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”.
The PPH Emergency Care Using a Bundle Approach training program is highly interactive and designed to be completed over three days in-person or via a virtual hybrid approach. Please click on the ''Thinkific Platform'' button below to freely access both clinical and non-clinical trainings.
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.
Joint Statements of Recommendation for the prevention and treatment of PPH
The International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) have published two joint statements of recommendation for the prevention and treatment of postpartum haemorrhage (PPH).
The Joint statement of recommendation for the use of uterotonics for the prevention of postpartum haemorrhage and the Joint statement of recommendation for the use of tranexamic acid for the treatment of postpartum haemorrhage are the culmination of strong and effective collaboration between FIGO and ICM – two of the world’s leading organisations representing specialists in midwifery, obstetrics and gynaecology.
Please find the joint the two joint statements below:
FIGO Generic Postpartum Haemorrhage Protocol and Care Pathways
The FIGO Generic Postpartum Haemorrhage Protocol and Care Pathways is now available to download online in English and French.
FIGO and ICM, working to support in-country Expert Working Groups in Burkina Faso, Ethiopia, Ghana, Rwanda, South Sudan, and Uganda, have developed a generic PPH protocol and clinical pathway tool, based on World Health Organization PPH recommendations, to inform a systematic approach towards the development of policy for PPH management in health facilities. The protocol provides examples of key definitions, early identification of risk, estimation of blood loss, choice of uterotonics, prevention and treatment at various levels of care, effective multidisciplinary teamwork, communication, and referral.
Please find the resources available below.
FIGO announces new IJGO supplement: Improving access to essential medicines to reduce postpartum hemorrhage morbidity and mortality
FIGO’s Improve Access to essential medicines to reduce PPH morbidity and mortality Project (IAP) (2021 – 2022) has published an open access supplement in Issue 158(S1) of the International Journal of Gynecology and Obstetrics (IJGO). The supplement, published on 28 June 2022, provides seven original contributions on medicines and management of PPH.
Supplement key findings
The papers in this new supplement broadly cover policy and regulatory issues, research and development, including new medicines in the pipeline and new routes of administration of old medicines, addressing quality of medicines in low- and middle-income countries (LMICs). There are also strategies to improve PPH prevention and treatment.
Key findings in the supplement highlight the importance of developing and disseminating context-specific, evidence-based PPH guidelines for improved quality of care and the critical role of innovation in the prevention and treatment of PPH. Quality assurance systems along the supply chain of essential medications are needed as an integral part of the health system for optimal outcomes.
The papers in the supplement are as follows:
- Improving postpartum hemorrhage care: Policy, practice, and research
- FIGO and the International Confederation of Midwives endorse WHO guidelines on prevention and treatment of postpartum hemorrhage
- Challenges in updating national guidelines and essential medicines lists in Sub-Saharan African countries to include WHO-recommended postpartum hemorrhage medicines.
- A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014–2017.
- Differences in obstetric practices and outcomes of postpartum hemorrhage across Nigerian health facilities.
- Innovations in the prevention and treatment of postpartum hemorrhage: Analysis of a novel medicines development pipeline database.
- Alternative routes to intravenous tranexamic acid for postpartum hemorrhage: A systematic search and narrative review.
- Quality of oxytocin and tranexamic acid for the prevention and treatment of postpartum hemorrhage in Kenya, Nigeria, South Africa, and Tanzania.