Prevention and treatment of postpartum hemorrhage in low-resource settings

This statement does not change the 2 previous statements on management of the third stage of labor (both available at http://www.figo.org/projects/prevent/pph): ICM/FIGO Joint Statement – Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage [1]; and ICM/FIGO Joint Statement – Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings [2]. The following guideline provides a comprehensive document regarding best practice for the prevention and treatment of postpartum hemorrhage (PPH) in low-resource settings. FIGO is actively contributing to the global effort to reduce maternal death and disability around the world. Its mission statement reflects a commitment to the promotion of health, human rights, and wellbeing of all women—especially those at greatest risk for death and disability associated with childbearing. FIGO promotes evidence-based interventions that, when applied with informed consent, can reduce the incidence of maternal morbidity and mortality. This statement reflects the best available evidence, drawn from scientific literature and expert opinion, on the prevention and treatment of PPH in low-resource settings. Approximately 30% (in some countries, over 50%) of direct maternal deaths worldwide are due to hemorrhage, mostly in the postpartum period [3]. Most maternal deaths due to PPH occur in low-income countries in settings (both hospital and community) where there are no birth attendants or where birth attendants lack the necessary skills or equipment to prevent and manage PPH and shock. The Millennium Development Goal of reducing the maternal mortality ratio by 75% by 2015 will remain beyond our reach unless we prioritize the prevention and treatment of PPH in low-resource areas [4]. FIGO endorses international recommendations that emphasize the provision of skilled birth attendants and improved obstetric services as central to efforts to reduce maternal and neonatal mortality. Such policies reflect what should be a basic right for every woman. Addressing PPH will require a combination of approaches to expand access to skilled care and, at the same time, extend life-saving interventions along a continuum of care from community to hospital [1,2]. The different settings where women deliver along this continuum require different approaches to PPH prevention and treatment. Despite Safe Motherhood activities since 1987, women are still dying in childbirth. Women living in low-resource settings are most vulnerable owing to concurrent disease, poverty, discrimination, and limited access to health care. FIGO has a central role to play in improving the capacity of national obstetric and midwifery associations to reduce maternal death and disability through safe, effective, feasible, and sustainable strategies to prevent and treat PPH. In turn, national obstetric and midwifery associations must lead the effort to implement the approaches described in this statement. Lobby governments to ensure healthcare for all women. Advocate for every woman to have a midwife, doctor, or other skilled attendant at birth. Disseminate this statement to all members through all available means, including publication in national newsletters or professional journals. Educate their members, other healthcare providers, policy makers, and the public about the approaches described in this statement and about the need for skilled care during childbirth. Address legislative and regulatory barriers that impede access to life-saving care, especially policy barriers that currently prohibit midwives and other birth attendants from administering uterotonic drugs. Ensure that all birth attendants have the necessary training—appropriate to the settings where they work—to administer uterotonic drugs safely and implement other approaches described in this statement, and ensure that uterotonics are available in sufficient quantity to meet the need. Call upon national regulatory agencies and policy makers to approve misoprostol for PPH prevention and treatment and to ensure that current best-evidence regimens are adopted. Incorporate the recommendations from this statement into current guidelines, competencies, and curricula. We also call upon funding agencies to help underwrite initiatives aimed at reducing PPH through the use of cost-effective, resource-appropriate interventions. Postpartum hemorrhage has been defined as blood loss in excess of 500 mL in a vaginal birth and in excess of 1 L in a cesarean delivery [5]. For clinical purposes, any blood loss that has the potential to produce hemodynamic instability should be considered a PPH. Clinical estimates of blood loss are often inaccurate. Primary (immediate) PPH occurs within the first 24 hours after delivery. Approximately 70% of