• Controle convulsions with Magnesium Sulfate and/or Valium
  • Treat hypertension  
  • Deliver as rapidly and least traumatically as possible
      • Gestational age > 36 weeks
        • Urgent C/S
      • Gestational age < 36 weeks
        • Vaginal delivery
        • Induction and/or augmentation
          • Oxytocin
      • Vaginal delivery
      • Induction and/or augmentation
        • Misiprostol (Cytotec)
      • Destructive delivery if needed
  • Monitor vital signs closely
  • Continue antihypertensive treatment
  • Give regular doses of Magnesium Sulfate and/or Valium to prevent convulsions
  • Keep a syringe with 5-10 mg valium at bedside for immediate i.v. administration to control breakthrough convulsions
  • Watch out for signs of DIC (HELLP)



  • Atony of the uterus
  • Retained placental parts
  • Uterine rupture
  • Cervical and/or vaginal tears


  • Resuscitate with fluids
  • Massage the uterus manually
  • Apply firm and continuous pressure suprapubically with a closed fist for a full 10 minutes
    • Eyes on the watch!
  • Oxytocin infusion i.v. (preferred)
    • 30 units in 500 cc in Normal Saline
    • Infused over 2 to 4 hours
  • Misostoprol (Cytotec) tablets (if oxytocin is not available)
    • 2 – 4 tablets
      • Oral or rectal adminstration

Bleeding does not subside:

  • Bring patient to operating theater
  • Place legs in stirrups
  • Examine by intracavitary palpation
    • Placental parts present:
      • Remove
    • Uterine rupture present:
      • Laparotomy and repair
    • Neither retained placenta nor rupture of the uterus is present:
      • Pack firmly with gauze
      • Remove gauze pack in the operating theater after 24 hours
  • Transfuse one or two units of fresh blood

  • Perform hysterectomy as a last resort

Speculum Examination:

  • It is usually difficult and messy to identify bleeding site(s) from cervical tears
  • Attempts to suture the friable tissue results in further tearing and bleeding
  • Proceed directly with gauze packing in the absence of retained placental parts or ruptured uterus.


Early presentation:

Induce delivery of the retained placenta:

  • Nitroglycerine sublingually or nasally
  • Misostoprol (Cytotec)  
  • Oxytocin

Late presentation:

Manual or instrumental removal:

  • Introduce one hand into the uterus
  • Use the ulnar border of the intrauterine hand to dissect the placenta from the uterine wall
  • Apply contra pressure on outside of the uterus with other hand on abdomen
  • In case a closed or closing cervix does not allow the entire hand to enter the intrauterine cavity, two fingers are usually sufficient
    • If not, use instruments
    • A large sponge forceps (ring forceps) will do
Manual Removal of Placenta

Very late presentation with severe anemia and/or sepsis:

Supravaginal (subtotal) hysterectomy.