Prevention, Identification

and Management of PPH

Learning Objectives
By the end of this session, learners will be able to:

• Define PPH and list its causes

• Describe the importance of AMTSL and other measures to prevent PPH

• Describe ways to identify PPH clinically

• Describe ways to identify and manage shock

• Describe the cause specific management of PPH

• Demonstrate the initial management of retained placenta and atonic PPH including bimanual uterine
compression, aortic compression and condom tamponade on model
 Prevention of PPH is the Most Important
Part of its Management
PPH can be prevented by:
› Ensuring BPCR, SBA and treatment of anaemia
› Early identification of prolonged and obstructed
labour by partograph
Haemorrhage › Avoiding unnecessary augmentation, fundal
Others 31% 27%
pressure and episiotomies
› Controlled head delivery with perineal support
Sepsis 11% › Active Management of Third stage of Labour
(AMTSL)
Abortion 8%
› Checking of completeness of placenta after
delivery
Obstructed
labour 9% Hypertensive
disorders 14%
Source- WHO 2014

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 ICM/FIGO Joint Statement on Active Management of
the Third Stage of Labor (AMTSL)

• AMSTL has been proven to reduce the incidence of

postpartum hemorrhage, reduce the quantity of blood loss
and reduce the use of transfusion
• AMSTL should be offered to all women who are giving birth
• Every attendant at birth needs to have the knowledge, skills
and critical judgment needed to carry out AMSTL

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Prevention of PPH-AMTSL
• The three critical steps of AMTSL are:
 Administration of uterotonic drug
» For facility births: Inj. Oxytocin-10IU, IM/Tab
Misoprostol-600mcg,oral or Inj. Carbetocin 100 mcg
IM/IV within 1 minute of delivery of baby after ruling out
another baby in the uterus
» For home births: Advanced Distribution of Misoprostol to
pregnant women for self administration (ADMSA)
 Controlled cord traction during contractions
 Feel uterine tone. Massage uterus if uterus is relaxed
• One additional step is delayed clamping of cord within 1-3
minutes or till cord pulsations stop
• Approximately 66% cases of PPH can be prevented if AMTSL is
done in all cases (normal and caesarean) after delivery
• It helps in expulsion of placenta and reduction in blood loss

CHAMPION TRIAL: For comparison study of Inj. Carbetocin with

other uterotonics in prevention of PPH
Injection oxytocin - First choice of uterotonic for prevention of PPH
• Use of Oxytocin in childbirth:
› Induction of labour/ Augmentation of labour 2012 & 2018 WHO
recommendations
› AMTSL
› PPH management
• Inexpensive, Widely available, quick action fewer side effects
• Storage – 2-8 degree C in complete cold chain, never frozen to ensure quality.
• Onset of action – immediate with IV and 2-3 minutes with IM
• Duration of action – Peak action is 30 minutes after IV & upto 60 mins when given IM IM.
• Dose for AMTSL – 10 IU IM/IV within one minute of delivery of last baby

• Precaution – always rule out another baby before any uterotonic for AMTSL otherwise
this may lead to strong uterine contraction/ruptured uterus/death of mother/fetal
asphyxia/cerebral palsy or death of baby
• Getting ready: be sure to have oxytocin drawn up in the syringe before the birth
Injection room temperature stable carbetocin or heat stable carbetocin (HSC)
• Storage: doesn’t require refrigeration during transportation and storage

• Potency: high potency in hot climate, must be protected from light.

› At 30 degree and 75 % relative humidity potency is minimum of 4 years.
› At 40 degree and 75% relative humidity potency is minimum of 6 months
› At 50 degree it is 3 months
› At 60 degree it is 1 month

• Uses: In AMTSL for prevention of PPH, where oxytocin is not available, and its quality cannot be guaranteed or cold storage for oxytocin is
not available. Only single dose to be administered

• Onset of action: 1 min after IV injection and 2 min after IM injection

• Duration of action: 1 hr. after IV and 2 hrs after IM injections

• Dose: For AMTSL dose is 100 mcg IM/IV given within one minute of birth after last baby

• Precaution – always rule out another baby before any uterotonic for AMTSL otherwise this may lead to strong uterine contraction which
may kill both women and the baby

• Contraindications: Pregnancy, serious cardiovascular disorders, epilepsy, liver and kidney disorders. IT SHOULD NOT BE USED FOR
INDUCTION OR AUGMENTATION OF LABOUR

• Side effects: Nausea, Abdominal pain, headache, shivering and fever

• Getting ready: be sure to have the carbetocin out and ready to give before the birth
Overarching challenges with clinical management of PPH

 PPH is often not detected early = life-saving treatment is not

promptly initiated
 Delayed or inconsistent use of all WHO recommended 1st line
interventions for PPH management
WHO recommendations on Assessment of 1st Global Summit on PPH March
PP blood loss & use of treatment bundle 2023- To end preventable maternal
deaths due to PPH b/w 2023-2030
for PPH
What is a bundle?

