Al-Zirqi I, Vangen S, Forsen L, Stray-Pedersen B. Prevalence and risk factors of severe obstetric haemorrhage. BJOG: An International Journal of Obstetrics & Gynaecology. 2008; 115:(10)1265-72

Andersson O, Hellstrom-Westas LENA, Andersson D, Clausen J, Domellöf M. Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstet Gynecol Scand. 2012;

Bais JM, Eskes M, Pel M, Bonsel GJ, Bleker OP. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol. 2004; 115:(2)166-72

Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011; (11)

Begley CM, Guilliland K, Dixon L, Reilly M, Keegan C. Irish and New Zealand midwives' expertise in expectant management of the third stage of labour: The ‘MEET'study. Midwifery. 2012; 28:(6)733-9

Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-05. BJOG. 2007; 114:(11)1388-96

Brocklehurst P, Hardy P, Hollowell J Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;

Burns EE, Boulton MG, Cluett E, Cornelius VR, Smith LA. Characteristics, interventions, and outcomes of women who used a birthing pool: a prospective observational study. Birth. 2012; 39:(3)192-202

Bose P, Regan F, Paterson-Brown S. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2006; 113:(8)919-24

Buckland SS, Homer CS. Estimating blood loss after birth: using simulated clinical examples. Women Birth. 2007; 20:(2)85-8

Buckley SJ. Leaving well alone in the third stage of labour. Midwifery Today. 2011; 30-32

Cameron MJ, Robson SC. Vital statistics: an overview. A textbook of Postpartum hemorrhage.London: Sapiens Publishing; 2006

Cohain J. 3,4,5,10 minute protocol for third stage management. Birth. 2010; 37:(3)

Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery. 2013; 29:(7)759-64

Damodaran S, Khatri K, Mahmood TA, Monaghan SC. Waterbirths in Fife: A 6-year observational study. J Obstet Gynaecol. 2010; 30:(7)753-63

Davis D, Baddock S, Pairman S Risk of severe postpartum hemorrhage in low-risk childbearing women in New Zealand: Exploring the effect of place of birth and comparing third stage management of labor. Birth. 2012; 39:(2)98-105

Draycott T, Winter C, Crofts J, Barnfield S. PROMPT (Practical Obstetric Multiprofessional Training) Course Manual.London: RCOG Press; 2008

Driessen M, Bouvier-Colle MH, Dupont C Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. Obstet Gynecol. 2011; 117:(1)21-31

Fahy K, Hastie C, Bisits A, Marsh C, Smith L, Saxton A. Holistic physiological care compared with active management of the third stage of labour for women at low risk of postpartum haemorrhage: A cohort study. Women Birth. 2010; 23:(4)146-52

Fry J. Physiological third stage of labour: support it or lose it. British Journal of Midwifery. 2007; 15:(11)693-5

Lalonde A Prevention and treatment of postpartum hemorrhage in low-resource settings. Int J Gynaecol Obstet. 2012; 117:(2)108-18

Griffiths D, Howell C. Massive obstetric haemorrhage. In: Johanson R, Cox C, Grady K, Howell C (eds). London: RCOG Press; 2003

Harper B. Waterbirth basics: from newborn breathing to hospital protocols. Midwifery Today Int Midwife. 2000; (54)9-15

Harris T. Changing the focus for the third stage of labour. British Journal of Midwifery. 2001; 9:(1)7-12

Karavolos S, Al-Habib A, Madgwick K, Fakokunde A, Okolo S, Yoong W. Improving the accuracy of estimated blood loss at obstetric haemorrhage using clinical reconstructions. BJOG. 2007; 114:(1)117-8

Kirkham M. Birth centres: a social model for maternity care. Books for Midwives. 2003;

Knight M, Callaghan W, Berg C Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009; 9

Lilley G, Burkett-St-Laurent D, Precious E Measurement of blood loss during postpartum haemorrhage predicts fall in haemoglobin. Int J Obstet Anesth. 2015; 24:(1)8-14

Mavrides E, Allard S, Chandraharan E Prevention and management of postpartum haemorrhage. BJOG. 2016; 124:e106-e149

