Strategy for the
Reduction of Morbidity and Mortality
from
POSTPARTUM HAEMORRHAGE
Reproductive Health Task Force
Safe Motherhood Unit
Ministry of Public Health
Islamic Government of Afghanistan
2005
FOREWARD
Intrapartum Working Group
Strategy on Prevention and Management of PPH
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Intrapartum Working Group
Strategy on Prevention and Management of PPH
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Table of Contents
FOREWARD .............................................................................................................................. i
STRATEGY FOR THE REDUCTION OF MATERNAL MORTALITY FROM
POSTPARTUM HEMORRHAGE ............................................................................................ 3
Definition of PPH .................................................................................................................. 3
THE INTERVENTIONS FOR REDUCING MORTALITY FROM PPH ............................... 4
Preventing PPH in Situations WITHOUT a Skilled Birth Attendant ................................... 4
Community Awareness and Behavior Change Communication (BCC) ............................. 4
Birth Planning.................................................................................................................... 5
Promotion of Skilled Attendance At Birth .......................................................................... 5
Detection and Treatment of Anemia .................................................................................. 6
Community Based Distribution and Education on the Use of Misoprostol for Routine
Use in the Third Stage of Labor......................................................................................... 6
Family Planning and Birth Spacing .................................................................................. 7
Managing PPH in Situations WITHOUT a Skilled Birth Attendant .................................... 7
Birth Planning.................................................................................................................... 7
Community Emergency Plans ............................................................................................ 8
Referral Strategies ............................................................................................................. 8
Preventing PPH in Situations WITH a Skilled Birth Attendant ........................................... 9
Community Awareness and BCC ....................................................................................... 9
Antenatal Care (to include Birth Planning)....................................................................... 9
Detection and Treatment of Anemia ................................................................................ 10
Family Planning and Birth Spacing ................................................................................ 10
Use of the Partograph to Reduce Prolonged Labor ........................................................ 10
Limiting Episiotomy in Normal Birth .............................................................................. 11
Active Management of the Third Stage of Labor ............................................................. 11
Routine Inspection on the Placenta for Completeness .................................................... 12
Routine Inspection of the Perineum and Lower Vagina for Lacerations ........................ 12
Routine Immediate Postpartum Monitoring .................................................................... 13
Management of PPH in Situations WITH a Skilled Birth Attendant ................................. 13
Active Triage of Emergency Cases .................................................................................. 13
Rapid Assessment and Diagnosis..................................................................................... 13
Emergency Protocols for PPH......................................................................................... 14
Basic and Comprehensive Emergency Obstetric Care .................................................... 14
CONCLUSION ........................................................................................................................ 15
Figure 4. Strategies for Reduction of Mortality from Postpartum Hemorrhage .................. 17
APPENDIX 1: Use Of Oxytocic Drugs In Pregnancy and Childbirth Care ............................ 18
References for information on oxytocic drugs..................................................................... 21
Intrapartum Working Group
Strategy on Prevention and Management of PPH
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Strategy on Prevention and Management of PPH
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STRATEGY FOR THE REDUCTION OF MATERNAL MORTALITY FROM
POSTPARTUM HEMORRHAGE
The Prevention and Management of Postpartum Hemorrhage
Maternal mortality in Afghanistan is unacceptably high and the Ministry of Health has taken
substantial steps to address this problem. Globally, the most common cause of maternal
mortality is postpartum hemorrhage (PPH), accounting for 25% of maternal deaths. However,
in Afghanistan, while PPH is still the most common cause of death, it is responsible for 38%
of the maternal deaths, much higher than the global average1. This is an urban as well as a
rural problem as noted in Table 1.
There are various reasons for these terrible
statistics, yet there can be a single
response: to make the reduction of death
from postpartum hemorrhage a focused
strategy within the overall framework of
reproductive health in Afghanistan.
Knowing the burden that PPH puts on the
health sector, a targeted strategy can
increase the likelihood that appropriate
actions can be taken.
Table 1. Percentage of Maternal Deaths Due
to Postpartum Hemorrage, by Province
Province
Percent of maternal
deaths due to PPH
Kabul
50%
Laghman
30%
Kandahar
36%
Badakshan
24%
AFGHANISTAN
38%
Reduction of PPH must recognize the reality in Afghanistan that more than 90% of people
deliver without the assistance of a skilled provider. Any strategy must look at a variety of
interventions that can be employed in environments with a skilled attendant, as well as
environments without. As well, such a strategy must consider options for prevention as ewll
as treatment. Figure 1. shows the basic framework for interventions, while Figure 4 gives the
interventions in detail. This paper describes the potential interventions, and suggests
strategies for implementing these interventions.
Figure 1. Framework for Reduction of PPH
Without a Skilled
Attendant
Prevention
Strategies
Management
Strategies
With a Skilled
Attendant
Potential Interventions
Definition of PPH
The loss of at least 500 ml of blood following delivery is defined as a PPH. How a particular
individual is able to withstand that amount of blood loss determines if that PPH will result in
a death or simply a complication. For some women who are very anemic at the start of labor,
the loss of even 250 ml of blood puts their lives at risk; whereas a healthy woman who is not
anemic may loose 1000 ml of blood or more without serious morbidity.
1
MOH/UNICEF/CDC RAMoS study, 2002.
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Thus, although PPH is defined by this cutoff, those with less blood loss can still experience
shock and need aggressive treatment to save their lives.
THE INTERVENTIONS FOR REDUCING MORTALITY FROM PPH
Figure 4 lists the interventions, by category, that should be a part of a comprehensive strategy
for reducing PPH. All these activities and interventions come together in a comprehensive
approach to the reduction of death from postpartum hemorrhage.
Preventing PPH in Situations WITHOUT a Skilled Birth Attendant
In order to have an impact on preventing PPH at the community level, in places where there
are typically no skilled birth attendants, the community and family must be supported to take
the following actions.

