Postpartum Hemorrhage and

Maternal Mortality
• Postpartum hemorrhage (PPH) is the single most important direct cause of
maternal deaths in developing countries with an estimated 14 million cases
of pregnancy-related hemorrhage each year. (WHO 1998)
• Even if a woman survives a PPH, she is likely to suffer from anemia and other
health consequences; and she may receive a blood transfusion that can
expose her to HIV or hepatitis.
• Although some conditions may predispose a woman to hemorrhage, PPH
cannot be predicted, and every woman is at risk of developing a PPH.

Definition of Postpartum Hemorrhage

• Postpartum hemorrhage (PPH) is excessive bleeding following
birth. Reseachers have traditionally established blood loss more than 500
ml as "PPH" and blood loss more than 1000 ml as "severe PPH."
• However, accurate measurement of blood loss is difficult, if not impossible.
(Razvi et al. 1996)
• A more clinically useful definition might be any blood loss that causes a
physiologic change (e.g., low blood pressure) that threatens a woman's life.
• A healthy woman with a hemoglobin of 12g/ml who loses 500 ml of blood
may suffer no ill consequences; however, a woman with a hemoglobin of
6g/ml may lapse into life-threatening shock from such blood loss.

Highlights
PPH can also be determined by measuring hemoglobin (Hb) during labor and 24
hours post delivery to see the drop in Hb%.
Contribution of PPH to Maternal
Mortality

• The World Health Organization (WHO) estimates that nearly 515,000 women
die from complications of pregnancy and childbirth every year. (WHO 2001)
• Adding to the tragedy of maternal mortality is the fact that when a mother
dies there is a ten-fold increase in the risk of death for her newborn.
• PPH is the single most important direct cause of maternal deaths in
developing countries with an estimated 14 million cases of pregnancy-
related hemorrhage each year. (WHO 1998)
• A woman can die within two hours after the onset of PPH if she does not
receive proper treatment.

Highlights
Maternal mortality due to PPH is highest in those places where there is:

• Limited access to skilled attendants

• An inadequate transport system

• Poor or absent emergency services

Consequences of PPH
Even if a woman survives a PPH, she is:

• Likely to suffer from anemia and other health consequences

• May receive a blood transfusion that may expose her to HIV or hepatitis

The woman may be subject to surgery (e.g., hysterectomy) with:

• Inevitable pain, cost, and infertility

• The risk of infection, anesthesia complication, and other surgical
complications
Highlights
Consequences of Anemia

• Fatigue and impaired endurance with resultant impaired physical work

capacity

• Compromised cognitive function

• Possible increased risk of postpartum depression

Why the High Risk Approach Doesn't

Work
Although some conditions may predispose a woman to hemorrhage, still EVERY
woman is at risk of developing a PPH.

• When using the "risk approach," often only those women who were in a "high
risk" category received active management of the third stage of labor
(AMTSL).
• This practice, as well as the inability to distinguish those women who will
have PPH from those women who will not, has meant that most women
who develop PPH are in a low-risk category.
• Therefore, every woman should be

o Attended by a skilled attendant who is able to deal with prevention

as well as management of PPH
o Offered AMTSL to help prevent PPH
o Vigilantly monitored immediately following birth

Did you know?

No risk scoring system has yet been devised that is able to predict which women
will have a PPH and which will not.
Highlights
"Even healthy, non-anaemic women can have catastrophic blood loss."
Causes of Postpartum Hemorrhage
• The causes of postpartum hemorrhage (PPH) are:
o Atonic uterus
o Retained placenta (or fragments)
o Lacerations/tears
o Ruptured uterus

• Up to 90% of hemorrhages occurring immediately postpartum result from an

atonic uterus (a failure of the uterus to contract properly after the infant is
born).

Atonic Uterus
• The majority of cases of postpartum hemorrhage (PPH) occur in the
immediate postpartum period (within 24 hours after birth).
• One study in Egypt found that 88% of deaths from PPH occurred within the
first four hours postpartum. (Kane 1992)
• Immediate PPH is most commonly due to uterine atony (failure of the uterus
to contract properly after the infant is born) and a retained placenta or
placental fragments (McCormick et al. 2002)

Retained Placenta (or Fragments)

Human placenta (baby side) after delivery

• A retained placenta or retained placental fragments occurs when the

placenta is not expelled within 30 minutes following the birth of the baby.
• The retention of the placenta or fragments also inhibits the ability of the
uterus to contract and contributes to hemorrhage.
Lacerations/Tears
Inspecting lower vagina and perineum for lacerations that may need to be repaired
to prevent further blood loss

• Lacerations or tears of the cervix, vagina, or perineum are the second most
common cause of PPH.
• Such tears usually occur at the time of the birth of the baby.