 A group of “things” often bound together with a strap

 In AMPLI-PPH we started out calling TXA, HSC and ADMSA a “bundle” of drugs for PPH.
 A bundle is a structured way of improving the processes of care and patient outcomes: a
small set of evidence-based practices — generally three to five — that, when performed
collectively and reliably, have been proven to improve patient outcomes.
 Key to clinical bundles: All components of a bundle are given in the shortest possible time,
without waiting for a response to individual interventions.
 When the complete set (or “bundle”) has been given, improvement in outcomes has been
shown for some diagnoses.

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What was the design of the E-MOTIVE study?

• Multi-country, cluster-randomized trial

• 80 hospitals randomly assigned to receive trial intervention for 7 months, with a 2-
month transition period for training and implementation, or to continue providing
usual care
• Included both early detection and treatment bundle
› Detection: Calibrated blood-collection drape
› Bundle: Uterine massage, oxytocic drugs, TXA, intravenous fluids, examination, and escalation of
treatment when needed
• Primary outcome was a composite of severe PPH (blood loss, ≥1000 ml), laparotomy for
bleeding, or maternal death from bleeding
• Looked for impact on detection and treatment of PPH in patients having vaginal delivery
CONCLUSION: Among patients having a vaginal delivery, use of the E-MOTIVE bundle led
to a lower risk of severe postpartum hemorrhage, laparotomy for bleeding, or maternal
death from bleeding compared to usual care.
FIGO recommendations on the prevention & treatment of PPH
2022
Recommendations for prevention of PPH:
1. Use of uterotonics for prevention of PPH during the third stage of labor is recommended for all births.
(Inj. Oxytocin/Inj Carbetocin/Methyl ergometrine/oral misoprostol
2. In settings where skilled birth attendants are unavailable, controlled cord traction (CCT) is not
recommended.
3. Sustained uterine massage is not recommended as an intervention to prevent PPH in women who have
received prophylactic oxytocin
4. Postpartum abdominal uterine tonus assessment for early identification of uterine atony is
recommended for all women
FIGO recommendations on the prevention & treatment of PPH 2022
Recommendations for treatment of postpartum hemorrhage:
1. Uterotonics: IV oxytocin infusion is choice. Other uterotonics are- intramuscular ergometrine, oxytocin–
ergometrine fixed dose, or a prostaglandin drug (including sublingual misoprostol, 800 μg) is recommended
2. The use of isotonic crystalloids is recommended in preference to the use of colloids for the initial intravenous
fluid resuscitation of women with PPH
3. Early use of intravenous 1 gm tranexamic acid in 10 mins as soon as PPH is diagnosed but within 3 h of birth in
addition to standard care is recommended for women with clinically diagnosed PPH following vaginal birth or
cesarean delivery
4. Uterine massage is recommended for the treatment of PPH
5. Mechanical compression methods are recommended if women do not respond to t/t with uterotonics
6. Use of NASG is recommended as temporizing measure
7. The use of uterine packing is not recommended for the treatment of PPH due to uterine atony after vaginal
births
8. Uterine artery embolization or surgical interventions if bleeding does not stop despite conservative
management
9. The priority is to stop the bleeding before the patient develops coagulation problems and organ damage from
under-perfusion
Identification of PPH
1. Quantification of blood loss- measurement: Blood loss of
>500 ml in vaginal births or >1000ml in CS occurring within
the first 24 h of delivery. Revised definition by ACOG 2017:
blood loss of more than or equal to 1000 ml, or blood loss
that was accompanied by signs or symptoms of hypovolemia
occurring within 24 h after birth, regardless of the mode of
delivery
2. Visual estimation of blood loss- has high potential to
underestimate blood loss
3. Hemodynamic status by evaluation of clinical parameters.
Recently added shock index, rule of 30 & obstetric early
warning systems
Definitions
1. Primary PPH: is defined as blood loss of 500 mL or more within 24
hours of a vaginal birth or 1000 mL or more after cesarean delivery, or
any blood loss sufficient to compromise hemodynamic stability.
2. Severe PPH: is defined as blood loss of 1000 mL or more after
vaginal birth or 1500 mL or more after cesarean delivery.
3. Massive PPH: which is blood loss of either 2000 mL OR 2500 mL or
more (depending on definition used) within 24 hours of birth or when
the woman is hemodynamically compromised OR showing signs of
shock as a result of obstetric hemorrhage of any amount over 500 mL.
4. Secondary PPH: is defined as excessive blood loss from the genital
tract after 24 hours following delivery, until six weeks post-delivery.
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Signs & Symptoms of shock due to PPH

