PPH Prevention and Management at Health Facilities

Jeffrey M. SmithAsia Regional Technical Director

AME Regional MeetingBangkok March 2010

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OBJECTIVES

Describe global guidance on postpartum hemorrhage prevention and management in health care facilities

Review specifically the provision of Active Management of Third Stage of Labor

Discuss policy and situational considerations for the implementation of PPH reduction strategies

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A Pause for Epidemiology

Obstetric-Related Deaths per year

Maternal Deaths: 536,000 Neonatal Deaths: 3.4

million (most obstetrical)

Stillbirths: 4 million (most obstetrical)

Infectious Disease Deaths per year

HIV Deaths: 2 million TB Deaths: 1.6 million Malaria Deaths: 1.3

million

TOTAL Obstetrical Deaths per year = 6.5 million

TOTAL Infectious Disease Deaths per year = 5 million

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Distribution of Maternal Deaths Asia Specific Distribution

Unclassified 6%

Other Indirect12%

Ectopic Preg0%

Embolism 0%

Other Direct

2%

Anaemia13%

Obstructed Labor9%

Abortion6%

Sepsis12%

Hypertensive9%

Haemorrhage31%

Haemorrhage

Hypertensive

Sepsis

Abortion

Obstructed Labor

Anaemia

Ectopic Preg

Embolism

Other Direct

Other Indirect

Unclassified

Khan, et al; WHO Analysis of Causes of Maternal Deaths; Lancet April 2006

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Recommendations for PREVENTION of PPH in Health Care Facilities

Active management of third stage of labour (AMTSL) should be offered by all skilled attendants at every birth to prevent postpartum haemorrhage (PPH).

Oxytocin is the uterotonic of choice for prevention of PPH.

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Evidence for AMTSL

AMTSL prevents PPH by over 60% (RR: 0.38,

95% CI 0.32-0.46) and therefore should be offered by all skilled birth attendants at every childbirth.

Oxytocin is the preferred drug because It is effective in 2-3 minutes after injection, has minimal side effects, can be used in all women, and is more stable in storage than ergometrine.

Oxytocin is the better choice than ergometrine or misoprostol, when all are available

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Integrating the Steps for AMTSL

Integration of AMTSL with: Immediate newborn care Support for breastfeeding Immediate postplacental

insertion of IUCD Obstetrical emergencies

1. Give oxytocin immediately: Within 1 minute of birth of baby Oxytocin 10 units IM

2. Deliver the placenta by controlled cord traction Wait until cord pulsations cease

or 2-3 minutes Delayed cord clamping reduces

newborn and infant anemia

3. Massage the uterus Ensure uterine tone

Integrated Steps for AMTSL and Immediate Newborn Care: Skilled Birth Attendant With Oxytocin

Deb Armbruster and Sushie Engelbrecht, POPPHI Project

AMTSL and Breastfeeding

Bolus of oxytocic is necessary to achieve the strong contraction that helps separate placenta and establish good uterine tone

AMTSL helps achieve uterine tone Ongoing breastfeeding helps maintain uterine

tone Breastfeeding is an essential maternal/newborn

care practice, but not sufficient for AMTSL

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AMTSL: A NECESSARY Part of Care for Normal Birth

Every birth should be attended by a skilled attendant

All national policies on skilled care during childbirth must include the provision of AMTSL

Every skilled birth attendant should be allowed to provide AMTSL

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AMTSL: Who, How, Where?

Countries need to do an analysis of People who attend births and are

called “skilled attendants” Permission and ability of those

cadre to perform AMTSL Logistic systems that support

provision of oxytocin Policies and service delivery

frameworks that clearly state at which levels of the health care system skilled care, including AMTSL, can be provided.

HMIS/monitoring systems that track the implementation of AMTSL

PPH: Other causes and other prevention strategies

Causes Retained placenta Retained placental fragments Episiotomy and lacerations Uterine rupture

Prevention Strategies Partograph Avoid unnecessary episiotomy Inspection of placenta Inspection for lacerations Postpartum monitoring for

minimum of 6 hours

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Afghanistan Yes

Bangladesh Yes

Cambodia Partial

East Timor Partial

Egypt Partial

India Partial

Indonesia Partial

Nepal Partial

Pakistan Partial

Palestine Partial

Philippines Partial

Vietnam Partial

Yemen Partial

Midwives and BEOC

Do policies allow midwives to provide a complete set of

BEOC interventions?

Align People, Services and Systems

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Major Obstetrical

Killers

Global Definition

of Basic EOC

Policies and Clinical

Guidelines

Midwifery Job Description,

Competencies Capabilities and

Environment

Consistency and Alignment

Oxytocin in pre-filled Uniject™ device

• Uniject™ :

– Used in vaccines (HBV / tetanus) and contraceptives

– Validating / early introduction for oxytocin and gentamicin

• Oxytocin in Uniject™

– Studies in Indonesia, Angola,

Vietnam, and Mali have shown that

Uniject is:

– preferred by providers,

– units cannot be re-used, and

– utilization / storage /

elimination are easier Deb Armbruster and Sushie Engelbrecht,

POPPHI Project

Time-Temperature Indicator for Oxytocin in Uniject™

Chemical time and temperature cumulative exposure factor

Rate of color change calibrated by manufacturer based on stability studies

Advantages: Improvement in overall quality assurance of

programs – only effective oxytocin would be used

Flexible cold chain management Longer “out of cold chain” periods possible

than with other products Product can be available at peripheral

health facilities and for home births with skilled providers

Deb Armbruster and Sushie Engelbrecht, POPPHI Project

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Management of PPH

Must be treated like an emergency Mobilize resources / staff Shout for help

General management Stabilize the patient Treat for shock

Determine the cause Specific management

Based on diagnosis

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PPH Clinical Interventions

Basic EmOC Management of shock Uterotonics Bimanual compression Suturing of lacerations Aortic compression Manual removal of placenta Antishock garment

Comprehensive EmOC

Uterine artery ligation B-lynch procedure Hysterectomy Blood transfusion

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Evidence regarding TREATMENT of PPH in Health Care Facilities:

Cochrane Review 2006 Search for pharmacological, surgical or

radiological interventions for the treatment of PPH

Insufficient data on surgical and radiological techniques

3 trials on use of misoprostol No proven benefit for reduction of

PPH, maternal mortality or surgery

New clinical trials on use of misoprostol 2006 - 2009 Some completed and ongoing trials by Gynuity and others suggest a

possible role for misoprostol in management of PPH

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Strategy for Reduction of PPH:MOPH of Afghanistan

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Conclusions

At health care facilities Prevention strategy is clear!

– AMTSL for all deliveries Management approach is less clear

– On-going studies to be followed

Need to consider not just technical interventions but also the programmatic approach ALL SBAs should be authorized and

trained to provide AMTSL and basic management of PPH

The best technical intervention is only the best when we can get it to the greatest number of people

Thank You!

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