Community Awareness and Behavior Change Communication (BCC)
While prevention of hemorrhage may be in the hands of the provider and the woman,
prevention of mortality from PPH is an issue for the entire community. Communities should
be taught regarding the necessity of skilled care at birth, and that their actions are central to
making a difference for women. BCC tools, such as the Birth Planning Flip Chart should be
used to educate and inform all members of the community and to foster a dialogue around
action to prevent mortality and morbidity.
In situations where there is no skilled attendant, the Birth Planning Flip Chart can be used by
 Female CHWs to help pregnant women and their families make concrete plans and
know what they can expect of their community
 Female CHWs to engage TBAs and other female village leaders about the need for
planning and the options offered by health services
 Male CHWs to discuss with mullahs and shuras the importance of preventive action
and rapid responses in times of emergencies
 Male CHWs to help men and husbands know the concrete things that they must do to
prepare for a healthy birth
 TBAs and family diyas to guide families in preparations for birth, and advocate for
the use of available, local PPH reduction strategies (such as misoprostol2)
 Male and female CHWs (as well as some TBAs) to educate communities about
danger signs, design community interventions and understand the importance of
skilled attendance and health services
 All members of the community to promote the concepts of birth preparedness and
complication readiness.
As well, communities must work with health care providers to identify reasons why women
do or do not seek delivery services at health facilities. Women, families, communities and
2
The Ministry of Health is ready to undertake a pilot project to understand the mechanism by which misoprostol
can be best used in the Afghan context to prevent postpartum hemorrhage.
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health care providers should work together to develop culturally appropriate delivery services
that enable women to confidently seek care at health facilities.

Birth Planning
Women and families, especially decision-makers within families, should develop a specific
plan for their birth, including what to do in the event of a complication. Much of what a
woman needs for having a healthy birth can be anticipated, such as choosing an appropriate
place for birth, having the right supplies and materials, etc. Furthermore, lack of planning can
contribute to making a simple problem become a big complication. For example, when a
laboring woman does not arrange for someone to care for her other children, she may make
decisions to leave the birthing area prematurely to care for other children, thus increasing her
risk of complications.
A critical component of the birth plan should be the choice of where to deliver and with
whom to deliver. Women should consider all the benefits and limitations of delivering at
home, and the possibilities of NOT delivering at home. This conclusion should not be
reached simply based on tradition, lack of information or the sudden onset of labor prior to
the consideration of birth location.
The birth plan should also include a list of needed materials for the birth including: perineal
pads/cloths, soap, clean bed cloths, placenta receptacle, clean razor blade, waterproof/plastic
sheet3 and clean cord ties.

Promotion of Skilled Attendance At Birth
A key intervention for reducing PPH is the presence, at the birth, of a health care provider
who is trained in the necessary interventions to save life. Only a skilled attendant should
practice active management of the third stage of labor4 and administer oxytocin, a central part
of that intervention. As well, only a trained and skilled provider can determine if the placenta
has been delivered completely and how much postpartum bleeding is normal. An experienced
provider will know how to help the uterus remain contracted following delivery, to prevent
additional blood loss, or repair a laceration that is bleeding. Skilled providers can identify
problems early, and intervene early, in order to limit blood loss.
For the coming years in Afghanistan, it will be difficult to have a midwife in every
community, nor should this be the goal, as skilled providers must have adequate clinical
volume to maintain their skills. It will be possible, ultimately, to have a midwife at many
facilities that serve these women and communities. Midwives must be facility based, but with
a strong outreach program to enable them to move into communities and provide personal
care to women as needed. By having midwives posted at basic and comprehensive health
3
Although a plastic sheet is recommended, it should not suggest that women should lie down on this sheet to
deliver their baby. Birth in the squatting position is an often used technique that assists with normal birth.
4
Active management of the third stage of labor includes administration of oxytocin (within 1 minute of
delivery), early clamping and cutting of the umbilical cord and controlled cord traction. It is not recommended
that this combination of interventions be practiced by traditional practitioners (TBAs).
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centers, women and their families know where to go to request the care they need for a
healthy birth.

