Postpartum hemorrhage


Postpartum hemorrhage (PPH) is responsible for around 25% of maternal mortality worldwide (WHO, 2007), reaching as high as 60% in some countries. PPH can also be a cause of long-term severe morbidity, and approximately 12% of women who survive PPH will have severe anemia (Abou-Zahr, 2003; WHO, 2006). Additionally, women who have severe PPH and survive (“near misses”) are significantly more likely to die in the year following the PPH (Impact International, 2007).
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Morbidity and mortality due to PPH are largely preventable through skilled care during childbirth. However, delays in identifying hemorrhage, delays in transport to the appropriate point of care, and delays in receiving the recommended treatment all contribute to high rates of maternal mortality and morbidity due to PPH. Women may give birth without any assistance. Alternatively, a relative, a member of the community, or a traditional birth attendant (TBA), often without formal health training, may attend births occurring in the community. These women may not have access to interventions to either prevent or treat PPH.  In some cases, women may give birth in facilities where skilled birth attendants lack the necessary skills, equipment, or supplies to prevent and manage PPH and shock. 
Causes and risk factors
Experts have traditionally defined early (primary) PPH as vaginal bleeding in excess of 500 mL within 24 hours after delivery. Severe PPH is blood loss exceeding 1,000 mL. Clinicians around the world recognize that some women who are severely anemic when they give birth will die from hypovolemic shock before they have lost 500 mL of blood. Unfortunately, there is no better or more definitive definition for PPH.
There are several possible reasons for severe bleeding during and after the third stage of labor: uterine atony (failure of the uterus to contract properly after delivery), trauma (cervical, vaginal, or perineal lacerations), retained or adherent placental tissue,clotting disorders, and inverted or ruptured uterus. More than one of these can cause postpartum hemorrhage in any given woman. Uterine atony is the leading cause of immediate PPH (75–90 percent) (Koh et al, 2009).
Predicting who will have PPH based on risk factors is difficult because two-thirds of women who have PPH have no risk factors (Jhpiego, 2001).Therefore, all women are considered at risk, and hemorrhage prevention must be incorporated into care provided at every birth. In addition, women should be encouraged to give birth with a skilled birth attendant who can manage PPH should it occur, in spite of preventive measures.
Prevention
PPH is one of the few obstetric complications with an effective preventiveintervention.  Active management of the third stage of labor (AMSTL), defined as intramuscular administration of 10 IU of oxytocin, controlled cord traction (CCT) and fundal massage after delivery of the placenta, substantially reduces the risk of PPH.  A meta-analysis from four facility-based clinical trials showed a 62% reduction in the risk of PPH associated with AMTSL (Prendiville et al, 2000). The World Health Organization (WHO), International Federation of Gynecologists and Obstetricians (FIGO) and the International Confederation of Midwives (ICM) recommend that skilled birth attendants provide AMTSL for all vaginal births (ICM and FIGO, 2003; ICM and FIGO, 2006). In the absence of a skilled birth attendant who can provide all of the components of AMTSL, the WHO, FIGO, and ICM recommend that oxytocin (10 IU) or misoprostol (400-600 mcg orally) should be given by a health worker trained in its use to prevent PPH.  Oxytocin is preferred to other uterotonic drugs where its use is feasible (Mathai et al, 2007; WHO, 2006).
Other preventive measures may either increase the woman’s chance of survival or prevent conditions associated with causes of PPH. These measures include:
  • During antenatal care: Detect and treat anemia, develop a birth preparedness plan to ensure giving birth with a skilled attendant, distribute misoprostol to pregnant women during the third trimester of pregnancy in case they give birth without a skilled birth attendant
  • During labor: Use a partograph to monitor and guide management of labor and quickly detect unsatisfactory progress, encourage the woman to keep her bladder empty, limit induction or augmentation use for medical and obstetric reasons, do not encourage pushing before the cervix is fully dilated, do not use fundal pressure to assist the birth of the baby, perform selective episiotomy for medical and obstetric reasons only, assist the woman in the controlled delivery of the baby’s head and shoulders to help prevent tears
  • During third stage of labor: Provide AMTSL(the single most effective way to prevent PPH), do not massage the uterus prior to delivery of the placenta, do not use fundal pressure to assist the delivery of the placenta, do not perform CCT without administering a uterotonic drug, do not perform CCT without providing countertraction to support the uterus.
  • After delivery of the placenta: Routinely inspect the vulva, vagina, perineum, and anus to identify genital lacerations, routinely inspect the placenta and membranes for completeness, evaluate if the uterus is well contracted and massage the uterus at regular intervals after placental delivery to keep the uterus well-contracted and firm (at least every 15 minutes for the first two hours after birth), teach the woman to massage her own uterus to keep it firm, monitor the woman for vaginal bleeding and uterine hardness every 15 minutes for at least the first two hours, encourage the woman to keep her bladder empty during the immediate postpartum period
Treatment
Severe PPH occurs in approximately 11% of live births (WHO, 2005). The incidence is thought to be much higher in developing countries where many women do not have access to a skilled attendant at delivery and where active management of the third stage of labor may not be routine. Of the women who suffer severe blood loss postpartum, approximately 1% of these die as a result (Fawcus, 2007). If PPH does occur, positive outcomes depend on how healthy the woman is when she has PPH (particularly her hemoglobin level), how soon a diagnosis is made, and how quickly effective treatment is provided after PPH begins.