Hypotension: systolic BP,

Tachycardia: Pulse, >110/minute Tachypnea: Fast
<90 mm of Hg
respiratory rate

Hypothermia: Skin cold and clammy Semi Conscious Unconscious

Recognising massive PPH

Shock Index
Rule of 30

Base deficit
> 6 (mmol/L)
 “Rule of 30”
30% loss in blood volume = moderate shock

Heart rate rise Respiratory

Systolic BP fall
by 30 rate rise by 30
by 30mmHg
beats/min breaths/min

Haemoglobin
Urine output
(hematocrit)
<30ml/hr
drop by 30%
Shock Index or OSI

SI is defined as the ratio of heart rate to systolic blood pressure

SI=HR/SBP OSI: 0.7-0.9 Non pregnant: 0.5-0.7
Helps in early identification of women at risk of hypovolemia as the result of obstetric causes
reliable indicator of adverse maternal outcomes
The SI, together with the rule of 30, are important tools that may aid clinicians
in an emergency
to determine the amount of blood loss and the degree of hemodynamic
instability
FIGO considers that the shock index can be a marker of the severity of PPH and can alert teams to
hemodynamic instability when its value is greater than 0.9. SI>1 increases the likelihood of blood
transfusion.
A threshold of SI ≥0.9 should be tested to alert community healthcare providers of the need for urgent
transfer
Classification of hypovolemic shock
Signs Class I Class II Class III Class IV

Blood loss 500-1000 1200-1500 1800-2100 > 2400

(mL) 15% 20-25% 30-35% > 40%
Pulse/min Normal 100 120 140

Systolic BP Normal Normal 70-80 60

(mm Hg)
Tissue No Pallor, rapid Collapse,
Perfusion symptoms or signs respiration, anuria, Rapid RR
restlessness, (air hunger), cold
oliguria, cold skin skin

Mental Normal Agitated Confused,

status response agitated,
aggressive

The blood loss is replaced by IV fluids.

IV fluids should be given when losses amount to 700mls
Initially give 1 lt in 20 min and decide further fluid requirement based on the vital parameters

Blood Volume 65 ml/Kg

Causes of PPH

Primary/ Immediate PPH Secondary/ Delayed PPH

Occurring during delivery till 24 From 24 hours postpartum till 42
hours postpartum days or 6 weeks
• Tone - Atonic PPH - Most • Infection in the uterus
common cause (70%) • Retained placental fragments
• Tears or trauma (15-20%)
• Tissue - retained or incomplete
placenta, membranes (Increase
risk of PPH by 3.5 times)
• Thromboembolic –
Coagulopathy (Can be inherited
or acquired)
Management of PPH-
GoI protocol
Final care bundles for postpartum hemorrhage

•FIGO recommends incorporation of the PPH bundle approach in the

management of PPH.
Management of PPH – Bundle Approach
Active Management of the Third Stage of Labor (AMTSL)

AMTSL

Uterotonic. Inj. CCT Feel uterine tone-

Oxytocin/HSC/T Massage if relaxed
ab misoprotol
 CALL FOR HELP! – Immediate TRIAGING, ABCDE
Rapid initial assessment – vitals and Resuscitation by ERT

CALL for HELP

First Response
Bundle
E MOTIVE
Check for uterine tone.
If relaxed then Massage
to contract the uterus
and express clots
Uterotonic Medications
Recommended -
Oxytocin/misoprostol/
Methyl
ergometrine/combination of
oxytocin and
methylergometrine
Drugs for PPH Management
Drug Dose and route Continue dose Max dose Precaution and
contraindication
Oxytocin 20IU in 1000ml IV infuse 20 IU in Not more Do not give IV as bolus
RL/DNS 1000ml RL/DNS than 3L of IV
60 drops/ min 40 drops/min fluids
IV infusion IV infusion containing
Oxytocin

Ergometrine IM or IV (slowly) Repeat 0.2. mg after Five dose High BP, PE, Heart
0.2 mg 15 min. If required (Total 1.0mg) disease
give 0.2 mg IM/IV
slowly every 4 hrs