Detection and Treatment of Anemia
Studies in Afghanistan have demonstrated that approximately 71% of women have some
degree of iron-deficiency anemia5. Given this alarmingly high statistic, it is reasonable to
assume that ALL pregnant women are in need of iron and folate supplementation during
before, during and after pregnancy. Community health workers should distribute iron and
folate to all women in the community who are pregnant, and where possible, to all women
who are planning pregnancy.
CHWs should also be taught, where there is no skilled attendant, how to make a clinical
diagnosis of anemia, and when to refer cases that seem to not respond to iron
supplementation. CHWs should know:


How to make a clinical diagnosis of anemia
o Pale palms or fingernail beds; pale conjunctiva or oral mucosa
o Fatigue and shortness of breath (from only slight exertion)
Which women to refer for evaluation at the health facility
o Any woman who is short of breath
o Any woman who is so fatigued that she cannot perform her routine household
work
o Any woman with obvious signs of anemia
o Any woman who does not appear to improve after 3 months of iron and folate
supplementation
While anemia itself does not cause postpartum hemorrhage, the treatment of anemia will help
women to be able to withstand serious morbidity and mortality if they do face a hemorrhage.
Women who have higher hemoglobin levels will have a greater reserve if they face a
hemorrhage during pregnancy and delivery. If a woman is severely anemic at the start of her
labor, then she can only lose a small amount of blood during the labor and birth before her
health is at risk. Provision of iron and folate to treat anemia and increase hemoglobin levels
will help women be more prepared for the possibility of a pregnancy-related hemorrhage.

Community Based Distribution and Education on the Use of Misoprostol for Routine Use
in the Third Stage of Labor
Recent evidence has demonstrated that women who deliver at home may still be able to
benefit from selected recent medical advances6. The routine use of 600 mcg of oral
misoprostol, immediately following delivery of the baby and before delivery of the placenta,
is an effective way to reduce postpartum blood loss. Misoprostol causes uterine contractions
similar to oxytocin and ergometrine, but unlike oxytocin and ergometrine, is available as a
tablet and is heat-stable, making it uniquely accessible to women who are delivering at home.
5
6
MICS, 2003, UNICEF
http://www.mnh.jhpiego.org/resources/PPH.pdf
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A study done in Indonesia demonstrated that a program of community-based education about
postpartum hemorrhage and distribution of misoprostol was safe, acceptable, feasible and
effective at reducing postpartum hemorrhage and subsequent morbidity and mortality.
Further information is needed in order to understand how to best develop a program for
reducing postpartum hemorrhage using misoprostol in Afghanistan. Well designed studies
have proven that misoprostol is effective in reducing postpartum hemorrhage. Additional
effort and resources are not needed to prove what is already known. However, the best
method for using misoprostol in the Afghan context has yet to be determined. Therefore, a
pilot program to understand the mechanism for successful education of users and families, as
well as, distribution and use of misoprostol at the community level in Afghanistan is clearly
needed.

Family Planning and Birth Spacing
Research and global experience have demonstrated that one of the most important initiatives
for improving women’s health and reducing mortality is to help them plan their pregnancies
and space their births. When a woman’s health is at its best – meaning she is not anemic, she
is not suffering from micronutrient deficiencies and she is properly rested with respect to
work and other child care responsibilities – she is more likely to have a healthy pregnancy
and birth. Indeed, the concept of “too young, too old, too many, too close” suggests increased
risk in pregnancies which are too frequent or too close together.
Once a family has achieved the number of children that it desires and feels prepared to care
for, it should be supported to reduce the chances of unplanned pregnancy. Traditional and
modern family planning methods should be made available to women so as to reduce the
number of times that an individual woman faces the risk of complications of pregnancy. Birth
spacing options – especially postpartum methods – should be made available to women and
men.
Community health workers should be taught and supported to provide appropriate birth
spacing methods according to their job description, including lactational amenorrhea method,
condoms, oral pills and injectables.
Managing PPH in Situations WITHOUT a Skilled Birth Attendant
While the above listed interventions are useful in prevention of PPH, they will not prevent all
cases of PPH. Therefore, program planners and implementers must consider additional
interventions that allow for the management of PPH when there is no skilled attendant.

