PPH Chart Review GUIDE
Based on Liberia National Treatment Guidelines & WHO 2012 PPH
prevention and treatment guidelines
PPH Prevention
Active Management of
3rd Stage of Labor


Note : Controlled cord traction not necessary element per WHO
2012 guidelines (although may be administed without adverse
effects if by skilled birth attendant)
 Inspection of placenta for retained fragments
(documentation if placenta complete or
incomplete)manual removal of retained products if
placenta incomplete (due to high bleeding risk)
 Cervix and vagina inspected for presence/absence of
lacerations suture repair documented if lacerations
recorded
Placenta
Lacerations
Monitoring for PPH
Abdominal uterine tonus
assessment
(for early identification of
uterine atony—leading
cause of PPH)
Vaginal Bleeding
Heart Rate
Uterotonic administered immediately after delivery of
fetus (within one minute) : Oxytocin 10 IU IM/IV preferred
uterotonic
If oxytocin not available, either ergometrine 0.2 mg IM or
oral misoprostol 600 micro-grams (Note : ergometrine
contra-indicated if BP elevated, > 120/80)

Uterine tonus Documented every 15 minutes for first hour then
every 4 hours for next 24 hours
Note :Liberia guidelines recommend monitoring vital signs + uterine
firmness and presence/absence of vaginal bleeding at least every
15 minutes for 1st 2 hours then every 4 hours for following 24
hours ; in-country expert review recommended every 15 minutes
first hou then every 4 hours for next 24 hours
 Quantified (# of estimated cc’s) every 15 minutes 1st hour then
every 4 hours for next 24 hours
 Documented every 30 minutes 1st 2 hours then minimum of
twice per day
PPH Diagnosis
PPH diagnosis documented if :
 Estimated blood loss (EBL) > 500 cc
 EBL > 250 cc in setting of anemia (Hematocrit < 34)
 Change in clinical status with any degree of vaginal bleeding
(elevated HR > 100, shortness of breath, dizziness)
Evaluation and Treatment of PPH
Immediate first steps if
 Intravenous Oxtocin 10 units IV and then controlled IV drip
PPH detected
per protocol
 If bleeding does not slow with IV Oxytocin, consider
intravenous ergometrine (IF BP normal; otherwise contra-
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indicated) or a prostaglandin drug (e.g. sublingual misoprostol,
800 μg)
 Assessment for uterine atony bimanual uterine massage
 IV fluid (large bore if possible ; consider 2 IVs)
 Inspection for vaginal and cervical tears  immediate repair
if detected
 Hematocrit or hemoglobin (if available)
 Blood type and screen (for possible transfusion) (if available)
 Consider blood transfusion if Hemoglobin < 7 mg/dl or
unstable hemodynamic status
 If bleeding does not stop with uterotonic treatment and other
available conservative interventions (e.g. uterine massage)
proceed to surgical intervention
Treatment/monitoring
once stabilized
 Monitor hematocrit and bleeding status (consider blood
transfusion if hemoglobin < 7 mg/dl or for any hemodynamic
instability (e.g. tachycardia, shortness of breath)
 Begin Iron supplementation (Ferrous sulfate 325 mg three
times per day if tolerated)
Post-partum &
Discharge


Pre-discharge counseling re : PPH danger signsimmediate
care-seeking for any bleeding or danger signs
Oral iron supplementation
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