Treatment for primary postpartum haemorrhage
RHL practical aspects by Fawcus S
This section outlines the functions that need to be performed at each level of health care to prevent and manage postpartum haemorrhage (PPH). The recommendations below are mostly based on expert opinion and observational studies rather than randomized controlled trials. For best results they should be converted into algorithms for local use.
FIRST CONTACT (PRIMARY CARE) LEVEL
At the primary health care level, the actions listed below can be taken to prevent and treat PPH.
Prevention (Systematic Review - SR) (1)
- Use of prophylactic haematinics and the treatment of anaemia in pregnancy.
- Active management of the third stage of labour with 10 IU oxytocin, (1) (SR).
- Risk assessment during antenatal care or early labour in order to identify women at risk of PPH, so that delivery can be planned at a referral-level health care centre (2).
- Use of partogram to prevent prolonged/obstructed labour.
Treatment (Expert committee) (3, 4).
- Resuscitation with intravenous lines and crystalloids.
- Diagnosis of the cause of PPH.
- Treatment of uterine atony. The standard first-line regimen is oxytocin infusion plus syntometrine. This could be replaced by either oxytocin infusion plus rectal misoprostol (hypertensive women) or, rectal misoprostol alone (5).
- Suturing of vaginal and perineal tears.
- Removal of placenta from cervical os.
- Intraumbilical injection of oxytocin for retained placenta (6)
- Arrangement of urgent transport for intractable haemorrhage.
- Initiation of temporizing procedures for transit—e.g. packing, compression, tamponade.
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
Prevention and treatment (Expert committee) (3, 4). At a secondary care level most activities that are needed are similar to those of primary care level. However, at this level there should be the possibility of doing more invasive diagnostic and therapeutic interventions
- Diagnosis of cause of PPH.
- Use of blood products in resuscitation.
- Central venous pressure monitoring of fluid balance with massive haemorrhage.
- Uterotonics including the standard regime, rectal misoprostol and prostaglandin F2 alpha.
- Manual removal of placenta.
- Repair of cervical tears.
- Laparotomy for B Lynch suture/stepwise uterine artery ligation/hysterectomy.
AT HOME OR IN THE COMMUNITY
Prevention and treatment (Expert Committee) (3, 4).
- Education about the unpredictable nature of PPH.
- Promotion of availability of skilled attendants at delivery.
- Education about uterine massage.
- Setting up of community transport systems.
- Establishment of referral links with traditional birth attendants.
References
- Abalos E. Management of the third stage of labour: RHL commentary (last revised: 7 July 2004). The WHO Reproductive Health Library No 8;Update Software Ltd, Oxford, 2005.
- Tsu VD. Postpartum haemorrhage—Zimbabwe: a risk factor analysis. British journal of obstetrics and gynaecology 100;1993:327-333.
- Guidelines for maternity care in South Africa. Pretoria, Department of Health;2000.
- Saving mothers. Policy and management guidelines for common causes of maternal death. Pretoria, Department of Health;2001.
- Lokugamage AV, Sullivan KR, Niculescu 1, Tigere P, et al. A randomised study comparing rectally administered misoprostol versus syntometrine combined with an oxytocin infusion for the cessation of primary postpartum haemorrhage. Acta obstetrica gynecologica scandinavica 2001;80:835-839.
- Carroli G, Bergel E. Umbilical vein injection for management of retained placenta. Cochrane review. Cochrane library. Issue 1. 2006.
This document should be cited as: Fawcus S. Treatment for primary postpartum haemorrhage: RHL practical aspects (last revised: 8 May 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.