Birth Planning
A woman, her family and her community must be prepared in the event that she develops
danger signs during labor and birth at home. Heavy bleeding before, during or after the birth
must be responded to immediately with a previously prepared emergency plan. That plan
must include
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



Decision making – who will make the decision to leave if there is a complication
Emergency transport – including who has the vehicle or donkey/cart, and is fuel
available or must it be purchased
Emergency funds – enough for transport, medications, blood transfusion and medical
services. As this amount may be more than any family can afford, communities may
consider a community fund, designed for any community member who is in need of
it.
Walking blood donor – in case a transfusion is necessary when the woman arrives to
the facility.
As well, women, families, mullahs, community groups and all concerned parties must be
educated about the tell-tale signs of danger in pregnancy and during and after birth. The
following danger signs indicate the need to enact the complication readiness plan:
 Vaginal bleeding
 Difficulty breathing
 Fever
 Severe abdominal pain
 Severe headache/blurred vision
 Convulsions/loss of consciousness

Community Emergency Plans
Communities, as well as women and families, need to develop, review and implement
emergency plans for addressing the needs of women who develop complications during
pregnancy and birth. For those women who chose to deliver at home – then experience
excessive bleeding – plans must be in place to mobilize community resources to aid the
woman’s access to curative care. Communities should have plans in place to mobilize
emergency funds, transport, blood donors and support mechanisms to allow women to get to
nearby or far off medical services.
As well, communities should consider what means of communication they might use in an
emergency. Where radios or telephones are available, members of the community should
know how to access them. Where they are not available, communities should consider how to
communicate their needs in the shortest time interval possible. In the current security
situation in Afghanistan, communities should also work with local police to develop a
mechanism to allow safe passage/escort in times of heightened security or curfew.

Referral Strategies
Given that all clinical services are not available at all levels of the health system, referral
strategies must be developed to link women in need with available services. Communities,
mullahs and all those consulted in an emergency must know where services are available and
how to move women between various levels of the health system.
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Preventing PPH in Situations WITH a Skilled Birth Attendant
In order to have an impact on preventing PPH in hospitals, CHCs and BHCs with a skilled
attendant, the provider and the staff of the health facility, as well as the woman, the family
and the community, must be supported to take appropriate actions.
When anemia is detected early in pregnancy, patients should be provided the medical
interventions to correct this anemia, and vigilantly followed up. When anemia is severe the
woman should be sent to an appropriate facility for treatment, including blood transfusion, if
necessary.
Providers must also standardize the intrapartum care provided in facilities to include certain
critical elements that reduce the likelihood of PPH, including:
 routine use of the partograph,
 restriction of episiotomy,
 routine postpartum inspection of the placenta for completeness
 routine inspection of the vulva and vagina for lacerations,
 routine use of active management of the third stage of labor, and
 routine postpartum monitoring of the woman for a minimum of 6 hours.

Community Awareness and BCC
Community participation will also play a great role in prevention and management of PPH in
the presence of a skilled provider. Without the support of community leaders and mullahs,
women will have limited access to skilled attendants and appropriate clinical facilities.
Communities must understand and advocate for routine use of skilled birth attendants for
every pregnant woman. They must understand the unpredictability of obstetric complications
and the natural course of postpartum hemorrhage when a skilled attendant is not present.
Communities must actively participate in initiatives to include them and their views in the
development and continual improvement of clinical services. Communities must work with
clinical facilities to develop culturally appropriate birthing areas where women feel welcome
and safe. It is in these facilities that women can get the skilled care needed to prevent and
manage postpartum hemorrhage.

Antenatal Care (to include Birth Planning)
Antenatal care – with a focus on birth planning – can be an important part of a
comprehensive effort for reduction of mortality from PPH. An effective antenatal encounter,
which allows a skilled provider to impact postpartum hemorrhage includes:
 History taking to understand if the woman has previously suffered from postpartum
hemorrhage
 History taking for conditions that suggest that the woman needs additional care,
including history of prolonged or obstructed labor, previous cesarean section or close
interval between pregnancies
 Physical examination focusing on clinical signs of sever anemia
 Routine distribution of iron and folate, due to endemic levels of anemia,
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




Measurement of hemoglobin levels to assessment for severe anemia, with treatment if
detected,
Birth planning to help the woman and her family develop a birth preparedness and
complication readiness plan
Discussion of appropriate options for birth spacing following the delivery
Plan for follow up, to evaluate the impact of treatment for anemia or to further the
discussion of the birth plan.
Detection and Treatment of Anemia
As noted above, anemia during pregnancy increases a woman’s risk of morbidity from a
postpartum hemorrhage. ANC visits provide an opportunity to identify and treat anemia with
sufficient time to impact the health of the woman. If severe anemia is detected, the woman’s
name should be put on a list for intensive follow up by the health provider. She should have
regular visits, including consultation with an obstetrician or physician, if necessary. She
should be provided sufficient iron for the duration of the pregnancy and the postpartum
period.