immediate PPH cases are due to uterine atony. Atony of the uterus is defined as the failure of the uterus to contract adequately after the child is born. Secondary (late) PPH occurs between 24 hours after delivery of the infant and 6 weeks post partum. Most late PPH is due to retained products of conception, infection, or both. Tone: uterine atony, distended bladder. Trauma: uterine, cervical, or vaginal injury. Tissue: retained placenta or clots. Thrombin: pre-existing or acquired coagulopathy. The most common and important cause of PPH is uterine atony. Myometrial blood vessels pass between the muscle cells of the uterus; the primary mechanism of immediate hemostasis following delivery is myometrial contraction causing occlusion of uterine blood vessels—the so-called "living ligatures" of the uterus (Fig. 1). Muscle fibers of the uterus. Image reproduced, with permission, from Ref. [6]. Pregnant women may face life-threatening blood loss at the time of birth. Anemic women are more vulnerable to even moderate amounts of blood loss. Most PPH can be prevented. Different approaches may be employed, depending on the setting and the availability of skilled birth attendants and supplies. Data support the routine use of active management of the third stage of labor (AMTSL) by all skilled birth attendants, regardless of where they practice; AMTSL reduces the incidence of PPH, the quantity of blood loss, and the need for blood transfusion, and thus should be included in any program of intervention aimed at reducing death from PPH [7]. Administration of oxytocin (the preferred storage of oxytocin is refrigeration but it may be stored at temperatures up to 30 °C for up to 3 months without significant loss of potency) or another uterotonic drug within 1 minute after birth of the infant. Controlled cord traction. Uterine massage after delivery of the placenta. The Bristol [8] and Hinchingbrooke [9] studies compared active versus expectant (physiologic) management of the third stage of labor. Both studies clearly demonstrated that, when active management was applied, the incidence of PPH was significantly lower (5.9% with AMTSL vs 17.9% with expectant management [8]; and 6.8% with AMTSL vs 16.5% without [9]) (Table 1). Within 1 minute of delivery of the infant, palpate the abdomen to rule out the presence of an additional infant(s) and give oxytocin 10 IU intramuscularly (IM). Oxytocin is preferred over other uterotonic drugs because it is effective 2–3 minutes after injection, has minimal adverse effects, and can be used in all women. If oxytocin is not available, other uterotonics can be used, such as: ergometrine or methylergometrine 0.2 mg IM; syntometrine (a combination of oxytocin 5 IU and ergometrine 0.5 mg per ampoule IM [10]); or misoprostol 600 μg orally. Uterotonics require proper storage: Ergometrine or methylergometrine: 2–8 °C and protect from light and from freezing. Misoprostol: in aluminum blister pack, room temperature, in a closed container. Oxytocin: 15–30 °C, protect from freezing. Counseling on the adverse effects and contraindications of these drugs should be given. Warning! Do not give ergometrine, methylergometrine, or syntometrine (because it contains ergot alkaloids) to women with heart disease, pre-eclampsia, eclampsia, or high blood pressure. The 18th Expert Committee on the Selection and Use of Essential Medicines met in March 2011 and approved the addition of misoprostol for the prevention of PPH to the WHO Model List of Essential Medicines. It reported that misoprostol 600 μg administered orally can be used for the prevention of PPH where oxytocin is not available or cannot be safely used. Misoprostol should be administered by healthcare workers trained in its use during the third stage of labor, soon after birth of the infant, to reduce the occurrence of PPH [11,12]. The most common adverse effects are transient shivering and pyrexia. Education of women and birth attendants in the proper use of misoprostol is essential. Recent studies in Afghanistan and Nepal demonstrate that community-based distribution of misoprostol can be successfully implemented under government health services in a low-resource setting and, accompanied by education, can be a safe, acceptable, feasible, and effective way to prevent PPH [13,14]. A single dose of 600 μg administered orally (data from 2 trials comparing misoprostol with placebo show that misoprostol 600 μg given orally reduces PPH with or without controlled cord traction or use of uterine massage [8]). Controlled cord traction only when a skilled attendant is present at the birth. Uterine massage after delivery of the placenta, as appropriate. If the newborn is healthy, you can clamp the cord close to the perineum once cord pulsations stop or after approximately 2 minutes and