Safe Motherhood: Drug Management
and Active Management of the Third
Stage of Labor
Session Objectives
• Understand PPH and its prevention
• Understand the drug management cycle and its importance
to prevention of PPH
• Promote active management of the third stage of labor as
an intervention to prevent postpartum hemorrhage
• Identify programmatic changes that might be made to
ensure that drug management supports AMTSL
What is Postpartum Hemorrhage?
• Excessive bleeding
~ More then 500ml (severe PPH >1,000ml)
• During the third stage of labor
~ Period between birth of the infant and delivery of
the placenta
~ Retained placenta
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
~ Vaginal and cervical lacerations (tears)
~ Surgery (C-section, Episiotomy)
Underlying conditions
worsening PPH
Life-threatening complications of pregnancy can
occur in any woman. However, risk can be
increased, or an event worsened by:
• High fertility (increase risk): too early, too often,
too many, too late
• Malaria
• Anemia
• Hypertension/eclampsia
• Helminth infestation
Third Stage of Labor
• 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
The numbers
• Of about 529,000 maternal deaths in 2000, 95%
occurred in Africa
• An African woman runs a 1 in 16 lifetime risk of
dying from pregnancy complications
• About half of infant deaths are linked to poor
maternal care, health and death
Lifetime Risk of maternal death
One (1) woman in:
Benin
12
Guinea Bisseau
n/a
Burkina Faso
14
Liberia
n/a
Cameroon
26
Mali
10
Cape Verde
n/a
Mauritania
16
Chad
9
Niger
9
Cote d’Ivoire
14
Nigeria
13
Gambia
13
Senegal
11
Ghana
18
Sierra Leone
n/a
Guinea
7
Togo
20
UNFPA 1995
• Treatment of PPH
• Prevention of PPH
Treatment of PPH
• Stopping the bleeding
• Replacing circulatory volume
• Restoring blood pressure and central circulation
(compression)
• Replacing clotting factors through transfusion of
whole blood, plasma, platelets
• Replacing RBCs
Prevention of PPH
“[We] always used to say that the life
threatening complications were
unpreventable and unpredictable. We
now know that the biggest maternal
killer, PPH, is in fact preventable with
an outstanding intervention.”
Mary Ellen Stanton
What can be done to prevent PPH?
At delivery for all women, skilled birth attendants can implement active
management of the third stage of labor through:
• Administering a uterus-contracting drug within one minute of birth.
Oxytocin is the first line recommended drug according to WHO
(IMPAC)
• 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
~ Family planning supplies for women leaving care setting
Procedure for AMTSL
• 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
Awareness and support for AMSTL
• Evidence shows that up to 60% of PPH is
preventable through use of AMSTL.
• Piloted introduction of the intervention has shown
to safe lives and save money.
• Joint FIGO and ICM statement that describes and
recommends AMSTL
Other Ways to Reduce Postpartum
Blood Loss
• Prevent prolonged and obstructed labor:
~ Many providers don’t use the partograph
• Avoid episiotomy:
~ Some providers perform episiotomy routinely
For discussion
– Have you, as providers, had
experience with administering
AMSTL?
– When might AMSTL not be
provided as specified in a
standard, fully, or for all births?
– Why or why not?
Why pharmaceutical management?
As public health service providers, we need practical
ways to work together to close the gap between
need for essential drugs, access to and widespread
use of these drugs.
In this case, an uninterrupted supply of uterotonics
for all women at labor and delivery.
What is Pharmaceutical
Management?
• Group discussion
Pharmaceutical Management Cycle
Selection
Use
Management
Support
Distribution
Policy and Legal Framework
Procurement
Points to remember about drug
management
• A cycle of components
• What happens in one component has an impact on
the function of other components
• Responsibilities for cycle implementation rest
with all managers, service providers, procurement
officers, administrators, and pharmacists
Where do we start
applying the cycle?