Family Planning and Birth Spacing
As noted previously, birth spacing plays an important role in the promotion of general health,
including healthy subsequent pregnancies. Birth spacing improves the health of the woman
by increasing the interval between pregnancies and reduces the chance of unplanned
pregnancy and the number of times a woman is exposed to the risks that come with
pregnancy.
All skilled providers should be very familiar with the various methods of birth spacing and be
able to competently provide counseling and services in the following methods:
 Natural methods, such as the standard days method and lactational amenorrhea
method
 Condoms
 Oral pills
 Injectables
 Intrauterine device
When a couple decides that they have achieved their desired family size, the provider should
be able to discuss with them various options for limiting the number of pregnancies,
including, IUD, vasectomy and tubal ligation.

Use of the Partograph to Reduce Prolonged Labor
Prolonged labor, as well as intrapartum infection as a result of prolonged labor or prolonged
rupture of membranes, are contributing factors to uterine atony, the number one cause of
PPH. Routine use of the partograph – for all women in labor – assists the provider to detect
prolonged labor and act in a timely manner to limit its impact.
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Limiting the length of labor reduces the chance of infection, as well as postpartum “uterine
fatigue”, a situation that can make the uterus less responsive to oxytocic drugs postpartum.
When the uterine muscle is fatigued from long labor it requires higher doses and different
types of uterotonic agents in order to sustain uterine tone postpartum, and reduce blood loss.

Limiting Episiotomy in Normal Birth
While uterine atony is the most common cause of PPH, vaginal and vulvar lacerations are
also a significant cause. Most women, including primiparous women, can successfully have a
vaginal delivery without the need for an episiotomy. Routine or common use of episiotomy
increases the chance that a woman will lose an excessive amount of blood.
Providers should be trained in techniques to reduce the need for episiotomy. Clear evidence
has demonstrated that the majority of episiotomies are not necessary7. Selective rather than
routine use of episiotomy results in lower levels of perineal trauma, decreased need to suture
while not increasing need for newborn resuscitation or lowering Apgar scores at birth.
All institutional deliveries should include routine inspection of the perineum and lower
vagina following the delivery, in an effort to reduce undiagnosed vulvovaginal trauma and
undetected blood loss.

Active Management of the Third Stage of Labor
Active management of the third stage of labor is a central intervention in the prevention of
postpartum hemorrhage.8 All women who deliver with a skilled provider, whether in a
hospital, health center or home, should receive active management of the third stage of labor.
As shown in Figure 2, active management of the third stage of labor:
 Reduces postpartum hemorrhage (≥ 500 mL) by 62%
 Reduces severe postpartum hemorrhage (≥ 1000 mL) by 67%
 Reduces the need for postpartum transfusion by 66%
 Reduces prolonged third stage by 82%
In order to successfully implement a strategy of routine active management, health care
facilities must:
 Make active management the standard of care
 Ensure adequate supplies of oxtocin in the delivery room
 Train all providers in the technique
 Put systems in place to facilitate its application (readiness of delivery sets, availability
of oxytocin, statistics to track the trends in postpartum hemorrhage, etc.)
7
Carroli G, Belizan J. Episiotomy for vaginal birth (Cochrane Review). In: The Cochrane Library, Issue 3, 2004.
Chichester, UK: John Wiley & Sons, Ltd.
8
Neilson JP. 1998. Evidence-based intrapartum care: evidence from the Cochrane Library. Int J Gynecol Obstet. 63 (Suppl
1): S97-102.
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Figure 2. Active vs. Expectant Management of Third Stage of Labor
ACTIVE vs. EXPECTANT MANAGEMENT OF THIRD STAGE
6 studies 4850 women
95% CI
Postpartum Hemorrhage >500 ml
0.38 (0.32-0.46)
Loss of blood >1000 ml
0.33 (0.21-0.51)
Maternal hemoglobin 24-48 h postpartum <9 g/l
0.40 (0.29-0.55)
Need for transfusion
0.34 (0.22-0.56)
Third stage >40 min
0.18 (0.14-0.24)
Manual removal of placenta
1.21 (0.82-1.78)
Postpartum curettage
0.74 (0.43-1.28)
Vomiting
2.19 (1.68-2.86)
Nausea
1.83 (1.51-2.23)
Apgar<7 at 5º min.
1.00 (0.38-2.66)
Newborn admission to ICU
0.82 (0.60-1.11)
No breastfeeding at discharge
0.92 (0.82-1.04)
.1 .2
1
5 10
A study done in Guatemala, demonstrated that there were substantial financial savings to
hospitals when active management was applied routinely. These savings, in need for
transfusion, occupancy of hospital beds, need for other uterotonic drugs and volume of linen
to be laundered, far outweigh the costs of the 10 IU vial of oxytocin.

Routine Inspection on the Placenta for Completeness
Following delivery of the placenta, there should be a routine inspection of the placenta to
ensure that it is complete. The provider should evaluate the maternal surface of the placenta
as well as the membranes to ensure that no portion remains in the uterus, as this can cause
postpartum bleeding or infection.