Maslovitz S, Barkai G, Lessing JB, Ziv A, Many A. Improved accuracy of postpartum blood loss estimation as assessed by simulation. Acta Obstet Gynecol Scand. 2008; 87:(9)929-34

Mercer JS. Current best evidence: a review of the literature on umbilical cord clamping. J Midwifery Womens Health. 2001; 46:(6)402-14

National Institute for Health and Care Excellence. Principle for Best Practice in Clinical Audit. 2002. (accessed 12 December 2017)

National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies [GC190]. 2014. (accessed 23 October 2017)

Norman J. Haemorrhage, Saving mother's lives. Reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011; 118:1-203

Midwives rules and standards.London: NMC; 2012

Otigbah CM, Dhanjal MK, Harmsworth G, Chard T. A retrospective comparison of water births and conventional vaginal deliveries. Eur J Obstet Gynecol Reprod Biol. 2000; 91:(1)15-20

Royal College of Midwives. Evidence Based Guidelines for Midwifery-Led Care in Labour: Third stage of labour. 2012. (accessed 5 December 2017)

Schorn MN. Measurement of blood loss: review of the literature. J Midwifery Womens Health. 2010; 55:(1)20-7

Winter C, Macfarlane A, Deneux-Tharaux C Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe. BJOG. 2007; 114:845-54

Care in Normal Birth: A Practical Guide: Report of a Technical Working Group.Geneva: WHO; 1996

WHO recommendations for the prevention and treatment of postpartum haemorrhage.Geneva: WHO; 2012

Yoong W, Karavolos S, Damodaram M Observer accuracy and reproducibility of visual estimation of blood loss in obstetrics: how accurate and consistent are health-care professionals?. Arch Gynecol Obstet. 2010; 281:(2)207-13

Improving practice and reducing significant postpartum haemorrhage through audit

02 January 2018
Volume 26 · Issue 1



In 2012, there was a concern about the incidence of postpartum haemorrhage (PPH) and the prevalence of physiological third stage management at a midwife-led birthing unit.


To determine whether midwives considered risk factors for PPH and provided informed choice when planning third stage management, and whether there was any relationship between third stage management and PPH.


A cohort of 57 women who experienced a PPH >500mL was identified, and their records audited. Findings were shared with the midwifery team, who generated solutions. These were implemented in 2013/14 and a re-audit was conducted in 2015.


The re-audit showed that the incidence of PPH >1000mL had decreased. As a result of improvements in risk assessment and informed consent surrounding third stage management, no women were inappropriately managed physiologically during the third stage. Using an agreed pathway and PPH boxes was associated with an improvement in the quality and speed of treatment.


The audit cycle was used effectively to review practice. It identified deficiencies and helped the midwifery team to generate solutions, which resulted in improved outcomes for women.

The midwife-led birthing unit (MLBU) at Norfolk and Norwich University NHS Foundation Trust provides care for approximately 1000 healthy, low-risk women annually. Evidence has indicated that these women were more likely to experience normal birth with fewer interventions in a MLBU rather than in a consultant-led unit, with no changes as to the safety of mothers or babies (Brocklehurst et al, 2011). A risk assessment tool (Appendix 1), based on the best available evidence, is applied on admission to identify women as low-risk and to ensure that choices can be supported.

The MLBU philosophy is to support women's birth choices, focusing on normal physiological processes and avoiding unnecessary medical interventions. In 2012, 41% of women who gave birth at an MLBU experienced a physiological third stage of labour. The third stage lasts from the birth of the baby to the expulsion of the placenta and membranes (National Institute for Health and Care Excellence (NICE), 2014). ‘Physiological management’ awaits spontaneous separation and expulsion of the placenta: no drugs are routinely administered, the umbilical cord is not clamped or cut before the placenta has separated from the uterus and the placenta is birthed by maternal effort (NICE, 2014). Embracing physiology avoids disturbing initial mother-infant interactions important in bonding (Buckley, 2011) and allows physiological transfusion of blood to the neonate, reducing neonatal anaemia caused by under-transfusion (Harris, 2001; Mercer, 2001; Fry 2007, Andersson et al, 2012).

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • New content and clinical newsletter updates each month