The World Health Organisation has published new guidelines recommending that women who lose 300ml of blood after giving birth should be diagnosed with postpartum haemorrhage (PPH) – as opposed to in the past, when PPH was diagnosed only after the loss of 500ml of blood, which was often too late for interventions.
The update was a collaboration between the WHO, the International Federation of Gynaecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM), reports Health Policy Watch.
In the guidelines, launched at the President’s Session at FIGO’s World Congress in Cape Town on 5 October – also declared as the first World Postpartum Haemorrhage Day – doctors and midwives are now advised to monitor women closely after birth using a calibrated drape, a simple device that collects and accurately quantifies lost blood.
Once PPH is diagnosed, the guidelines recommend the immediate deployment of the MOTIVE bundle. This stands for: Massage of the uterus; Oxytocic drugs to stimulate contractions; Tranexamic acid (TXA) to reduce bleeding; Intravenous fluids; Vaginal and genital tract examination; and Escalation of care if the bleeding persists.
PPH affects millions of women annually and is one of the leading causes of maternal mortality, causing nearly 45 000 deaths. Even when not fatal, it can cause lifelong physical and mental health impacts, from major organ damage to hysterectomies, anxiety and trauma.
“Postpartum haemorrhage is the most dangerous childbirth complication because it can escalate with such alarming speed. Although not always predictable, deaths are preventable with the right care,” said Dr Jeremy Farrar, WHO Assistant Director-General.
Fast, feasible and effective
Motivation for the change comes from a large study published recently in The Lancet, which analysed 12 datasets involving 312 151 women, finding that blood loss of 300ml offered the “preferred sensitivity threshold”, particularly when combined with “any abnormal haemodynamic sign”, like increased pulse rate or a drop in blood pressure.
In rare cases where bleeding continues, the guidelines also recommend surgery or blood transfusions to safely stabilise the woman.
The guidelines also stress good antenatal and postnatal care to mitigate critical risk factors like anaemia, and for anaemic mothers to include daily oral iron and folate during pregnancy and intravenous iron transfusions when rapid correction is needed, including after PPH, or, if oral therapy fails.
The guidance also discourages routine episiotomies to reduce the likelihood of trauma and severe bleeding after birth.
During the third stage of labour, the guidelines recommend administering medicine to support uterine contraction, particularly oxytocin or carbetocin.
If intravenous options are not available and the cold chain is unreliable, misoprostol may be used as a last resort.
More evidence and protocols
According to a commentary in The Lancet, the new guidelines are “an equity intervention” and they align “the prevention–detection–treatment continuum with enablers (eg, supportive infrastructure)” and also state “what not to do when skills or supplies are scarce”.
“The guidance recognises where women give birth, who is present, and what commodities are reliably available, and it reduces ambiguity that so often paralyses action in the first minutes of a dire emergency.”
See more from MedicalBrief archives:
How Kenyan midwives help prevent postpartum haemorrhaging
Tranexamic acid decreasing death risk from post-partum blood loss
African study finds solution to reduce for childbirth-related haemorrhaging
Cochrane Review identifies alternative drugs better to prevent PPH