Actions for clinical teams
The actions for clinical teams are both upstream (putting in place the right conditions to reduce risk of PPH and enable effective clinical care) and downstream (remaining aware and responding appropriately during and immediate after the birth).
Upstream actions for clinical teams include prevention efforts, such as assessing pregnant women for risk factors such as anemia and referring women at high risk to healthcare facilities that can provide the correct level of care.
Downstream actions for clinical teams include following correct procedures during and after the birth.
1. Reducing risk
Most cases of PPH are impossible to predict, but some factors do make it more likely, including:
- anemia (see below)
- a very big fetus
- twins or triplets
- hydramniosis
- PPH in a previous pregnancy
- any bleeding in the last trimester of pregnancy
It is important that community leaders, village health volunteers, families and pregnant women themselves are aware of these risk factors. That way, proper planning can take place to ensure the best birthing care.
Focus on anemia
Anemia is considered a critical condition during pregnancy and an anemic pregnant woman is at higher risk at the time of birth. If the anemia is severe, even bleeding less than 500 ml can be fatal.
This is why detecting anemia (whether moderate or severe) during pregnancy is important. This enables the healthcare team to treat and follow up the anemia during the remainder of pregnancy and to discuss with the mother where would be best for her to give birth. (A higher-level facility should be able to monitor for, prevent and treat PPH better than one with fewer resources.)
For anemic women whose hemoglobin is less than expected (7–11g/dl), care centres must provide daily oral iron tablets for six months. Iron-rich diets have also proven to be effective, so teams need to provide sufficient advice and information about these diets.
Where a woman is anemic and at risk of PPH, facilities should make an early referral to higher facilities, to ensure easy access to transfusion and other medical care.
See also The Bleeding after birth action plan – a practical, effective method to prevent bleeding after birth in mothers.
2. Staying alert
It is almost impossible to predict PPH before it happens. This makes it crucial that medical professionals and caretakers do everything they can to prevent it.
One-to-two hours after birth is the period when the risk of PPH is highest. Every new mother must be monitored very carefully during this period.
The 'golden minute' refers to the first 60 seconds of a newborn baby's life, after they have fully left the birth canal. This period is a critical time for ensuring the baby has a good oxygen supply, but it is also a crucial timeframe for the mother.
3. Techniques during and after the birth
If PPH is discovered, severe blood loss can happen in a matter of minutes so it is essential to act quickly and stop excessive bleeding at once. Doing this will greatly increase the mother's chance of survival. This section details evidence-based interventions known to reduce incidence or harm from PPH
See the Bleeding after birth action plan for a detailed description of these steps.
Misoprostol
| Community level | Primary healthcare | Hospital |
| Yes |
Misoprostol is a fairly new drug that is an effective uterotonic, among other uses.
Misoprostol tablets are effective for routine use at home, taken by the new mother. They are handed out at ANC visits in the last trimester, with the pregnant woman advised to take them after giving birth at home if she cannot make it to the facility in time.
She is advised to either take them immediately after the birth of the placenta or in case of major bleeding after birth.
Non-pneumatic anti-shock garment
| Community level | PHC level | Hospital level |
| Yes |
This neoprene garment, used to treat shock and bleeding, is strapped to the legs and lower abdomen and tightened with Velcro strips. Evidence shows that where it is used correctly, it will save the lives of 80–90% of women with severe PPH. It can be ordered for around US$40 USD (for instance, from Maternova) and has a lifespan of more than 10 years. During this time, it can be used more than 100 times.
Active management of the third stage of labour
| Community level | PHC level | Hospital level |
| Yes |
This stage involves administering a uterotonic (usually oxytocin) immediately after the birth. Two optional steps include controlled cord traction to deliver the placenta; and massaging the uterine fundus after the placenta is delivered.
Oxytocin supplies may be of variable quality and need to be stored in a cold chain. For this reason, some countries are replacing it with heat-stable carbetocin, using this routinely at all births to prevent PPH. Heat-stable carbetocin is an injectable drug and costs the same as oxytocin. However, so far, it has not been proven effective for treating PPH, nor for induction or augmentation. This means that for years to come, oxytocin still needs to be available in the delivery room, alongside heat-stable carbetocin.
