PPH Prevention and Management
at Health Facilities
Jeffrey M. Smith
Asia Regional Technical Director
AME Regional Meeting
Bangkok
March 2010
OBJECTIVES
 Describe global guidance on postpartum hemorrhage
prevention and management in health care facilities
 Review specifically the provision of Active Management
of Third Stage of Labor
 Discuss policy and
situational
considerations for the
implementation of
PPH reduction
strategies
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A Pause for Epidemiology
Obstetric-Related Deaths
per year
 Maternal Deaths: 536,000
 Neonatal Deaths: 3.4
million (most obstetrical)
 Stillbirths: 4 million (most
Infectious Disease Deaths
per year
 HIV Deaths: 2 million
 TB Deaths: 1.6 million
 Malaria Deaths: 1.3
million
obstetrical)
TOTAL Obstetrical Deaths
per year = 6.5 million
TOTAL Infectious Disease
Deaths per year = 5 million
3
Distribution of Maternal Deaths
Asia Specific Distribution
Unclassified
6%
Other Ind irect
12%
Haem o rrhage
31%
Other
Direct
2%
Haemorrhage
Hypertensive
Sepsis
Em bo lism
0%
Abortion
Ecto p ic
Preg
0%
Obstructed Labor
Anaemia
Ectopic Preg
Embolism
A naem ia
13%
Other Direct
Hyp ertensive
9%
Other Indirect
Unclassified
Obstructed Labo r
9%
Abortion
6%
Sep sis
12%
Khan, et al; WHO Analysis of Causes of Maternal
Deaths; Lancet April 2006
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Recommendations for PREVENTION of
PPH in Health Care Facilities
 Active management of
third stage of labour
(AMTSL) should be
offered by all skilled
attendants at every birth
to prevent postpartum
haemorrhage (PPH).
 Oxytocin is the
uterotonic of choice for
prevention of PPH.
5
Evidence for AMTSL
 AMTSL prevents PPH by over 60% (RR: 0.38,
95% CI 0.32-0.46) and therefore should be
offered by all skilled birth attendants at every
childbirth.
 Oxytocin is the preferred drug because

It is effective in 2-3 minutes after injection,
 has minimal side effects,
 can be used in all women, and
 is more stable in storage than ergometrine.
 Oxytocin is the better choice than ergometrine
or misoprostol, when all are available
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Integrating the Steps for
AMTSL
1. Give oxytocin immediately:


Within 1 minute of birth of baby
Oxytocin 10 units IM
2. Deliver the placenta by
controlled cord traction


Wait until cord pulsations cease
or 2-3 minutes
Delayed cord clamping reduces
newborn and infant anemia
3. Massage the uterus

Ensure uterine tone
Integration of AMTSL with:
 Immediate newborn care
 Support for breastfeeding
 Immediate postplacental
insertion of IUCD
 Obstetrical emergencies
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Integrated Steps for AMTSL and Immediate Newborn
Care: Skilled Birth Attendant With Oxytocin
Deb Armbruster and Sushie Engelbrecht,
POPPHI Project
AMTSL and Breastfeeding
 Bolus of oxytocic is necessary to achieve the
strong contraction that helps separate placenta
and establish good uterine tone
 AMTSL helps achieve uterine tone
 Ongoing breastfeeding helps maintain uterine
tone
 Breastfeeding is an essential maternal/newborn
care practice, but not sufficient for AMTSL
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AMTSL: A NECESSARY Part of Care for
Normal Birth
 Every birth should be attended by a skilled
attendant
 All national policies on skilled care during
childbirth must include the provision of AMTSL
 Every skilled birth attendant should be
allowed to provide AMTSL
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AMTSL: Who, How, Where?
Countries need to do an analysis of
 People who attend births and are
called “skilled attendants”
 Permission and ability of those
cadre to perform AMTSL
 Logistic systems that support
provision of oxytocin
 Policies and service delivery
frameworks that clearly state at which
levels of the health care system
skilled care, including AMTSL, can be
provided.
 HMIS/monitoring systems that track
the implementation of AMTSL
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PPH: Other causes and
other prevention strategies
Causes




Retained placenta
Retained placental fragments
Episiotomy and lacerations
Uterine rupture
Prevention Strategies





Partograph
Avoid unnecessary episiotomy
Inspection of placenta
Inspection for lacerations
Postpartum monitoring for
minimum of 6 hours
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Midwives and BEOC
Afghanistan
Yes
Bangladesh
Yes
Cambodia
Partial
East Timor
Partial
Egypt
Partial
India
Partial
Indonesia
Partial
Nepal
Partial
Pakistan
Partial
Palestine
Partial
Philippines
Partial
Vietnam
Partial
Yemen
Partial
Do policies allow midwives
to provide a complete set of
BEOC interventions?
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Align People, Services and Systems
Major
Obstetrical
Killers
Global
Definition
of
Basic
EOC
Policies
and Clinical
Guidelines
Midwifery Job
Description,
Competencies
Capabilities and
Environment
Consistency and Alignment
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Oxytocin in pre-filled Uniject™ device
• Uniject™ :
– Used in vaccines (HBV / tetanus)
and contraceptives
– Validating / early introduction for
oxytocin and gentamicin
• Oxytocin in Uniject™
– Studies in Indonesia, Angola,
Vietnam, and Mali have shown that
Uniject is:
– preferred by providers,
– units cannot be re-used, and
– utilization / storage /
elimination are easier
Deb Armbruster and Sushie Engelbrecht,
POPPHI Project
Time-Temperature Indicator
for Oxytocin in Uniject™




 Chemical time and temperature
cumulative exposure factor
 Rate of color change calibrated by
manufacturer based on stability studies
 Advantages:
Deb Armbruster and Sushie Engelbrecht,
POPPHI Project
 Improvement in overall quality assurance of
programs – only effective oxytocin would be
used
 Flexible cold chain management
 Longer “out of cold chain” periods possible
than with other products
 Product can be available at peripheral
health facilities and for home births with
skilled providers
Management of PPH
 Must be treated like an
emergency
 Mobilize resources / staff
 Shout for help
 General management
 Stabilize the patient
 Treat for shock
 Determine the cause
 Specific management
 Based on diagnosis
17
PPH Clinical Interventions
Basic EmOC







Management of shock
Uterotonics
Bimanual compression
Suturing of lacerations
Aortic compression
Manual removal of placenta
Antishock garment
Comprehensive
EmOC




Uterine artery ligation
B-lynch procedure
Hysterectomy
Blood transfusion
18
Evidence regarding TREATMENT of PPH
in Health Care Facilities:
Cochrane Review 2006
 Search for pharmacological, surgical or
radiological interventions for the treatment
of PPH
 Insufficient data on surgical and
radiological techniques
 3 trials on use of misoprostol
 No proven benefit for reduction of
PPH, maternal mortality or surgery
New clinical trials on use of misoprostol 2006 - 2009
 Some completed and ongoing trials by Gynuity and others suggest a
possible role for misoprostol in management of PPH
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Strategy for Reduction of PPH:
MOPH of Afghanistan
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Conclusions
 At health care facilities

Prevention strategy is clear!
– AMTSL for all deliveries

Management approach is less clear
– On-going studies to be followed
 Need to consider not just technical
interventions but also the programmatic
approach

ALL SBAs should be authorized and
trained to provide AMTSL and basic
management of PPH
 The best technical intervention is only the
best when we can get it to the greatest
number of people
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Thank You!
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