Routine Inspection of the Perineum and Lower Vagina for Lacerations
In addition to conducting a routine inspection of the placenta, the provider should also inspect
the perineum and the lower vagina for lacerations. A careful and gentle inspection may reveal
bleeding areas that need to be sutured. All second degree lacerations must be sutured, both to
control bleeding and to restore perineal integrity. First degree lacerations should repaired
only if they are bleeding or are needed to restore normal anatomy.
If the woman is not bleeding, or bleeding lightly, it is rarely necessary to conduct a deep
pelvic inspection to evaluate the integrity of the cervix. This frequently causes substantial
pain for the woman and rarely demonstrates a laceration in need of repair in the absence of
bleeding.
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
Routine Immediate Postpartum Monitoring
The immediate postpartum period is a time of rapid involution of the uterus and great
physiological changes for the woman. It is also a time of great risk as the majority of PPH
occurs during this time. While PPH can and does occur after this initial 6 hour period, it is
less likely. Therefore, it is essential to monitor women in the first 6 hours post delivery as
part of a comprehensive plan to reduce PPH and mortality and morbidity from it.
Furthermore, women who deliver in a facility and think that they are fine, may go home early
from that facility. If heavy bleeding later develops, they may be less likely to return because
they have left the facility and may feel that the most dangerous period is over.
Immediate postpartum monitoring should include the following points, demonstrated here in
a sample postpartum monitoring flow sheet.
Figure 3. Immediate Postpartum Monitoring Sheet
Time
Blood Pressure
(post delivery)
Pulse
Uterine Tone
Vaginal Bleeding
(firm or soft)
(light, moderate or heavy)
00:30
01:00
02:00
06:00
Management of PPH in Situations WITH a Skilled Birth Attendant

Active Triage of Emergency Cases
Cases of postpartum bleeding that arrive at the facility should be identified as an emergency
and moved rapidly into the evaluation area. All members of the staff – from guards and
cleaners to midwives and doctors – should be able to identify women in need of emergency
evaluation.
Systems can be put in place to move those cases through the common initial delays that
families encounter at the entrances to busy hospitals. Guards can be taught to ask some
screening questions (“Do you have heavy bleeding?”, “Have you fainted or become very
weak?”), referral facilities can be provided with red “Alert!” cards, that help identify
emergency referrals, and families can be taught key words (“bleeding”, “fainting”) that
capture the attention of providers.
Regardless of the strategy, the speed with which people access the assessment areas should
be monitored to ensure that the triage system is working properly.

Rapid Assessment and Diagnosis
Once inside the facility, patients need rapid assessment and diagnosis of PPH. A scheme of
rapid initial assessment of all patients should be routine for all presenting patients, so as to
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screen those with a life-threatening emergency. This assessment scheme can be applied by
any level of health worker, who then alerts appropriate personnel to further the evaluation.
The general approach to a patient who presents with bleeding must include:
o Assessment:
 History – including an assessment for shock
 General Physical Exam – including an assessment for shock
 Pelvic Examination
 Appropriate laboratory tests
o Diagnosis
o Plan and Intervention, and
o Evaluation.
In order for this scheme to work, providers must be available at all times in the facility to
make rapid diagnostic decisions.

Emergency Protocols for PPH
A patient who is diagnosed with PPH must receive immediate standardized resuscitation
measures regardless of the cause. Initial measures are enacted to treat or prevent shock, while
mobilizing other personnel and resources to further identify the specific cause for the
hemorrhage.
Standardized approaches in diagnosis and treatment of PPH (as outlined in the WHO Manual
Management of Complications in Pregnancy and Childbirth) should be posted in the
emergency treatment area and delivery room. All staff should be trained in the decisionmaking processes required to manage PPH and should be familiar with the posted protocols.
In order to ensure the readiness of services to respond to emergencies such as PPH,
emergency drills should be periodically conducted (approximately every 3 months) for staff
in the delivery room and emergency treatment areas. The periodic review of these standard
protocols should serve as a quality assurance mechanism to ensure that the facility is always
ready to respond to a PPH emergency.

