Postpartum haemorrhage: prevention in the third stage, estimating blood loss, fundal massage and Colombia's Código Rojo
- Safe practice
Postpartum bleeding is a leading cause of maternal death. The nurse watches uterus and bleeding, measures the loss and has a fixed role in the Código Rojo.
What it is
Postpartum haemorrhage is a leading cause of maternal death, and about two thirds of cases have no known risk factor, so prevention applies to every woman. The nurse helps with active management of the third stage, checks uterine tone and bleeding every 15 minutes in the first 2 hours and measures blood loss instead of guessing it. When bleeding is excessive, Colombia uses the Código Rojo: an organised team response with a time sequence and a role for each person. Drugs, fluids and blood products are given according to the order and the institutional protocol; this page gives the checks, not the amounts.
What it requires
- Causes, the 4 T (Bogotá guide): tone (uterine atony, about 70 %), trauma (tears, about 20 %), tissue (retained placenta, about 9 %) and thrombin (clotting problems, about 1 %).
- Risk factors include placenta praevia, abruption, caesarean, chorioamnionitis, twins, a very large baby, polyhydramnios, several previous births, instrumental birth, induction, obesity and a previous haemorrhage.
- WHO 2025 first-response bundle (MOTIVE): uterine massage, oxytocic drugs, tranexamic acid, IV fluids, examination of the genital tract and escalation if bleeding continues.
- WHO 2025 asks staff to act earlier when blood loss comes with abnormal vital signs.
- Res. 3280: an emergency obstetric kit and a non-pneumatic anti-shock garment must be available where births are attended.
Components
- Minute 0, activation: the alarm reaches the whole team; consciousness, perfusion, pulse, blood pressure and oximetry are assessed and shock is classified.
- Minutes 1 to 20, resuscitation: oxygen, two large IV lines, blood samples, warm fluids, bladder catheter, bimanual massage by the doctor and first-line drugs.
- Minutes 20 to 60, stabilisation: keep circulating volume, constant massage for atony, further drugs and surgery if she stays unstable.
- After 60 minutes: advanced care, blood products and an intermediate or intensive care bed.
How it is applied (and why)
- After the birth, palpate the uterus and look at the bleeding every 15 minutes for 2 hours — most haemorrhages happen in this time.
- Measure the loss with a collector bag, calibrated drape or by weighing pads and sheets, per protocol — guessing underestimates it.
- If the uterus is soft, massage it through the abdomen until it is firm and bleeding eases, and call — massage pushes out clots.
- Check the bladder and empty it as ordered — a full bladder is one thing to check when the uterus bleeds.
- If bleeding is excessive or a sign of shock appears, shout for help and activate the Código Rojo — this alerts the whole team at once.
- Raise her legs, give oxygen as the protocol says and keep her warm with blankets and warmed fluids — hypothermia worsens bleeding.
- Help place two large-bore IV lines (gauge 14 or 16) and take the ordered samples — fluids and blood go in fast through large lines.
- Nurse in charge (Bogotá guide): on her left; gives and records first-line drugs and ordered blood products, places the catheter, supervises.
- Assistants: one places the second line and runs fluids; one labels tubes, writes orders and logs times; one brings the kit, calls, warms, gets blood.
- Once stable, check bleeding, uterine tone and perfusion every 15 minutes for 4 hours — bleeding can return.
In nursing practice
- Heavy bleeding with a contracted uterus suggests a tear; a uterus that cannot be felt on the abdomen suggests uterine inversion (WHO).
- WHO: sustained uterine massage is not used as routine prevention when the woman has already had prophylactic oxytocin; massage is for atony.
- During transfer: vital signs every 15 to 30 minutes, urine output every hour, uterine tone and massage every 15 minutes, and two working IV lines (Res. 3280).
- After a haemorrhage, teach self-care and the signs of anaemia and infection, and make sure she has follow-up.
Common mistakes
- Judging the loss by eye or only by the pad in place.
- Waiting for low blood pressure to act: pulse, perfusion and consciousness change first.
- Everyone doing the same task in the Código Rojo while another task is left undone.
- Using cold fluids and leaving the woman uncovered.
Test yourself
Think of the answer, then tap the question to see it.
Which are the 4 T of postpartum haemorrhage?
Tone, trauma, tissue and thrombin.
How is shock classified in Código Rojo?
By the most abnormal of consciousness, perfusion, pulse and systolic pressure.
How is the shock index calculated, and which value triggers immediate transfusion in the Bogotá guide?
Heart rate divided by systolic pressure; a value above 1.
Who activates the Código Rojo?
The first person who sees the bleeding woman.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Resolución 3280 de 2018: lineamientos técnicos y operativos de la Ruta de Promoción y Mantenimiento de la Salud y de la Ruta Materno Perinatal (Ministerio de Salud y Protección Social de Colombia, 2018); Guía de hemorragia posparto: Código Rojo (Secretaría Distrital de Salud de Bogotá, 2014); Global health agencies issue new recommendations to help end deaths from postpartum haemorrhage (World Health Organization, 2025); Managing complications in pregnancy and childbirth: a guide for midwives and doctors, 2nd ed. (World Health Organization, 2017).
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Representative model, for educational purposes only.