1. PPH Prevention and Management at Health Facilities Jeffrey M. Smith Asia Regional Technical Director AME Regional Meeting Bangkok March 2010

2. 2 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

3. 3 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

4. 4 Distribution of Maternal Deaths Asia Specific Distribution Khan, et al; WHO Analysis of Causes of Maternal Deaths; Lancet April 2006

5. 5 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.

6. 6 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

7. 7 Integrating the Steps for AMTSL Integration of AMTSL with:  I mmediate 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  Deliver the placenta by controlled cord traction  Wait until cord pulsations cease or 2-3 minutes  Delayed cord clamping reduces newborn and infant anemia  Massage the uterus  Ensure uterine tone

8. Integrated Steps for AMTSL and Immediate Newborn Care: Skilled Birth Attendant With Oxytocin Deb Armbruster and Sushie Engelbrecht, POPPHI Project

9. 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 9

10. 10 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

11. 11 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

12. 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 12

13. 13 AfghanistanYes BangladeshYes CambodiaPartial East TimorPartial EgyptPartial IndiaPartial IndonesiaPartial NepalPartial PakistanPartial PalestinePartial PhilippinesPartial VietnamPartial YemenPartial Midwives and BEOC Do policies allow midwives to provide a complete set of BEOC interventions?

14. Align People, Services and Systems 14 Major Obstetrical Killers Global Definition of Basic EOC Policies and Clinical Guidelines Midwifery Job Description, Competencies Capabilities and Environment Consistency and Alignment

15. 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

16. 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

17. 17 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

18. 18 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

19. 19 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

20. 20 Strategy for Reduction of PPH: MOPH of Afghanistan

21. 21 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

22. Thank You! 22