hold the cord in one hand (immediate cord clamping may be necessary if the newborn requires resuscitation) [15,16]. Controlled cord traction. Place the other hand just above the woman's pubic bone and stabilize the uterus by applying counter-pressure during controlled cord traction. Keep slight tension on the cord and await a strong uterine contraction (2–3 minutes). With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta. Continue to apply counter-pressure to the uterus. If the placenta does not descend during 30–40 seconds of controlled cord traction, do not continue to pull on the cord: Gently hold the cord and wait until the uterus is well contracted again. With the next contraction, repeat controlled cord traction with counter-pressure. As the placenta delivers, hold the placenta in 2 hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery. If the membranes tear, gently examine the upper vagina and cervix wearing sterile/disinfected gloves and use a sponge forceps to remove any pieces of membrane that are present. Look carefully at the placenta to be sure none of it is missing (3, 4). If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placenta fragments and take appropriate action [17]. Examining the maternal side of the placenta. Reproduced, with permission, from Ref. [18]. Examining the fetal side of the placenta. Reproduced, with permission, from Ref. [19]. Immediately after expulsion of the placenta, massage the fundus of the uterus through the abdomen until the uterus is contracted. Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed during the first 2 hours. Ensure that the uterus does not become relaxed (soft) after you stop uterine massage. In all of the above actions, explain the procedures and actions to the woman and her family. Continue to provide support and reassurance throughout. FIGO promotes the routine use of AMTSL as the best, evidence-based approach for the prevention of PPH and emphasizes that every effort should be made to ensure that AMTSL is used at every vaginal birth where there is a skilled birth attendant. However, FIGO recognizes that there may be circumstances where the accessibility or the supply of uterotonics may be sporadic owing to interruptions in the supply chain, or it may be nonexistent in a country because it is not part of the approved list of essential medicines or included in the national guidelines/protocols. It is in this context that the birth attendant must know how to provide safe care (physiologic management) to prevent PPH in the absence of uterotonic drugs (Table 2). The following guide reflects the best practice, drawn from scientific literature and expert opinion, in the management of the third stage when uterotonics are not available. Near term, it is estimated that at least 600 mL/min of blood flows through the intervillous space. This flow is carried by spiral arteries and accompanying veins. With separation of the placenta, these vessels are avulsed. Hemostasis at the placenta site is achieved first by contraction of the myometrium that compresses the blood vessels followed by subsequent clotting and obliteration of their lumens. Thus, adhered pieces of placenta or large blood clots that prevent effective myometrium contraction can impair hemostasis at the implantation site. Fatal post partum haemorrhage can result from uterine atony despite normal coagulation however conversely, if the myometrium within and adjacent to the denuded implantation site contracts vigorously, fatal hemorrhage from the placenta implantation site is unlikely, even in circumstances when coagulation may be severely impaired. Ensures the birth will be conducted in a semi-sitting position and/or position of comfort for the mother, and places the infant on the mother's thorax/chest to provide skin-to-skin contact for warmth and to encourage breast feeding as soon as possible. Monitors both the mother's and the infant's vital signs (see below). In the case where the birth attendant needs to care for another woman in labor/delivery, she needs to find help to observe vital signs and/or bleeding. In this case, the person who takes over monitoring of vital signs needs to report back to the primary birth attendant. The cord is left alone until either it has stopped pulsating or the placenta has been delivered, at which point the cord is then clamped or tied and cut. A change in the size, shape, and position of the uterus; palpating the uterus should be avoided. A small gush of blood. The cord lengthens at the vaginal introitus. The woman may become uncomfortable, experience contractions, or feel that she wants to change position. She may also indicate heaviness in the vagina and a desire to bear down. Most placentas will be delivered within 1 hour; if this does not occur, the attendant must seek