Important clinical interventions and technologies are available to prevent and treat PPH but are either underutilized or not accessible to women giving birth in communities or peripheral health care facilities. To manage PPH non-surgically, evidence exists to support the following interventions:
  • Initial general management: administration of oxytocin, emptying the urinary bladder, fluid replacement, examination of birth canal and placenta,
  • Specific management for uterine atony: uterotonic drugs, uterine massage, bimanual compression of the uterus (external or internal), aortic compression, balloon condom catheter, hemostatics
  • Specific management for genital lacerations: repair of genital lacerations, hemostatics, compression
  • Specific management for retained placenta: manual removal
  • Continued management until the woman reaches the appropriate facility or the appropriate provider: anti-shock garment, IV perfusion, “walking” blood bank
If conservative non-surgical treatment has failed, one or more of the following surgical interventions may be necessary (FIGO and POPPHI, 2009):
  • B-Lynch suture (use Monocryl suture or Vicryl number 2): The B-Lynch suture aims to exert continuous vertical compression on the uterine vascular and muscular system. Laparatomy, uterine exteriozation and an opened uterine cavity are always necessary.
  • Uterine artery embolization: A patient must be sufficiently stable to transport to the angiography suite. Embolization should be considered early because it may take time to mobilize services. When embolization is successful, the patient can rapidly recover without undergoing additional surgery. Embolization not only saves the life of the patient, but also the uterus and adnexal organs, thus preserving fertility.
  • Internal iliac artery ligation: This could be used as a prophylactic or therapeutic operation. There is a need for a competent obstetrician who is conversant and competent at pelvic gynecological procedures.
  • Stepwise devascularization: The essential requirements are not simple and may not be available in every unit. There is a need for a competent obstetrician who is conversant and competent at pelvic gynecological procedures, and who has a working knowledge of the pelvic anatomy, including the vascular and neurological supply of the pelvic organs.
  • Hysterectomy: Hysterectomy is the best immediate option to save the hemorrhaging woman’s life when uterine atony is unresponsive to uterotonics and where facilities for embolization are not available and/or the obstetrician is not well versed with the technical aspects of conservative surgical procedures or iliac artery ligation.
Ongoing research
While work on preventing and treating PPH has been considerable, there is a great deal that needs to be done to continue the momentum and expand access to interventions that address the considerable morbidity and mortality caused by PPH. Many organizations, including those listed on this website, are involved in ongoing research and demonstration projects. Results from these studies and demonstration projects will increase the evidence base for interventions being promoted and provide guidance for their implementation. We can all make a difference, one woman at a time.
References
  • World Health Organization (WHO). Recommendations for the Prevention of Postpartum Haemorrhage (summary of results from a WHO technical consultation, October 2006). Geneva: WHO; 2007.
  • Abou-Zahr C. The global burden of maternal death and disability. British Medical Bulletin. 2003;67:1–11.
  • World Health Organization (WHO). Maternal Health and Safe Motherhood Programme. Mother-baby package: implementing safe motherhood in countries. WHO/FHE/MSM/94.11 Geneva: WHO; 1996.
  • Impact International. Measuring and Addressing Outcomes After Pregnancy: A Holistic Approach to Maternal Health. Immpact International: Aberdeen, United Kingdom; February 2007. Available at:www.prb.org/pdf07/Outcomes.pdf. Accessed April 2, 2007.
  • Koh E, Devendra K, Tan L K. B-Lynch suture for the treatment of uterine atony. Singapore Med J 2009; 50(7): 693-697.
  • JHPIEGO. Preventing Postpartum Hemorrhage: Active Management of the Third Stage of Labor—A Maternal And Neonatal Health Program Best Practice. JHPIEGO Trainer News. Washington, DC: JHPIEGO; November 2001. 
  • Prendiville, W.J., D. Elbourne, and S. McDonald, Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev, 2000(2): p. CD000007.
  • International Confederation of Midwives and International Federation of Gynaecology and Obstetrics, Joint Statement, Management of the third stage of labour to prevent postpartum hemorrhage. 2003: The Hague, London.
  • International Confederation of Midwives (ICM), International Federation of Gynaecology and Obstetrics (FIGO). Prevention and Treatment of Post-partum Haemorrhage: New Advances for Low Resource Settings Joint Statement. The Hague: ICM; London: FIGO; 2006.
  • Mathai, M.G., A.M. et al., WHO Recommendations for the Prevention of Postpartum Haemorrhage. 2007, World Health Organization: Geneva.
  • World Health Organization. The World Health Report 2005.
  • Fawcus S. Treatments for primary postpartum haemorrhage: RHL commentary (last revised: 8 May 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.
  • FIGO and POPPHI. Job aid: Management of PPH. PATH: DC, 2009.