OG16.1-3 | Third Stage Complications — Glossary

Incomplete inversion: the uterine fundus dimples inward but does not pass through the cervical os; diagnosed by fundal dimpling on abdominal palpation.

Complete inversion: the inverted fundus passes through the cervical os and lies in the vaginal canal but does not protrude beyond the introitus.

Prolapsed inversion: the inverted uterine fundus protrudes beyond the vaginal introitus and is visible as a smooth, dark-red mass at the perineum.

Systematic mnemonic for PPH causes: Tone (uterine atony), Tissue (retained placenta/membranes), Trauma (genital tract lacerations, uterine rupture/inversion), Thrombin (coagulation disorders/DIC).

Total inversion: both the uterus and the vaginal walls are inverted and visible externally; the most severe degree.

Evidence-based protocol comprising uterotonic administration (oxytocin 10 IU IM) within 1 minute of delivery, controlled cord traction, and uterine massage; reduces PPH incidence by approximately 40%.

Uterine inversion occurring within 24 hours of delivery; the most common and most dangerous timing; the cervix is still dilated and manual reduction (Johnson manoeuvre) is usually feasible.

Emergency bridge technique for catastrophic PPH: a closed fist pressed posteriorly just above the umbilicus compresses the abdominal aorta against the vertebral column, reducing pelvic perfusion pressure; confirmed by reduced femoral pulse.

Physiological mechanism of NASG action: circumferential external compression of lower limb venous capacitance vessels mobilises 500–1000 mL of peripheral blood into the central circulation, raising cardiac preload and mean arterial pressure.

Brace suture technique encircling the uterus to compress the uterine cavity mechanically; applied when manual compression temporarily controls atonic PPH at open caesarean section; preserves the uterus.

Intrauterine balloon catheter filled with 300–500 mL warm saline to apply hydrostatic tamponade to the placental bed; the 'tamponade test' assesses whether surgical intervention can be avoided.

Mechanical haemostatic technique for atonic PPH: one hand placed vaginally in the anterior fornix elevates the uterus anteriorly, the other hand presses the fundus posteriorly from the abdominal wall, compressing the uterine body and placental bed vessels between them.

Method for controlled cord traction in AMTSL: the suprapubic (external) hand pushes the contracted uterus upward while gentle traction is applied to the umbilical cord, preventing the fundus from following the cord inward.

Synthetic prostaglandin F₂α analogue; potent uterotonic given 250 µg IM (maximum 8 doses); absolutely contraindicated in asthma due to bronchoconstriction.

Uterine inversion persisting for more than 4 weeks; the cervix has contracted firmly; surgical reduction is usually required; may present with vaginal discharge, irregular bleeding, or chronic anaemia rather than acute collapse.

Improvised intrauterine balloon assembled from a Foley catheter with a sterile condom tied to its tip; inflated with 300–500 mL warm saline; validated as equivalent to the Bakri balloon in RCTs in low-resource settings.

In uterine inversion, the contracted lower uterine segment or cervix that tightens around the inverted fundus, making manual reduction impossible without tocolysis or surgical incision.

Application of fundal pressure to deliver the placenta; when applied forcefully or prematurely (before placental separation), it is a recognised iatrogenic cause of uterine inversion and should not be used as a primary third-stage technique.

Blood product derived from thawing FFP, rich in fibrinogen, Factor VIII, and von Willebrand factor; specifically indicated when fibrinogen falls below 2 g/dL in PPH-DIC.

Systemic activation of coagulation with consumption of clotting factors and platelets, leading to simultaneous thrombosis and bleeding; in obstetrics triggered by placental abruption, amniotic fluid embolism, PPH, and sepsis.

Ergot alkaloid uterotonic producing sustained tonic uterine contraction via α-adrenergic and 5-HT receptor activation; raises blood pressure; absolutely contraindicated in hypertension and pre-eclampsia.

Approach to massive haemorrhage combining balanced blood product transfusion (PRBC:FFP:Platelets 1:1:1), tranexamic acid, and correction of the lethal triad (hypothermia, acidosis, coagulopathy); mechanical techniques serve as bridges to haemostatic resuscitation.

Surgical technique for uterine inversion when the Huntington procedure fails: a posterior midline incision of the cervical constriction ring is made abdominally to widen the ring, after which Huntington-style traction reduces the fundus; the incision is then repaired.

