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 pull to the delivery. If the membranes gently the and and use a to any of that are at the placenta to be of it is If a of the maternal is or there are membranes with retained placenta and the maternal of the placenta. with permission, from Ref. the of the placenta. with permission, from Ref. after of the placenta, massage the of the uterus through the abdomen until the uterus is for a contracted uterus every minutes and repeat uterine massage as during the first 2 Ensure that the uterus does not after you stop uterine In all of the above the and to the woman and Continue to support and FIGO promotes the routine use of AMTSL as the evidence-based for the prevention of PPH and that every effort should be to ensure that AMTSL is used at every vaginal birth where there is a skilled birth FIGO that there may be where the or the of uterotonics may be owing to in the or it may be in a because it is not of the approved of or included in the national It is in this that the birth attendant must to care to prevent PPH in the of uterotonic drugs (Table The following reflects the best drawn from scientific literature and expert opinion, in the management of the third stage when uterotonics are not it is that at 600 of blood through the This is by and With of the placenta, these vessels are at the placenta is first by contraction of the that the blood vessels by and of their of placenta or blood that prevent effective contraction can hemostasis at the post can from uterine if the within and to the hemorrhage from the placenta is even in when may be the birth will be in a of for the and the infant on the to for and to encourage as soon as the and the In the where the birth attendant to care for another woman in to help to In this the over of to to the primary birth The cord is until it has or the placenta has been at the cord is or and A change in the and of the uterus; the uterus should be A of The cord at the vaginal The woman may or that to change may also in the and a to Most will be within 1 if this does not the attendant must If there is presence of at any time, to be and treatment of PPH the woman into an for the placenta to be or the woman to push or with to deliver the placenta should be only after of have been the placenta in hands or a If the membranes are to the birth attendant can by the placenta in 2 hands and gently it until the membranes are tension to the delivery. the attendant can the membranes gently and from the with an of the Controlled cord traction is not in the of uterotonic drugs or to of of the placenta because this can cause a uterine the every minutes during the first 30 every minutes for the next 30 and every 30 minutes for the next 2 of the uterine the for and the uterus is contracted (the uterus will be in the around the and should to the the and heart every minutes for the first 2 the placenta for with in prevention of PPH, some women will still require treatment for interventions and or and to basic or comprehensive obstetric care for treatment are to the of women. healthcare should be trained to prevent PPH, to the of PPH, and to be to treat PPH. should their and skills in on a through that and obstetric to in this are such as and It is also that obstetric in for care of PPH. such are for all and to the treatment of PPH, eclampsia, and other obstetric a birth can be life-saving skills obstetric first with is a and program that to access to basic life-saving and in and community members are such as uterine massage and that can be a in a comprehensive PPH prevention and treatment program to the of treatment is of hemorrhage and of treatment. the of care in basic of uterotonic drugs and of the products of comprehensive also blood 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 of the it to contract blood and blood through the uterus. It is a and effective first for treatment of PPH. For a is preferred because it provides a of the Uterine within 1 of of such as ergometrine, methylergometrine, and syntometrine cause the muscle of the and the lower uterus to contract the can be in different 0.2 or 0.5 the dose of ergometrine or methylergometrine is 0.2 mg 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 and effective treatment for PPH due to uterine in women have oxytocin as well as those 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 that misoprostol significantly reduces the need for additional interventions has been reported after μg of misoprostol is no about the and of the dose for treatment of PPH when given to women have 600 μg of misoprostol orally. is that misoprostol provides no when given with other uterotonic drugs for the treatment of PPH, and misoprostol as an treatment with oxytocin for PPH is not loss is more 500 mL or 2 after a vaginal or in excess of 1 L after a cesarean delivery. A is an by a in blood and may and Call for help and up an a and a Place the woman on a such as a delivery or with The birth attendant a hand on the of the uterus and gently until it is and This out blood and the uterus to the bladder. The woman may be to on or may need to be if uterotonic as soon as 10 IU IU in 1 L of at per Continue oxytocin IU in 1 L of at per until hemorrhage Ergometrine or methylergometrine if oxytocin is not available or if used 0.2 mg may from to 0.2 or 0.5 IM or can be given If 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 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 and ergometrine 0.5 1 ampoule IM cause Misoprostol oxytocin is not available or is not dose of μg For management of PPH, oxytocin should be preferred over ergometrine or methylergometrine a combination of ergometrine and such as If oxytocin is not available, or if the does