This chapter includes significant literature underpinning the causes, initial and advanced management, investigation and aftercare required when a woman loses more than 500mL of blood at the time of birth. This common, but life-threatening, obstetric emergency is described including recent pivotal publications in the field. Key learning points: Understand prevention, causes and treatment of major postpartum haemorrhage (PPH). Understand the effect of antenatal anaemia on PPH. Early recognition of PPH and prompt systematic management remain cornerstones of effective care. Always aim to measure or weigh, rather than estimate, blood loss, where possible. Prioritise early fluid resuscitation: intravenous fluid (and blood transfusion if required) should not be delayed because of false reassurance from a single haemoglobin result. Escalate to senior team members of the multi-professional team. Give tranexamic acid early, alongside uterotonics. Consider the use of cell salvage and point-of-care clotting assessment. Consider early hysterectomy, if medical and surgical interventions are ineffective. Document details of management and post PPH care accurately and clearly.

Repetitive, intense or sustained uterine contractions constitute the predominant cause of hypoxic stress to human fetuses during labour. This is because contraction of the myometrial fibres compresses the branches of the uterine arteries and the spiral arterioles supplying the placental bed, which results in a transient cessation of oxygen delivery to the placenta. Compression of the umbilical cord loops between the uterine wall and the fetal body parts during uterine contractions may lead to the occlusion of blood vessels within the umbilical cord. This may lead to impaired transfer of oxygen and nutrients to the fetus and removal of carbon dioxide and metabolic by-products from the fetus. Excessive frequency of uterine contractions (uterine tachysystole), increased intensity of the uterine contractions (hypertonus), and increased duration (tocospanus) can independently contribute to fetal hypoxic stress, increasing the likelihood of hypoxic–ischaemic encephalopathy (HIE) and its long-term sequalae, and perinatal deaths. Therefore, a combination of uterine tachysystole, hypertonus and tocospanus may have disastrous consequences for the fetus, as well as the mother.

The third stage of labour is defined as the time from the birth to the delivery of the placenta, which in the majority of cases is uneventful but unexpected complications can arise that can lead to significant morbidity and mortality. This chapter describes the normal physiology and how haemostasis is achieved. Expectant (physiological) and active management are described. Details of the dose and route of administration of the uterotonics are discussed. The importance of inspection of the perineum, delayed cord clamping and the correct technique for controlled cord traction is outlined. Pathological conditions such as retained placenta, its causes, management and mismanagement are discussed. The chapter concludes describing the benefits of immediate provision of postpartum long-acting reversible contraception.

Postpartum hemorrhage (PPH) is the most common cause of maternal mortality worldwide and uterine atony is the most common cause of PPH. Timely diagnosis and prompt intervention are crucial to manage this potentially life-threatening condition. Early blood product replacement and interventions aimed at reducing bleeding and restoring uterine contractility are key components of treatment. A progression of medical therapy, uterine compression, and surgical intervention may be needed to resolve the PPH. A standardized approach to management of PPH due to atony can help improve outcomes. The Alliance for Innovation on Maternal Health provides information regarding care bundles addressing a multidisciplinary approach to treating PPH and may be a resource for labor and delivery units in their efforts to improve care.