• Tears may coexist with an atonic uterus.

Ruptured Uterus
• By the time a ruptured uterus is diagnosed, the fetus is frequently dead and
the mother's life in grave danger.
• Bleeding from a ruptured uterus may occur vaginally and so be visible.
• Or, if the fetal head blocks the pelvis, the bleeding may occur inside the
abdomen.
• Whether the bleeding is vaginal or intra-abdominal, immediate surgery is
necessary if the woman's life is to be saved.

Did you know?

All women should have counseling concerning postpartum family planning, and some
couples may consider voluntary permanent contraception.

However, when a woman suffers a ruptured uterus, she is at increased risk of rupture
with subsequent pregnancies. So, after the emergency is over, the option of voluntary
permanent contraception should be discussed with the woman and her family.

Causes of Postpartum Hemorrhage

Knowledge Recap
Now that you’ve completed this session, test your knowledge on this subject. Taking
this quiz will reinforce key points and identify gaps in learning.

After taking the Knowledge Recap, you’ll get to review the correct answers, and in
some cases, read an explanation.
Prevention of Postpartum
Hemorrhage One
• Healthy practices during pregnancy that help prevent the harmful
consequences of postpartum hemorrhage (PPH) are the prevention, early
detection, and treatment of anemia; the early detection and management of
vaginal bleeding problems; and complication-readiness preparations.
• Measures to be taken during labor to prevent PPH are:

o Preventing prolonged labor

o Preventing dehydration
o Early detection and management of vaginal bleeding problems
o Avoiding vaginal/perineal trauma

Healthy Practices During Pregnancy

Practices during pregnancy that help prevent postpartum hemorrhage (PPH) and its
life-threatening consequences include:

• Birth preparedness/ complication readiness

• Prevention, early detection, and management of anemia

Birth Preparedness/Complication
Readiness
If hemorrhage develops, a woman and her family need to be prepared to act
immediately.

Therefore, every woman and her family need to prepare for birth and be ready for a
complication by:

• Understanding that bleeding is a danger sign that needs immediate attention

• Developing a plan of response in case an emergency develops

• Making preparations prior to the beginning of a PPH

Did you know?

Every woman is at risk of PPH.

It may take only two hours from the time a woman starts bleeding for her to die.
What Should the Plan Include?
A birth-preparedness/complication-readiness plan should include:

• Presence of a skilled attendant

• An emergency transportation system

• Access to emergency finance

• Determination of who will make decisions

• Location of blood donors who are available to donate blood immediately, if

needed

Although this plan does not need to be a written document, components may be
included in the client record.
Highlights
"A skilled attendant is an accredited health professional - such as a midwife, doctor, or
nurse - who has been educated and trained to proficiency in the skills needed to
manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal
period, and in the identification, management, and referral of complications in women
and newborns."*

*This definition has been endorsed by UNFPA and the World Bank.

During Pregnancy - Anemia

• Healthy women as well as anemic women are at risk of a PPH. However, for
severely anemic women, blood loss of even 200 to 250 ml could prove fatal.
• Severe anemia is prevalent among women in many developing countries.
So, prevention of PPH in these countries is especially important.
• Treatment of anemia with iron supplementation will not prevent PPH but may
help women survive a hemorrhage if it occurs. (USAID 2005)
Healthy Practices During Labor
Practices during labor that help reduce the likelihood of PPH include:

• Preventing prolonged labor

• Preventing dehydration

• Early detection and management of vaginal bleeding problems

• Avoiding cervical, vaginal, and perineal trauma

o Avoiding routine use of forceps

o Restricting episiotomy

Preventing Prolonged Labor

A physician at a hospital in Bangladesh assists a woman in labor.

• Prolonged labor can be the result of an obstruction (the baby is too large or
in an incorrect position to be able to fit through the pelvis and birth canal).
• If not detected and treated, such an obstruction may result in a ruptured
uterus.
• Likewise, an overdistended uterus (from twins, excess amniotic fluid, large
baby), or induction of labor with oxytocin, or any condition that causes poor
uterine contractions during labor may also result in uterine atony, causing
PPH.
• Failure of the uterus to contract (atonia) is the primary cause of PPH.

