
IV and Blood Therapy
Establish and maintain IV access, collect blood specimens and assist with rapid fluid and blood component replacement.
Continuous Monitoring
Monitor pulse, blood pressure, respiratory status, consciousness, uterine tone, blood loss, temperature and urine output.
Documentation
Record observations, quantified blood loss, medications, fluids, blood products, procedures, clinical response and escalation accurately.
Prevention of PPH
Prevention begins long before the third stage of labour. Important strategies include recognising and correcting antenatal anaemia, identifying women at increased risk, ensuring delivery facilities are prepared for haemorrhage and providing an effective prophylactic uterotonic after birth.
- Identify and treat maternal anaemia during pregnancy.
- Identify obstetric risk factors before labour.
- Ensure blood availability for high-risk women when appropriate.
- Prepare uterotonics and emergency equipment before delivery.
- Give an effective prophylactic uterotonic after birth.
- Assess uterine tone after delivery.
- Measure postpartum blood loss objectively whenever possible.
- Monitor maternal vital signs closely after birth.
- Recognise abnormal bleeding early and initiate treatment promptly.
Most common cause of primary PPH: Uterine atony.
First-line prophylactic uterotonic: Oxytocin.
Major causes of PPH: Tone, Trauma, Tissue and Thrombin.
Current first-response bundle: MOTIVE — Massage, Oxytocics, Tranexamic acid, IV fluids, Examination and Escalation.
Important TXA principle: Give it as early as possible after PPH is diagnosed and within 3 hours of birth.
Clinical warning: Continued bleeding with a firm uterus should make you actively look for trauma and other causes rather than assuming uterine atony.
Key Take-Home Points
- The third stage begins after delivery of the baby and ends with complete delivery of the placenta and membranes.
- Effective contraction and retraction of the uterus are essential for postpartum haemostasis.
- The most important component of active management of the third stage is administration of a prophylactic uterotonic.
- Oxytocin 10 IU IM or IV is the preferred prophylactic uterotonic in WHO guidance.
- Delayed cord clamping of approximately 1–3 minutes is generally recommended in stable mother–newborn pairs.
- PPH should be treated at 500 mL blood loss or earlier at 300 mL when warning signs are present.
- Remember the causes using the 4 Ts: Tone, Trauma, Tissue and Thrombin.
- Initial PPH treatment should be simultaneous and organised using the MOTIVE bundle.
- Tranexamic acid should be administered early in clinically diagnosed PPH and within 3 hours of birth.
- Persistent bleeding requires rapid escalation to mechanical, radiological or surgical haemorrhage-control measures.
References and Further Reading
World Health Organization, International Federation of Gynecology and Obstetrics, & International Confederation of Midwives. (2025). Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage.
World Health Organization. (2026). Consolidated guidelines for the prevention, diagnosis and treatment of postpartum haemorrhage: Implementation guide.
World Health Organization. (2025). Bleeding after birth: Course on prevention, diagnosis and treatment of postpartum haemorrhage.
World Health Organization. Recommendations on assessment of postpartum blood loss and use of a treatment bundle for postpartum haemorrhage.
World Health Organization. Recommendation on tranexamic acid for the treatment of postpartum haemorrhage.
Gray, H. Anatomy of the Human Body. 20th US edition. Philadelphia: Lea & Febiger; 1918. Placental illustration used in this article is in the public domain.