2. Safe Motherhood: Drug Management and Active Management of the Third Stage of Labor

3. Session Objectives Understand PPH and its prevention Understand the drug management cycle and its importance to prevention of PPH Promote active management of the third stage of labor as an intervention to prevent postpartum hemorrhage Identify programmatic changes that might be made to ensure that drug management supports AMTSL

4. What is Postpartum Hemorrhage? Excessive bleeding ~More then 500ml (severe PPH >1,000ml) During the third stage of labor ~Period between birth of the infant and delivery of the placenta ~Retained placenta

5. What are the causes of PPH? Delayed separation and delivery of the placenta Failure of the uterus to contract Other causes of bleeding: ~Uterine rupture ~Vaginal and cervical lacerations (tears) ~Surgery (C-section, Episiotomy)

6. Underlying conditions worsening PPH Life-threatening complications of pregnancy can occur in any woman. However, risk can be increased, or an event worsened by: High fertility (increase risk): too early, too often, too many, too late Malaria Anemia Hypertension/eclampsia Helminth infestation

7. Third Stage of Labor After childbirth the muscles of the uterus contract and placenta begins to separate from the uterine wall. The amount of blood lost depends on how quickly placenta separation and delivery occurs. If the uterus does not contract normally, the blood vessels at the placenta site do not adequately contract and severe bleeding results. Source: Adapted from Harshad Songhvi, MNH/JHPIEGO, 2004

8. The numbers Of about 529,000 maternal deaths in 2000, 95% occurred in Africa An African woman runs a 1 in 16 lifetime risk of dying from pregnancy complications About half of infant deaths are linked to poor maternal care, health and death

9. UNFPA 1995 Lifetime Risk of maternal death One (1) woman in: Benin12Guinea Bisseaun/a Burkina Faso14Liberian/a Cameroon26Mali10 Cape Verden/aMauritania16 Chad9Niger9 Cote d’Ivoire14Nigeria13 Gambia13Senegal11 Ghana18Sierra Leonen/a Guinea7Togo20

10. Treatment of PPH Prevention of PPH

11. Treatment of PPH Stopping the bleeding Replacing circulatory volume Restoring blood pressure and central circulation (compression) Replacing clotting factors through transfusion of whole blood, plasma, platelets Replacing RBCs

12. Prevention of PPH “[We] always used to say that the life threatening complications were unpreventable and unpredictable. We now know that the biggest maternal killer, PPH, is in fact preventable with an outstanding intervention.” Mary Ellen Stanton

13. What can be done to prevent PPH? At delivery for all women, skilled birth attendants can implement active management of the third stage of labor through: Administering a uterus-contracting drug within one minute of birth. Oxytocin is the first line recommended drug according to WHO (IMPAC) Applying controlled cord traction and counter traction to the uterus Massaging the fundus of the uterus through the abdomen Monitoring for further signs of bleeding ~Family planning supplies for women leaving care setting

14. Procedure for AMTSL Palpate abdomen to rule out presence of another baby Within 1 minute of birth, give oxytocin 10 IU IM Await strong uterine contraction (2-3 minutes) Apply controlled cord traction while applying countertraction above pubic bone If placenta does not descend, stop traction and await next contraction After placental delivery, rub uterus fundus gently every 15 minutes for 2 hours to ascertain it is contracted Source: MCPC, WHO 2002

15. Awareness and support for AMSTL Evidence shows that up to 60% of PPH is preventable through use of AMSTL. Piloted introduction of the intervention has shown to safe lives and save money. Joint FIGO and ICM statement that describes and recommends AMSTL

16. Other Ways to Reduce Postpartum Blood Loss Prevent prolonged and obstructed labor : ~Many providers don’t use the partograph Avoid episiotomy: ~Some providers perform episiotomy routinely

17. For discussion –Have you, as providers, had experience with administering AMSTL? –When might AMSTL not be provided as specified in a standard, fully, or for all births? –Why or why not?

18. Why pharmaceutical management? As public health service providers, we need practical ways to work together to close the gap between need for essential drugs, access to and widespread use of these drugs. In this case, an uninterrupted supply of uterotonics for all women at labor and delivery.