15- Methyl IM o.25 mg 0.25 mg every 15 min 8 doses (total Asthma

prostaglandin F2- 2mg)
alpha

Misoprostol PGE-1 800 micrograms Single dose Single dose -

PR/sublingual

Inj. Tranexamic 1 gm slow IV in Can be repeated after Not more than H/O coagulopathy or
Acid 10 mins 30 mins 10 mg/Kg 3-4 active intravascular
times daily. clotting, convulsions
 Inj. Tranexamic
Acid
with in 3 hrs WOMAN trial
1gm IV – one dose
can be repeated in
30 mins
Conclusions from WOMAN trial
IV fluids:
- Wide bore cannula
- Crystalloids
- No massive infusions
- Investigations
- Arranging blood at the earliest
possible
 First Response:
Supportive Measures
Check for tears
and repair
Empty the
bladder
Empty the uterus
Response to Refractory
PPH Bundle
 Compression
Maneuvers:
- External Aortic Compression
- Bimanual Uterine Compression
 Bimanual Uterine Compression
• Empty urinary bladder with Foley’s
catheter
• Insert gloved hand in vagina, remove
any visible clots from vagina
• Place fist in anterior vaginal fornix
and press against anterior wall of
uterus
• Place other hand on abdomen
behind uterus, pressing against
posterior wall of uterus
• Maintain compression until bleeding
is controlled and uterus contracts
Compression of Abdominal Aorta
• Apply downward pressure with
closed fist over abdominal aorta
directly through abdominal wall
• With other hand, palpate
femoral pulse to check
adequacy of compression
o Pulse palpable = inadequate
o Pulse not palpable = adequate

• Maintain compression until

bleeding is controlled
Condom Tamponade
Insertion:
 Ensure that the bladder
is empty.
 Hold cervix with a ring
forceps.
 Place a Sims speculum in
posterior vaginal wall.
 Insert catheter with
condom tied onto the
end (tied using sterile
suture), into the vagina.
 Holding cervix with
forceps, push condom
further into uterus.

Source: Jhpiego
Condom Tamponade
Inflation:
 Connect open end of
catheter to IV set
attached to infusion
bag & inflate with
300 to 500 ml saline.
 Clamp catheter after
inflating.
 Maintain in-situ for
12 to 24 hours.
 Keep bladder empty
by indwelling Foley's,
put on woman on
prophylactic
antibiotics.
 Monitor the patient
closely.

Source: Jhpiego
Non-pneumatic
Anti Shock
Garment (NASG)
 Response to
Refractory PPH –
supportive
measures
Blood transfusion
 Transfer to a
higher level of
care
 •Cervical and vaginal lacerations
Surgical suturing
intervention • Compression sutures
•Uterine artery and ovarian artery
ligation
•Internal iliac artery ligation
•Uterine artery embolization
•Hysterectomy
•Others
 WHO and FIGO recommendations
› WHO (2009): Guidelines for the management of PPH and retained placenta
› WHO (2012): Recommendations for the prevention and treatment of PPH
› WHO (2017): Recommendation on Tranexamic Acid for the treatment of PPH
› WHO (2018): Recommendations on the use of uterotonics for the prevention of
PPH
› WHO (2020): Recommendation on Advance misoprostol distribution to
pregnant women for prevention of postpartum hemorrhage
› WHO (2020): Recommendation on routes of oxytocin administration for
prevention of PPH after vaginal birth
› WHO (2021): Recommendation on uterine balloon tamponade for treating
postpartum hemorrhage
› WHO (2021): Essential Medicines List (EML)
› WHO 2023 recommendations on Early identification & bundle approach in PPH
management
› FIGO 2022 recommendations on prevention & management of PPH
 Trials on prevention and management of PPH
• CHAMPION TRIAL- Carbetocin HAeMorrhage PreventION trial (For prevention of PPH). Heat-stable carbetocin was
noninferior to oxytocin for the prevention of blood loss of at least 500 mL or the use of additional uterotonic agents.

• EMOTIVE TRIAL- For ‘first response’ PPH treatment bundle

• WOMAN TRIAL- World Maternal Antifibrinolytic Trial- for management of PPH- TXA is safe, affordable, life saving treatment
of PPH

• TRAAP 1- TRAnexamic Acid for Preventing postpartum hemorrhage after vaginal delivery: TXA trial for vaginal
deliveries. Among women with vaginal deliveries who received prophylactic oxytocin, the use of tranexamic acid reduced the rate of PPH of at
least 500 ml that was significantly low compared to PPH rates with placebo

• TRAAP 2- TRAnexamic Acid for Preventing postpartum hemorrhage after cesarean delivery: TXA trial for
cesarean deliveries. Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment
resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 mL or red-cell transfusion by day 2 than placebo.

• RED trial- Refractory haEmorrhage Devices trial by WHO: The objective of this trial is to compare the efficacy of three uterine tamponade
devices (Ellavi® free-flow, Ellavi® fixed-volume, or STUT-Suction Tube Uterine Tamponade) with that of the site specific improvised UBT (Foley
catheter), in reducing the incidence of severe maternal morbidity or mortality in women who delivered vaginally and were diagnosed with atonic
refractory PPH. The trial started in July 2022 and is currently ongoing
Thank you!