Prevention of Postpartum Hemorrhage

1
Prevention of Postpartum Hemorrhage
Mary Ellen Stanton USAID CSHGP Conference Septembe
r 14, 2004
2
What is Postpartum Hemorrhage?

• Excessive bleeding
• More then 500ml (sever PPH gt1,000ml)
• During the third stage of labor
• Period between birth of the infant and delivery
  of the placenta

3
Third Stage of Labor Characteristics

• First Stage labor
• Second Stage full dilatation of cervix to
  delivery of the infant
• After childbirth the muscles of the uterus
  contract and placenta begins to separate from the
  uterine wall.
• The amount of blood lost depends on how quickly
  placenta separation and delivery occurs.
• If the uterus does not contract normally, the
  blood vessels at the placenta site do not
  adequately contract and severe bleeding results.
• Source Adapted from Harshad Songhvi,
  MNH/JHPIEGO, 2004

4
What are the causes of PPH?

• Delayed separation and delivery of the placenta
• Failure of the uterus to contract
• Other causes of bleeding
• Uterine rupture
• Tears
• Surgery (C-section, Episiotomy)

5
Why focus on preventing postpartum hemorrhage
(PPH)?

• Hemorrhage is the largest direct cause of
  maternal death 25-50 of all maternal deaths
• PPH is mostly unpredictable
• Most PPH is caused by uterine atony
• Active management at the third stage of labor can
  prevent 60 of postpartum hemorrhage
• Evidence-based, feasible, low-cost interventions
  exist
• Preventing PPH will significantly reduce maternal
  mortality and morbidity

6
What can be done to prevent PPH?

• Skilled birth attendants can implement
• active management of the third stage of labor
  through
• Administering a uterus-contracting drug, e.g.
  Oxytocin, Misoprostol within one minute of birth
• Applying controlled cord traction and counter
  traction to the uterus
• Massaging the fundus of the uterus through the
  abdomen
• Monitoring for further signs of bleeding

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Procedure for Active Management

• Palpate abdomen to rule out presence of another
  baby
• Within 1 minute of birth, give oxytocin 10 IU IM
• Await strong uterine contraction (2-3 minutes)
• Apply controlled cord traction while applying
  countertraction above pubic bone
• If placenta does not descend, stop traction and
  await next contraction
• After placental delivery, rub uterus fundus
  gently every 15 minutes for 2 hours to ascertain
  it is contracted

Source MCPC, WHO 2002
8
Benefits of Active Management of the Third Stage
of Labor

• Reduces incidence of PPH by 60
• Reduces the quantity of blood loss
• Reduces the use of blood transfusion

9
Maternal Outcomes of Active Management Trials
Source McMormick, Sanghvi, Kinzie, McIntosh,
IJGO2003.
10
Issue Two Methods of Third Stage Management

• Physiological (expectant) management.
• Uterotonics are not used.
• Placenta is delivered by gravity or maternal
  effort.
• Cord is clamped after delivery of the placenta.
• Active Management.
• Uterotonic (drug that contracts the uterus) is
  given as soon after birth of anterior shoulder as
  possible.
• As soon as the uterus contracts, placenta is
  delivered by controlled cord traction (CCT) with
  counter-traction on the uterus through the
  abdomen.
• Source Adapted from Harshad Songhvi,
  MNH/JHPIEGO, 2004

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Active Versus Expectant Management
Clinical estimation generally thought to be
underestimates by about 34-50
Oxytocin, ergometrine or both IM/IV
Prendiville, Elbourne, McDonald, The Cochrane
Library issue 3, 2003
12
Issue Requirements of Active Management of the
Third Stage of Labor

• Oxytocics and items needed for injection
• Requires a birth attendant with skills in
• observation
• giving an injection
• controlled cord traction
• Source Adapted from Harshad Songhvi,
  MNH/JHPIEGO, 2004

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Other Ways to Reduce Postpartum Blood Loss

• Prevent prolonged and obstructed labor
• Many providers dont use the partograph
• Avoid episiotomy
• Some providers perform episiotomy routinely

14
Uterotonic Drugs
15
Global Health Postpartum Hemorrhage Special
Initiative, 2003
ETHIOPIA 99 providers trained 24 service sites
National Coverage 6 55
16

• International Confederation of MidwivesInternatio
  nal Federation of Obstetricians Gynecologists
• Joint Statement - Management of the Third Stage
  of Labour to Prevent Postpartum Hemorrhage
• Active management of the third stage of labor
  should be offered to women
• Every attendant at birth needs to have the
  knowledge, skills and critical judgment and
  access to needed supplies and equipment

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Lessons from Targeted PPH Programs in Africa 1

• Focus on PPH prevention resonates with policy
  makers and providers it gets attention,
  energizes stakeholders and gets action
• Nevertheless, there may be resistance some need
  to be convinced
• It is important to identify receptivity and find
  champions
• There is great variation in the way providers
  practice even with up-to-date standards of care
• Letters/memos from MOH supportive of new PPH
  prevention policies are very helpful

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Lessons from Targeted PPH Programs in Africa 2

• Cold chain solutions differ by country
• Training to competency is shorter if the norm is
  some form of active vs. physiologic management of
  the third stage of labor so training models
  should vary
• Flexible non-dogmatic approaches are essential
  for clinical care as well as program elements
• With scarce financial resources, it is important
  to link with existing systems and resources

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Take-home Messages

• Postpartum Hemorrhage is the largest direct cause
  of maternal death
• Active management of the third stage of labor
• can prevent 60 of postpartum hemorrhage
• can be modified to the home birth setting
• Putting the spotlight on postpartum hemorrhage
  prevention will
• Reduce anemia
• Reduce emergencies
• Reduce need for transfusion
• Reduce maternal mortality