19. What is Pharmaceutical Management? Group discussion

20. Selection Management Support Distribution Procurement Use Policy and Legal Framework Pharmaceutical Management Cycle

21. Points to remember about drug management A cycle of components What happens in one component has an impact on the function of other components Responsibilities for cycle implementation rest with all managers, service providers, procurement officers, administrators, and pharmacists

22. Where do we start applying the cycle? Policy and legal framework Standard treatment guidelines (treatment protocols, prescribing policies) Essential drug (medicine list) Inventory management procedures and policies Personnel policies guiding prescribing, dispensing, administration procedures and practice

23. Standard Treatment Guidelines (STG) Usually a set of national guidelines, or protocols Systematically developed Appropriate treatments Specific clinical conditions Health care level specific Drugs – type, dose, mode of administration - essential for treatment of condition are specified

24. Standard Treatment Guidelines (STG) What to do in a clinical setting In what circumstances How to do it Which drugs and supplies are used and in which order of preference

25. Program responsibility in drug management for AMTSL For PPH prevention, this means: All births Quality, effective drugs and supplies The essential three steps must be delivered

26. Essential Drug (Medicine) List: the EDL Drugs on this list satisfy needs of majority of population Available at all times Safe and efficacious Cost and need Uterotonics for AMTSL meet these criteria

27. Drug Selection Following IMPAC guidelines, we would select: Oxytocin (this is the preferred drug for AMSTL when it can be stored properly and administered safely) 10 unit, IM administration Ergometrine 0.2. mg, IM administration (contraindicated in women with hypertension and/or heart disease)

28. Drugs and supplies for underlying conditions Malaria Bed nets, antimalarials (including IPT), malarial treatment (including quinine for cerebral and pregnancy) Micronutrients, occasionally blood Magnesium sulfate; diazepam; hydralazine; labetolol; nifedipine Antihelminthes Contraceptives and other family planning supplies

29. Stability of Uterotonics in Tropical Conditions Stability of oxytocin is better than ergomterine/methylergometrine especially with respect to light Store in dark, refrigerated space Remove only for use Short periods unrefrigerated (i.e., 1 month at 30° C, 2 weeks at 40° C) WHO, 1993

30. Considerations for Selecting Uterotonics Oxytocin is the first choice when it can be managed and administered safely If oxytocin unavailable, use ergot alkaloid or misoprostol Do not use ergometrine in women with hypertension or heart disease Store uterotonics (except misoprostol) away from light and in refrigerator Misoprostol has advantages when there is no cold chain.

31. Drug Procurement Preventive intervention for all women will require different quantities of drugs than does a treatment or selective prevention strategy Quantification needs to take place at the facility level Different drugs may be appropriate to different levels of the system, and quantification should take this into consideration In order to meet quantity requirements, budgeting for drugs must be routine and not exceptional

32. Drug Distribution and Storage: Uterotonics Oxtyocin and ergomterine require management in a cold chain Facilities and administrative levels that cannot maintain a cold chain may require alternate drugs Drugs that are not stored and distributed in proper conditions lose their effectiveness quickly Storage and distribution conditions should be monitored

33. Rational Drug Use What is “Rational Use”? All women at delivery Correct drug for indication Correct dose and appropriate administration At lowest possible cost considering safety, efficacy

34. Evidence that AMSTL is rational, or optimal use of uterotonic Reduces incidence of PPH by 60% Reduces the quantity of blood loss Reduces the use of blood transfusion

35. Prevention of PPH with AMSTL At delivery for all women, active management of the third stage of labor (AMSTL) ~Administration of a uterotonic ~Controlled cord traction ~Fundal massage ~Family planning supplies for women leaving care setting

36. Requirements of AMSTL Oxytocics and injection items Birth attendant with skills in: –observation –giving an injection –controlled cord traction Source: Adapted from Harshad Songhvi, MNH/JHPIEGO, 2004

37. Selection Management Support Distribution Procurement Use Policy and Legal Framework Pharmaceutical Management Cycle

38. Selection Management Support Distribution Procurement Use Policy and Legal Framework Pharmaceutical Management Cycle

39. Take-home Messages Postpartum Hemorrhage is the largest direct cause of maternal death Active management of the third stage of labor ~can prevent 60% of postpartum hemorrhage ~can be modified to the home birth setting Spotlighting PPH prevention will ~Reduce anemia ~Reduce emergencies ~Reduce need for transfusion ~Reduce maternal mortality

41. Thanks to: USAID/Office of Maternal Health and Nutrition Post-Partum Hemorrhage Prevention Initiative (PATH and Engender Health) Rational Pharmaceutical Management Plus Program The SEAM Project AWARE RH Advance Africa

42. Thank you for your time and attention Merci bien a vous