further assistance. If there is presence of excessive bleeding at any time, further assistance and/or transfer needs to be effected and treatment of PPH initiated. Encourages the woman into an upright position. Either waits for the placenta to be expelled spontaneously or encourages the woman to push or bear down with contractions to deliver the placenta (which should be encouraged only after signs of separation have been noted). Catches the placenta in cupped hands or a bowl. If the membranes are slow to deliver, the birth attendant can assist by holding the placenta in 2 hands and gently turning it until the membranes are twisted, then exerting gentle tension to complete the delivery. Alternatively, the attendant can grasp the membranes gently and ease them from the vagina with an up-and-down motion of the hand. Controlled cord traction is not recommended in the absence of uterotonic drugs or prior to signs of separation of the placenta because this can cause partial placental separation, a ruptured cord, excessive bleeding, and/or uterine inversion. Monitors the mother's vital signs every 5–10 minutes during the first 30 minutes, then every 15 minutes for the next 30 minutes, and then every 30 minutes for the next 2 hours. Blood pressure, pulse, level of the uterine fundus. Massages the uterus, looks for bleeding, and makes sure the uterus is contracted (the uterus will be found in the area around the navel and should feel firm to the touch). Observes the infant's color, respirations, and heart rate every 15 minutes for the first 2 hours. Examines the placenta for completeness. Even with major advances in prevention of PPH, some women will still require treatment for excessive bleeding. Timely interventions and appropriate access, or referral and transfer to basic or comprehensive emergency obstetric care (EmOC) facilities for treatment are essential to saving the lives of women. All healthcare professionals should be trained to prevent PPH, to recognize the early signs of PPH, and to be able to treat PPH. Healthcare professionals should refresh their knowledge and skills in emergency obstetrics on a regular basis through workshops that include didactic practical exercises and evaluations. There exist several in-service emergency obstetric courses developed to provide skill in this area, which are offered globally, such as ALSO, MOET, ALARM, MOREOB, and JHPIEGO. It is also recommended that obstetric units in hospitals introduce regular emergency drills for care of PPH. Once introduced, such emergency drills are invaluable for keeping all staff updated and alert to the emergency treatment of PPH, eclampsia, and other major obstetric emergencies. Anyone who attends a birth can be taught simple home-based life-saving skills (HBLSS). Community-based obstetric first aid with HBLSS is a family- and community-focused program that aims to increase access to basic life-saving measures and decrease delays in reaching referral facilities. Family and community members are taught techniques such as uterine fundal massage and emergency preparedness. Field tests suggest that HBLSS can be a useful adjunct in a comprehensive PPH prevention and treatment program [20]. Key to the effectiveness of treatment is early identification of hemorrhage and prompt initiation of treatment. Currently, the standard of care in basic EmOC facilities includes administration of intravenous (IV)/IM uterotonic drugs and manual removal of the placenta/retained products of conception; comprehensive EmOC facilities would also include blood transfusion and/or surgery FIGO the following drug regimens for the prevention and treatment of PPH (Fig. FIGO recommendations for drug regimens for the prevention and treatment of postpartum hemorrhage Oxytocin is the preferred It the of the upper of the it to contract blood vessels, and blood flow through the uterus. It is a safe and effective first for treatment of PPH. For a is preferred because it provides a flow of the Uterine within 1 of of administration such as ergometrine, methylergometrine, and syntometrine cause the muscle of both the upper and the lower uterus to contract the can be found in different 0.2 or 0.5 the recommended dose of ergometrine or methylergometrine is 0.2 mg which can be every hours for a of 5 in a are in women with disease, or because they can cause has that a single dose of misoprostol μg administered is a safe and effective treatment for PPH due to uterine atony in women who have oxytocin as well as those who have no oxytocin during the third stage of labor In without a skilled misoprostol may be the only available to PPH. on treatment of PPH found that misoprostol significantly reduces the need for additional interventions has been reported after μg of misoprostol There is no about the and of the