Tranexamic acid
| Community level | PHC level | Hospital level |
| Yes |
Tranexamic acid (TXA) is a drug that helps the blood coagulate more quickly by reducing the body’s normal ability to dissolve clots. Giving a woman with PPH TXA intravenously as soon as possible after the diagnosis of a major bleed reduces her chance of maternal mortality by 30%, with no reported side effects. The drug is fairly cheap drug, so it should be made routinely available at all health facilities in the world where babies are born.
Uterine balloon tamponade
| Community level | PHC level | Hospital level |
| Yes |
The uterine balloon tamponade (UBT) is a simple device inserted through the cervix and then gently inflated to stem the flow of blood. UBTs can save over 95% of PPH mothers who are in shock.
Since the invention of this device, in the 1980s, there have been many designs, ranging from pricey, disposable devices used in high-income countries to condom catheters improvised locally. Today, there are two pre-packaged, disposable low-cost options, extensively tested and certified:
- Ellavi an industrially made device produced by Sinapi, costing US$10–12
- Uterine Balloon Tamponade a device that is assembled from existing components, costing around US$3.
Aorta compression
| Community level | PHC level | Hospital level |
| Yes |
External aortic compression is an emergency manoeuvre designed to reduce postpartum hemorrhage and allow time for resuscitation and to control the bleeding. It involves manually pressing down on the abdomen to stem the flow of blood through the aorta to the vagina.
This simple technique is not taught to obstetricians as a means of controlling major pelvic hemorrhage, but if a woman has severe PPH it can be effective.
It is recommended in cases of severe life-threatening postpartum hemorrhage – particularly when a patient is being stabilised or transported. It may be used as an adjunct to other measures –especially in locations or situations where there is no access to advanced medical assistance.
Compression suture technique
| Community level | PHC level | Hospital level |
| Yes | ||
Uterine compression suture is a medical procedure used to help treat PPH – particularly to avoid a hysterectomy, which can be a last-resort treatment for PPH. It involves inserting stitches through the outside of the abdomen, to compress the uterus. There are various types, including the B-Lynch, Hayman and Pereira sutures. All three are effective at treating postpartum hemorrhage where the uterus fails to contract after delivery.
Compression sutures have been reported as an effective method in treating PPH, but experience with this method is thought to be limited.
Suturing the internal iIliac artery
| Community level | PHC level | Hospital level |
| Yes |
This technique involves closing up the internal iliac artery – the main vessel supplying blood to the pelvic viscera. Suturing this artery has a 40–100% success rate in controlling massive pelvic hemorrhage. All pelvic surgeons should be familiar with this procedure, to stop massive pelvic hemorrhage.
The procedure does carry a risk of operative injury, so the surgeon needs detailed knowledge of anatomic landmarks and basic steps of internal iliac artery suture, along with good exposure, to achieve the procedure with the manoeuvre of traction and counter-traction. It is best to suture both sides of the artery, to control the total blood flow in the pelvis, and this is best done with the surgeon changing operative side during the procedure.
4. Care bundles
In the past 20 years, a set of cost-effective interventions has been developed to help control moderate and severe PPH and save lives. Most are suitable for using at health centres and hospitals, but some can also be used in the community or at home.
These interventions are increasingly being incorporated into standardised, simplified approaches called care bundles. Each bundle includes just four key actions, alongside other steps such as emptying the bladder, suturing ruptures, checking that the placenta is complete and providing IV fluids.
The following set of actions were agreed at a World Health Organization expert consultation on PPH bundles in 2017.
Bundle 1
This is a standardised treatment approach for every case of PPH, comprising four actions, designed to be carried out at the same time:
- uterotonics
- uterine massage
- tranexamic acid (TXA)
- IV fluids (crystalloids)
Bundle 2
This offers a further set of actions for teams working with a woman who, in spite of interventions, continues to bleed profusely (‘refractory bleeding’):
- bimanual uterine massage
- aorta compression
- non-pneumatic anti-shock garment (NASG)
- uterine balloon tamponade (UBT)
Each of these two bundles consists of just four interventions to be provided routinely. This is intentional as it helps staff remember a small number of clinical interventions that should be done quickly without hesitation, rather than taking a step-by-step approach to individual interventions.
To be effective, a bundled approach must be part of a multi-faceted approach that includes enhanced training, standardised implementation and monitoring, and serious action at the local and federal levels of legislation.
Resources
- supported PPH bundle in the field
- supported action plan, used as educational material for PPH treatment.