not to oxytocin or ergometrine, an or misoprostol should be as treatment. If these are not available or if the does not to the a such as New should be as the third of if available of the uterus or of the uterus. with permission, from Ref. Use of an for the treatment of or to another of care, or for a to apply or uterine is the cause of PPH in the of the birth attendant should also retained products of the placenta vaginal or uterine uterine and to the woman and the need to do and that it may be Ensure hands and use if Place one hand in the and hand into a Place other hand on the of the uterus. the 2 hands to the uterus between applying to stop or the Keep the uterus until to (Fig. is a life-saving intervention when there is a postpartum the It may be considered at 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 of the and, to the is blood is from the in the and is the most at hand may have to out the to stop As soon as this is to a that the most is not up and interventions for a necessary blood is by the blood to the of and of with permission, from Ref. the to the if is and on the right of the woman. Place just above and to the of the woman's (the to the of the over the woman that the on the should be to the Do not use this is very the for a the and third of the right the and have been over the woman and the over the to it proper of the the must be no in the if the is the the and the until the is again. The should be on the as as the is to that the is at all may be used to stop at any It is a life-saving to the birth attendant should the woman during is a of such as and even or other that is to a and is into the uterus under This is to a and with sufficient mL to 500 to counter-pressure to stop the the care and the of the to pressure. oxytocin is for 24 If more If has and the woman is in mL to mL of the The is in for up to 24 it is over and If during the the and wait another 24 hours to a A may or stop in to or more cases without any need for that the (Fig. is effective in of cases and that this be of in the management of PPH the can if the is uterine or from another If the does not stop with it is to be from a or cause other uterine atony. of and and Both and are by available at The is a of and a and an a that over the uterus The by the the of the blood is to the and It also the of blood thus blood In trials in in and the was to significantly blood loss, reduce for atony, and maternal mortality and maternal associated with obstetric hemorrhage A of the for use to from to is currently in and The is applied to women to obstetric hemorrhage, with the and the other until the is closed (Fig. The woman can be to a if in such a in blood and The is not a woman will still need to have the of and The can remain in during any vaginal the can be for of the occurs only when the of is the woman has been for at 2 and blood loss is at the and minutes between and and the next through the of counter-pressure to the lower may by blood to the The is applied first to the (the with permission, from Ref. If does not stop treatment with other interventions uterine and or on the interventions should be The first is to stop the the and from approaches should be if these do not to more and uterine, and may be but in cases of life-threatening or should be without about these is available in of A of Postpartum a to Management and The of this can be for for low-resource settings for and treatment of PPH and blood loss oxytocin in and and the are still under for use in low-resource settings but may especially for women living from skilled care. the has been controlled and the woman is over the next hours is that the woman is a blood for a blood of at and a heart for a under that the uterus is and well and blood to a or other under the woman's and to extend and at the for about The blood will in the of the pubic of pressure. of the woman has should be given at a of 1 L in If access is not available or not give by if to or by of mL in 1 blood transfusion, including the of blood and other that have been The is as of the of the woman's and any interventions the presence of a skilled attendant until is controlled and the woman's is and as by the woman's the of of blood loss with a or other on birth delivery for treatment of PPH in uterine and the the most and effective of and the skills by birth attendants and for community to PPH. PPH can be at the community Disseminate this clinical guideline to all national associations of and and to implement the guideline at the and community support for this statement from agencies in the of maternal and neonatal health care, such as and that this guideline a to be by health policy makers and that this on the prevention of PPH be into the of and mother birth in the will be AMTSL for the prevention of PPH. skilled attendant will have in AMTSL and in for the treatment of PPH. health where will have of uterotonic and for the prevention and the treatment of PPH. are available in that comprehensive health care and of are trained in such as uterine and The of drugs and to prevent and treat PPH is by and countries are to the of Ensure and to healthcare to practice and the and of this intervention as a best practice healthcare birth attendants need to continue for a of need to be about management because they may practice in an where AMTSL may not be of all healthcare birth attendants in the practice of and management of PPH. and PPH prevention and treatment (Fig. the incidence of PPH and ensure at and national FIGO recommendations for the prevention and treatment of postpartum hemorrhage FIGO and its Committee members to the of and of and to the of this In the of Committee and are of The have no of

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