dose for treatment of PPH when given to women who have 600 μg of misoprostol orally. There is that misoprostol provides no when given with other uterotonic drugs for the treatment of PPH, and misoprostol as an adjunct treatment with oxytocin for PPH is not recommended Blood loss is more 500 mL or 2 after a vaginal or in excess of 1 L after a cesarean delivery. A rate is an early followed by a in blood pressure, and may include and Call for help and up an a and a Place the woman on a such as a delivery or with her her The birth attendant places a hand on the fundus of the uterus and gently until it is firm and contracted. This out blood clots and the uterus to the bladder. The woman may be able to on her or she may need to be if available. uterotonic as soon as 10 IU IU in 1 L of normal at per Continue oxytocin IU in 1 L of at per until hemorrhage Ergometrine or methylergometrine if oxytocin is not available or if bleeding despite used 0.2 mg may from country to country 0.2 or 0.5 IM or can be given If bleeding 0.2 mg IM can be every hours for a of 5 in a Do not 1 mg 5 in a is a because of the risk of and/or with use of drugs used to treat or If there is no treatment available to the hemorrhage, use the Use it only if the of ergometrine the of oxytocin 5 units and ergometrine 0.5 1 ampoule IM cause Misoprostol oxytocin is not available or administration is not dose of μg For management of PPH, oxytocin should be preferred over ergometrine or methylergometrine a combination of ergometrine and and/or such as If oxytocin is not available, or if the bleeding does not to oxytocin or ergometrine, an or misoprostol should be offered as treatment. If these are not available or if the bleeding does not to the a such as New should be offered as the third of if available of the uterus or massage. of the uterus. Reproduced, with permission, from Ref. [17]. Use of an for the treatment of or transfer to another level of care, or for a to apply or uterine atony is the cause of PPH in the of the birth attendant should also retained products of the placenta vaginal or uterine uterine and coagulation clotting to the woman and the need to do and that it may be Ensure hands and use if possible. Place one hand in the vagina and hand into a Place other hand on the fundus of the uterus. the 2 hands to the uterus between applying to stop or slow the bleeding. Keep the uterus until able to (Fig. is a life-saving intervention when there is a postpartum bleeding, the It may be considered at several different during management of PPH. does not prevent or any of the other to be to the cause of PPH and blood is to the upper part of the and, to the vital Blood is blood is from reaching the bleeding area in the and is the most person at hand may have to out the to stop bleeding. As soon as this is to a that the most person is not tied up and interventions for a necessary blood is by the blood supply to the of and of with permission, from Ref. the to the if she is and on the right side of the woman. Place left just above and to the left of the woman's (the to the left of the over the woman that the on the should be able to feel the Do not use this is very exerting feel the for a the and third of the right hand. Once the and have been over the woman and increase the over the to it proper of the the There must be no in the if the is the become the left and the until the is again. The should be on the as as the is to sure that the is at all may be used to stop bleeding at any It is a simple life-saving skill to the birth attendant should the woman during is a made of such as and even or other that is to a and is then into the uterus under This is to a and with sufficient mL to 500 to counter-pressure to stop bleeding. the bleeding the care and the of the to pressure. oxytocin is for 24 hours. If bleeding more If bleeding has stopped and the woman is in remove mL to mL of the The is left in for up to 24 it is over and then If bleeding during the the and wait another 24 hours to a A may or stop bleeding in to or more cases without any further need for that the (Fig. is effective in of cases and that this simple be part of in the management of PPH the can if the bleeding is uterine or from another If the bleeding does not stop with it is to be from a or cause other uterine atony. of and [19]. and [19]. Both and are by available at The is a made of and a and an which includes a that over the uterus The by the vessels, the of the blood is to the and It also compresses the of blood vessels, thus blood flow In trials in facilities in and the was to significantly decrease blood loss, reduce emergency for atony, and decrease maternal mortality and maternal associated with obstetric hemorrhage A of the for use prior to from

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