Basic and Comprehensive Emergency Obstetric Care
Once emergency cases are recognized and the cause of PPH is identified, the facility must
have the mechanisms – personnel, supplies, drugs and equipment – to properly manage the
case.
The elements of basic emergency obstetric care related to management of PPH include:
 Intravenous fluid resuscitation
 Parenteral oxytocics
 Parenteral antibiotics
 Manual removal of placenta
 Removal of placental fragments
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As well, there are critical measures that all staff should know for managing PPH cases:
 Uterine massage
 Bimanual uterine compression
 Aortic compression
 Emptying/catheterization of the bladder
 Placenta inspection
 Vulvar and vaginal inspection
 Cervical inspection
 Suturing of tears
 Uterine curettage
These clinical supervisors should ensure that all staff posted to the labor and delivery area are
proficient in the above listed measures.
For cases that do not respond to the above basic interventions, the elements of comprehensive
emergency obstetric care are necessary, and include:
 Obstetric surgery – laparotomy, uterine repair, hysterectomy and repair of high
vaginal and cervical trauma
 Anesthesia, and
 Blood transfusion.
Facilities should be classified as providing basic or comprehensive essential/emergency
obstetric care, then properly supported to effectively apply these services.
CONCLUSION
The basic strategies outlined in this paper are meant to provide guidance to all those people
helping to manage and implement Essential Obstetric Care services. Program managers and
health officers who are working to reduce maternal mortality from postpartum hemorrhage,
should implement these interventions and activities, depending on whether they work in
situations where they have or do not have skilled providers.
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Figure 4. Strategies for Reduction of Mortality from Postpartum Hemorrhage
Management
Prevention
Without a Skilled Birth Attendant
With a Skilled Birth Attendant






Community Awareness – BCC/IEC
Birth Planning
Promotion of skilled attendance at birth
Family Planning and Birth Spacing
Detection and treatment of anemia (clinical S&S)
Community Based Distribution of Misoprostol for
Routine Third Stage Use














Birth planning
Community emergency planning
Transport planning
Referral strategies



