Uterine atony: uterus soft and relaxed Placenta not delivered Treat for whole retained placenta If whole placenta still retained ■ Oxytocin ■ Manual removal with prophylactic antibiotics ■ Controlled cord traction ■ Intraumbilical vein injection (if no bleeding) Placenta delivered incomplete Treat for retained placenta fragments If bleeding continues ■ Oxytocin ■ Manage as uterine atony ■ Manual exploration to remove fragments ■ Gentle curettage or aspiration Be ready at all times to transfer to a higher-level facility if the Lower genital tract trauma: Treat for lower genital tract trauma If bleeding continues patient is not responding to the excessive bleeding or shock ■ Repair of tears ■ Tranexamic acid ■ treatment or a treatment cannot contracted uterus Evacuation and repair of haematoma be administered at your facility. Uterine rupture or dehiscence: Treat for uterine rupture or dehiscence If bleeding continues excessive bleeding or shock ■ Laparotomy for primary repair of uterus ■ Tranexamic acid Start intravenous oxytocin infusion ■ Hysterectomy if repair fails and consider: • uterine massage; • bimanual uterine compression; Uterine inversion: Treat for uterine inversion If laparotomy correction not successful • external aortic compression; and uterine fundus not felt ■ Immediate manual replacement ■ Hysterectomy • balloon or condom tamponade. abdominally or visible in vagina ■ Hydrostatic correction ■ Manual reverse inversion Transfer with ongoing intravenous (use general anaesthesia or wait for effect uterotonic infusion. Accompanying of any uterotonic to wear off) attendant should rub the woman’s abdomen continuously and, if necessary, apply mechanical Clotting disorder: Treat for clotting disorder compression. bleeding in the absence of ■ Treat as necessary with blood products above conditions Oxytocin – treatment of choice Ergometrine – if oxytocin is unavailable or bleeding continues despite Prostaglandins – if oxytocin or ergometrine are unavailable or bleeding Tranexamic acid oxytocin continues despite oxytocin and ergometrine • 20–40 IU in 1 litre of intravenous fluid at 60 drops • 0.2 mg intramuscularly or • If required, administer 0.2 mg Misoprostol: Prostaglandin F2α: • 1 g intravenously (taking 1 minute per minute, and 10 IU intramuscularly intravenously (slowly), intramuscularly or intravenously • 200–800 µg sublingually • 0.25 mg intramuscularly to administer) • Continue oxytocin infusion (20 IU in 1 litre of or Syntometrine® 1 ml (slowly) every 4 hours • Do not exceed 800 µg • Repeat as needed every 15 minutes 0.25 mg • If bleeding continues, intravenous fluid at 40 drops per minute) until • After 15 minutes, repeat • Do not exceed 1 mg (or five 0.2 mg intramuscularly repeat 1 g after 30 minutes haemorrhage stops ergometrine 0.2 mg intramuscularly doses) • Do not exceed 2 mg (or eight 0.25 mg doses).