Policy and legal framework
• Standard treatment guidelines (treatment protocols,
prescribing policies)
• Essential drug (medicine list)
• Inventory management procedures and policies
• Personnel policies guiding prescribing, dispensing,
administration procedures and practice
Standard Treatment Guidelines
(STG)
•
•
•
•
•
•
Usually a set of national guidelines, or protocols
Systematically developed
Appropriate treatments
Specific clinical conditions
Health care level specific
Drugs – type, dose, mode of administration - essential
for treatment of condition are specified
Standard Treatment Guidelines
(STG)
•
•
•
•
What to do in a clinical setting
In what circumstances
How to do it
Which drugs and supplies are used and in which
order of preference
Program responsibility in drug
management for AMTSL
For PPH prevention, this means:
• All births
• Quality, effective drugs and supplies
• The essential three steps must be delivered
Essential Drug (Medicine) List: the
EDL
• Drugs on this list satisfy needs of majority of
population
• Available at all times
• Safe and efficacious
• Cost and need
Uterotonics for AMTSL meet these criteria
Drug Selection
Following IMPAC guidelines, we would select:
• Oxytocin (this is the preferred drug for AMSTL
when it can be stored properly and administered
safely)
• 10 unit, IM administration
• Ergometrine 0.2. mg, IM administration
(contraindicated in women with hypertension
and/or heart disease)
Drugs and supplies for underlying
conditions
• Malaria Bed nets, antimalarials (including IPT), malarial
treatment (including quinine for cerebral and pregnancy)
• Micronutrients, occasionally blood
• Magnesium sulfate; diazepam; hydralazine; labetolol;
nifedipine
• Antihelminthes
• Contraceptives and other family planning supplies
Stability of Uterotonics in Tropical
Conditions
• Stability of oxytocin is better than
ergomterine/methylergometrine especially with
respect to light
• Store in dark, refrigerated space
• Remove only for use
• Short periods unrefrigerated (i.e., 1 month at 30°
C, 2 weeks at 40° C)
WHO, 1993
Considerations for
Selecting Uterotonics
• Oxytocin is the first choice when it can be managed and
administered safely
• If oxytocin unavailable, use ergot alkaloid or misoprostol
• Do not use ergometrine in women with hypertension or
heart disease
• Store uterotonics (except misoprostol) away from light and
in refrigerator
• Misoprostol has advantages when there is no cold chain.
Drug Procurement
• Preventive intervention for all women will require different
quantities of drugs than does a treatment or selective
prevention strategy
• Quantification needs to take place at the facility level
• Different drugs may be appropriate to different levels of
the system, and quantification should take this into
consideration
• In order to meet quantity requirements, budgeting for
drugs must be routine and not exceptional
Drug Distribution and Storage:
Uterotonics
• Oxtyocin and ergomterine require management in
a cold chain
• Facilities and administrative levels that cannot
maintain a cold chain may require alternate drugs
• Drugs that are not stored and distributed in proper
conditions lose their effectiveness quickly
• Storage and distribution conditions should be
monitored
Rational Drug Use
What is “Rational Use”?
•
•
•
•
All women at delivery
Correct drug for indication
Correct dose and appropriate administration
At lowest possible cost considering safety,
efficacy
Evidence that AMSTL is rational, or
optimal use of uterotonic
• Reduces incidence of PPH by 60%
• Reduces the quantity of blood loss
• Reduces the use of blood transfusion
Prevention of PPH with AMSTL
At delivery for all women, active management of the
third stage of labor (AMSTL)
~
~
~
~
Administration of a uterotonic
Controlled cord traction
Fundal massage
Family planning supplies for women leaving care
setting
Requirements of AMSTL
• Oxytocics and injection items
• Birth attendant with skills in:
–observation
–giving an injection
–controlled cord traction
Source: Adapted from Harshad Songhvi, MNH/JHPIEGO, 2004
Pharmaceutical Management Cycle
Selection
Use
Management
Support
Distribution
Policy and Legal Framework
Procurement
Pharmaceutical Management Cycle
Selection
Use
Management
Support
Distribution
Policy and Legal Framework
Procurement
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
• Spotlighting PPH prevention will
~
~
~
~
Reduce anemia
Reduce emergencies
Reduce need for transfusion
Reduce maternal mortality
Thanks to:
• USAID/Office of Maternal Health and Nutrition
• Post-Partum Hemorrhage Prevention Initiative
(PATH and Engender Health)
• Rational Pharmaceutical Management Plus
Program
• The SEAM Project
• AWARE RH
• Advance Africa
Thank you for your time and
attention
Merci bien a vous