Community Awareness – BCC/IEC
Antenatal Care (to include Birth Planning)
Detection and treatment of anemia
Family Planning and Birth Spacing
Use of Partograph to reduce prolonged labor
Limiting episiotomy in normal birth
Active Management of the Third Stage of Labor
Routine inspection of placenta for completeness
Routine inspection of perineum/vagina for lacerations
Routine immediate postpartum monitoring
Active triage of emergency cases
Rapid assessment and diagnosis
Emergency protocols for postpartum hemorrhage
management
 Basic EmOC
o intravenous fluid resuscitation
o manual removal of placenta
o removal of placental fragments
o parenteral oxytocics & antibiotics
 Comprehensive emoc
o blood bank/blood transfusion
o operating theatre/ surgery
Supporting Components: Women’s Empowerment; Respect for Human Rights; Access to Care; Community support &
mobilization; Access, utilization and quality of Essential Obstetric Care services.
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APPENDIX 1: Use Of Oxytocic Drugs In Pregnancy and Childbirth Care
Oxytocic drugs, particularly oxytocin, misoprostol, and ergometrine, are beneficial for certain
obstetric indications. The, indications, use, availability, misuse, contraindications, side
effects, storage, and cost for each of these oxytocic drugs are outlined below. This
information should be used to guide the use of these drugs in Afghanistan.
Oxytocin
Indications
Use
Availability
Misuse
Contraindications
Side Effects
Storage
Cost
Oxytocin is used for labor induction, labor augmentation, active
management of third stage, and management of PPH.
Oxytocin should only be used for induction/ augmentation in a
facility where Cesarean section is available.
Oxytocin should only be used by skilled attendants (midwives,
doctors, nurses with midwifery skills).
For active management of third stage: 10 units IM.
Oxytocin should be available at health facilities providing labor
and childbirth care.
Oxytocin should also be available from pharmacies but only
with a prescription from a doctor or a midwife.
Oxytocin should not be used by unskilled persons to speed up
labor and delivery, as this may result in ruptured uterus. In
countries where oxytocin is available to the general public,
there have been maternal and fetal deaths associated with its
use.
There are no contraindications to oxytocin use for active
management of third stage and management of PPH.
Labor induction/augmentation is contraindicated for fetal
distress, placenta previa, transverse fetal lie, cord prolapse with
live fetus, and obstetric hemorrhage.
When used during labor, oxytocin may cause uterine
hyperstimulation, which may result in fetal distress and possibly
uterine rupture.
However, in the postpartum period when used in the
recommended dose, oxytocin has no known side effects. The
total dose of oxytocin for the management of PPH should not
exceed 60 units.
Oxytocin should be stored at 4 to 8ºC but can be removed from
storage up to 48 hours before use.
Oxytocin is approximately 2 – 10 Afghanis per vial.
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Misoprostol
Indications
Use
Availability
Misuse
Contraindications
Side Effects
Storage
Cost
Misoprostol is indicated for the following conditions: missed
abortion; induction of labor following intrauterine fetal death;
and prevention and treatment of post-partum hemorrhage.
For labor induction, misoprostol should only be used in facilities
with the ability to provide cesarean section.
In general, misoprostol should only be used by skilled
attendants (midwives, doctors, nurses with midwifery skills);
however, in programs that support birth planning and childbirth,
it should be available at the community level through CHWs.
For missed abortion: 400-600 mcg by mouth every four hours
up to 24 hours.
For induction of labor following intrauterine fetal death: 50 mcg
per vagina every four hours until delivery.
For prevention of PPH: 600 mcg by mouth (one dose).
For treatment of PPH: 1000 mcg per rectum (one dose).
Misoprostol should be available at health facilities providing
labor and childbirth care and through CHWs at the community
level, as part of a program for birth planning and reduction of
PPH at home births.
Misoprostol should not be available to the general public.
As misoprostol is a new drug in Afghanistan, efforts should be
made by all healthcare providers and policy makers to limit its
use to those described above. Widespread misuse of this drug
will have a negative impact that may limit its availability and
public health impact.
Induction of labor (in fetal death) with misoprostol is
contraindicated for women with prior cesarean section or other
uterine scars.
Misoprostol may cause uterine hyperstimulation, which may
result in fetal distress and possibly uterine rupture. For this
reason its use in induction of labor is not recommended at this
time
Side-effects to misoprostol are dose-dependant; doses used for
labor induction are well-tolerated.
Doses used for post partum hemorrhage prevention and
treatment have been associated with fever and shaking chills.
Misoprostol should be stored at room temperature in a dry area.
While the production costs of misoprostol are low (i.e. 5-10
Afghanis per tablet), the market price ranges from 150-700
Afghanis per tablet.
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Ergometrine
Indications
Ergometrine is used for the treatment of post-partum
hemorrhage.
Use
Ergometrine should only be used by skilled attendants
(midwives, doctors, nurses with midwifery skills).
Availability
Ergometrine should be available at health facilities providing
labor and childbirth care.
Ergometrine should not be available to the general public and
should not be sold in pharmacies.
Misuse
Prophylactic use of oral ergometrine after childbirth has no
benefit and should be avoided.
Contraindications
Ergometrine is contraindicated in women with hypertensive
disorders (pre-eclampsia, eclampsia, essential hypertension),
ischemic cardiac disease, or history of a cerebrovascular
accident or myocardial infarction, due to risk of vasoconstriction
potentiating an ischemic event.
Ergometrine should not be administered by rapid IV infusion
due to risks of vasoconstriction.
Side Effects
The common side effects of ergometrine include nausea,
vomiting, rise in blood pressure, and headache.
Other side effects, which are rare, include symptomatic
myocardial and cerebral ischemia in patients with no
contraindications. Patients should therefore be monitored
closely after receiving this medication.
Storage
Ergometrine should be stored from 4 - 8ºC and not exposed to
light.
Cost
Ergometrine is approximately 4 Afghanis per vial.
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References for information on oxytocic drugs
Kwast BE. Maternity care in developing countries. In: Health matters. Public health in NorthSouth perspective. Van der Velden K et al (eds). Houten, Bohn Stafleu Van Loghum 1995.
Afghanistan: Country Profile Table. World Bank. Available at:
http://devdata.worldbank.org/external/CPProfile.asp?SelectedCountry=AFG&CCODE=AFG
&CNAME=Afghanistan&PTYPE=CP. Accessed: February 3, 2004.
Fact Sheet: Reproductive Health Indicators in Afghanistan. UNFPA. Available at:
http://www.unfpa.org/emergencies/afghanistan/factsheet.html. Accessed: February 24, 2004.
Ryden G, Sjoholm I. The metabolism of oxytocin in pregnant and non-pregnant women. Acta
Obstet Gynecol Scand 1971, 50:37.
American College of Obstetrics and Gynecology. ACOG Practice Bulletin: Induction of
Labor. ACOG Practice Bulletin Number 10. Washington, D.C:ACOG, 1999.
Egypt Ministry of Health and Population. Egypt: National Maternal Mortality Study 2000.
Report of Findings and Conclusions. Egypt: Directorate of Maternal and Child Health Care,
Ministry of Health and Population, 2001.
Goldberg AB, Greenberg MB, Darney PD. Misoprostol and pregnancy. N Engl J Med
2001;344:38-60.
Karkanis SG, Caloia D, Salenieks ME, Kingdom J, Walker M, Meffe F, Windrim R.
Randomized controlled trial of rectal misoprostol versus oxytocin in third stage management.
Obstet Gynaecol Can. 2002;24(2):149-54.
Hofmeyr GJ, Nikodem VC, de Jager M, Gelbart BR. A randomised placebo controlled trial
of oral misoprostol in the third stage of labor. Br J Obstet Gynaecol. 1998;105(9):971-5.
JHPIEGO. Preventing Post-partum Hemorrhage: A Community-Based Approach Proves
Effective in Rural Indonesia. Program Brief, Maternal & Neonatal Health. Baltimore,
JHPIEGO, 2004.
O'Brien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. Rectally administered misoprostol
for the treatment of postpartum hemorrhage unresponsive to oxytocin and ergometrine: a
descriptive study. Obstet Gynecol. 1998;92(2):212-4
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