A Bundled Approach
At SaveMothers.org, we support the implementation of a standardized treatment with a bundled approach to PPH response. A bundled approach means relying on “bundles of interventions”, where one bundle consists of 3-5 key clinical interventions. These are put into a bundle to make them easier to remember, and to emphasize that all of them should be done quickly and without hesitation. Through a bundled approach, facilities in low-income areas around the world can gain access to affordable, effective, and longterm solutions for PPH. In locations where medical and treatment materials are limited, a bundled approach provides the most value for a reasonable cost.
Our support of the bundled approach is paired with ongoing advocacy for enhanced training, standardized implementation and monitoring, and serious action at the local and federal levels of legislation. Through this multi-faceted approach, medical communities around the world can address the major challenges facing PPH treatment. These measures will allow for more effective PPH treatment by medical facilities and for more lives to be saved.
Click the buttons below to view our supported PPH bundle in the field, as well as our supported action plan, which is used as educational material for PPH treatment. WHO hosted an expert consultation on PPH Bundles in December 2017, and there was consensus that every post partum hemorrhage should be treated rapidly by four interventions: uterine massage, uterotonics, IV fluids (crystalloids) and tranexamic acid. For PPH that is refractory to these four interventions, they add aorta compression, bimanual uterine compression, insert UBT, and apply NASG as recommended guidelines. These are depicted under the left button below. Under the right button below, the same interventions are illustrated in “Helping Mothers Survive Bleeding After Birth”.
Anemia Prevention and Treatment
An anemic pregnant woman has less safety margin at the time of birth.
If the anemia is severe, even a bleeding of less than 500 cc can have a fatal outcome. Detecting moderate and severe anemia during pregnancy is important both to treat and follow up the anemia during the remainder of pregnancy, and also to discuss with the woman where it is best to give birth. A higher level facility should be able to monitor for, prevent and treat PPH better than a more resource strapped one.
Most cases of PPH are impossible to predict, but some factors do raise the risk of dangerous PPH. Apart from anemia, discussed above, a very big fetus, twins or triplets, hydramniosis, previous PPH, and any bleeding in the last trimester of pregnancy are risk factors for PPH in the current pregnancy. It is important that community leaders, village health volunteers, families and pregnant women themselves are aware of these risk factors, so that proper planning for the best birthing care can be done.
AMTSL as a prophylactic intervention is composed of a package of three components or steps: 1) administration of a uterotonic, preferably oxytocin, immediately after birth of the baby; 2) controlled cord traction (CCT) to deliver the placenta; and 3) massage of the uterine fundus after the placenta is delivered. In 2012, the results of a large WHO-directed, multi-centred clinical trial2 were published and showed that the most important AMTSL component was the administration of a uterotonic.
The WHO trial also demonstrated that the addition of CCT did almost nothing to reduce haemorrhage. The women who received CCT bled 10 mL less (on average) than women who delivered their placenta by their own effort. There was a real difference, however, in terms of the length of the third stage: third stage was an average of six minutes longer among those women who did not receive CCT. The authors acknowledged that this can be an important amount of time, not so much for the woman, but for the management of busy labour and delivery units.
Considering data from this trial and the existing evidence concerning the role of routine uterine massage in the prevention of PPH, the WHO issued new recommendations clarifying that although administration of a uterotonic remains central to the implementation of AMTSL, the performance of CCT and immediate fundal massage are optional components.
In the past 20 years, a set of cost-effective interventions, suitable for implementation at both health center and hospital level, has been developed. Some of these can also be used in the community or at home. We thus have another set of tools to control moderate and severe PPH. The use of these tools is also increasingly being combined in a standardized and simplified approach.
In countries with high rates of facility births, there is a new opportunity to save mothers’ lives from PPH, using the above tools in a standardized way together with other routine actions against PPH (emptying the bladder, suturing ruptures, checking that the placenta is complete, IV fluids etc). One approach to simplify a standardized PPH treatment approach is to recommend a core set of interventions (e.g. uterotonics, uterine massage, TXA and IV fluids) to be done all at once in every case of PPH, and for the few women that in spite of this continue to bleed profusely – “refractory bleeding” – give all the further key interventions (bimanual massage, aorta compression, NASG and/or UBT). These two “clinical bundles” thus both consist of 4 interventions to be provided “routinely” in the corresponding cases of PPH. The purpose of a clinical bundle is to help staff remember a small number of clinical interventions, and not take step by step approach to single interventions.
A WHO Technical Consultation in 2017 concluded that the above interventions - all are since long recommended by WHO for PPH - should be considered for national PPH programs. More research is ongoing in this field.