Surgical technique for uterine inversion reduction via laparotomy: Allis forceps are applied to the round ligaments and cup of inversion, and stepwise upward traction combined with vaginal assistance reduces the fundus.

Application of hydrostatic pressure from within the uterine cavity using an inflated balloon (Bakri balloon or condom catheter, 300–500 mL warm saline) to compress the placental bed spiral arteries and achieve haemostasis.

Manual technique for reducing acute uterine inversion: the inverted fundus is cupped in the palm with fingers pointing toward the posterior fornix and sustained upward pressure is applied along the vaginal axis toward the umbilicus until the fundus returns to its normal position.

Descriptive term for the oblique and figure-of-eight myometrial fibres that compress the spiral arteries at the placental bed when the uterus contracts after delivery; failure of this mechanism causes atonic PPH.

Structured haemostatic resuscitation protocol activating balanced blood product delivery at a ratio of PRBC:FFP:Platelets = 1:1:1 to prevent dilutional coagulopathy in massive obstetric haemorrhage.

Synthetic prostaglandin E₁ analogue; recommended PPH alternative at 800 µg sublingual or rectal where parenteral oxytocin is unavailable; thermostable, no refrigeration required.

Compression garment applied to lower limbs and abdomen to autotransfuse peripheral blood centrally; reduces blood loss by 40–50% and serves as a bridge to surgical intervention or during transfer.

Result of intrauterine balloon tamponade in which significant bleeding continues after balloon inflation; indicates that tamponade alone cannot control haemorrhage and surgical intervention (B-Lynch, devascularisation, hysterectomy) is required without delay.

Neoprene circumferential compression suit applied distal to proximal (legs → thighs → pelvis → abdomen) to autotransfuse peripheral blood centrally and reduce pelvic perfusion; reduces PPH blood loss by 40–50%; applied without an inflation pump.

Synthetic nonapeptide analogue of the hypothalamic hormone; first-line uterotonic for AMTSL and PPH treatment; acts on myometrial oxytocin receptors; given 10 IU IM or by IV infusion; no absolute contraindications at standard doses.

Abnormal placentation (accreta, increta, percreta) where chorionic villi invade the myometrium to varying depths; prevents physiological placental separation; major cause of intractable PPH, particularly after previous uterine surgery.

Result of intrauterine balloon tamponade in which bleeding ceases after balloon inflation; indicates haemostasis is achievable without surgical intervention; the balloon is maintained for 12–24 hours then deflated gradually.

Blood loss ≥500 mL after vaginal delivery or ≥1000 mL after caesarean section, occurring within 24 hours (primary) or 24 hours to 12 weeks (secondary) of delivery, or any blood loss causing haemodynamic instability.

Ratio of heart rate to systolic blood pressure (HR ÷ SBP); >1.0 indicates haemodynamic compromise in obstetric haemorrhage; >1.7 signals life-threatening haemorrhage requiring immediate unmatched blood transfusion.

Diagnostic test of haemostatic adequacy after intrauterine balloon inflation: positive = bleeding from vagina and drainage port ceases within 15–20 minutes (surgical intervention less likely needed); negative = continued significant bleeding (proceed to surgery).

Pharmacological relaxation of the contracted cervical ring to facilitate manual reduction of uterine inversion; agents include GTN 100–200 µg IV, terbutaline 0.25 mg SC, or MgSO₄ 4–6 g IV.

Antifibrinolytic agent inhibiting plasminogen activation; 1 g IV within 3 hours of PPH onset reduces all-cause mortality (WOMAN trial 2017); adjunct to uterotonics, not a substitute.

Principal blood supply to the uterus, arising from the anterior division of the internal iliac artery on each side; a target for surgical ligation in stepwise uterine devascularisation for PPH.

Failure of the myometrium to contract and retract after placental delivery, leaving spiral arteries at the placental bed patent; responsible for 70–80% of primary PPH cases.

Obstetric emergency in which the uterine fundus collapses inward through the uterine cavity toward or through the cervix, classified by degree (1st–4th) and timing (acute/subacute/chronic).

Neurogenic cardiovascular collapse caused by massive parasympathetic discharge from traction on the peritoneum, broad ligament, and round ligaments during uterine inversion; characterised by bradycardia and hypotension disproportionate to blood loss.