Early Detection and Management of

Vaginal Bleeding Problems
Vaginal bleeding late in pregnancy or during labor may be the result of:

Placenta previa (placenta lying on or near the cervix) - Women with placenta previa
are at higher risk for PPH and placenta accreta (the placenta growing into the wall of
the uterus and so not being able to detach following the birth of the baby). (WHO
2000)

Abruptio placenta (a placenta that detaches from the wall of the uterus prior to the
birth of the baby) - A consequence of abruptio placenta may be a failure of the
blood to clot, so that bleeding from the uterus does not stop even if the uterus is
contracted.

Ruptured uterus - A ruptured uterus that has not been repaired will continue to
bleed after the birth of the baby.
Highlights

The early detection and rapid management of vaginal bleeding from any cause during
late pregnancy or labor is important in reducing deaths from PPH.

Avoiding Vaginal/Perineal Trauma:

Forceps
Avoiding Routine Use of Forceps

• Using instruments to assist in the birth of the baby should be avoided as

much as possible, because the use of forceps is associated with an
increased risk of cervical and perineal trauma.
• When the use of instruments is indicated to assist the birth, a vacuum
extractor may result in less perineal trauma than forceps. (Meyer 1987)
• Pushing to facilitate the birth should not be encouraged or facilitated, with or
without instruments, until the cervix is completely dilated to avoid
lacerations of the cervix.

Did you know?

Cervical, vaginal, and perineal tears are the second most significant cause of PPH.

Avoiding Vaginal/Perineal Trauma:

Episiotomy
Restricting Episiotomy

• Several studies within the past few years have confirmed that episiotomy is
associated with a significantly increased blood loss, even when compared to
women who sustain a tear. (Onah and Akani 2004; Gulmezoglu/WHO 2004)
• Therefore, episiotomies should not be routine, but should be restricted to
those situations for which there is a clear indication, such as shoulder
dystocia, breech birth, or forceps delivery.

Highlights

The birth of the baby should be slow and controlled to allow the vaginal and perineal
tissue to stretch without tearing.
Prevention of Postpartum
Hemorrhage Two: AMTSL
• Key to the prevention of postpartum hemorrhage (PPH)is the use of active
management of the third stage of labor (AMTSL) for all women.
• A systematic review and meta-analysis (Cochrane Library) found that AMTSL
was associated with:
o Approximately 60% reduction in occurrence of PPH and severe
(>1000 mL) PPH
o Decreased need for blood transfusion
o Decreased postpartum anemia (hgb <9 g/dL)
o Approximately 80% reduction in the use of therapeutic uterotonic
drugs

• AMTSL is a three-part procedure that includes: administration of a uterotonic

immediately after the birth of the baby, delivery of the placenta by
controlled cord traction during the next strong contraction, and massage of
the uterus to maintain firmness following the delivery of the placenta.
• Oxytocin is the uterotonic of choice for AMTSL, but ergometrine - a
combination of oxytocin and ergometrine - or misoprostol are other drugs
that can be used for AMTSL.
• The mother is at greatest risk for PPH immediately after the birth;
therefore, a woman should be vigilantly monitored during the first hours
after birth.

Key Practice: Active Management of

Third Stage of Labor (AMTSL)
Definition: The third stage of labor is that period of time which begins with
completion of the birth of the baby and ends with completion of the delivery of the
placenta.

Characteristics of the Third Stage of Labor

The muscle fibers of the uterus are arranged in a "criss-cross" pattern surrounding
blood vessels.

• During the third stage of labor, these muscle fibers contract and
retract, causing the surface area inside the uterus to become smaller.
 • The placenta, of course, does not contract, and thus begins to separate as
the surface area of the uterus becomes smaller.

At the end of a term pregnancy:

• 500 to 800 ml of blood flow through the blood vessels at the placental site
every minute. (WHO 1996)
• As the placenta separates from the uterus, these vessels break and bleeding
occurs.
• Continuous, coordinated contractions of the muscles of the uterus form
"living ligatures" that compress the local blood vessels, controlling bleeding
at the placental site and allowing formation of a clot and deposition of
fibrin behind the placenta.
• When the uterus fails to contract, it is said to be atonic, blood vessels at the
placental site are not constricted, and hemorrhage occurs. (McCormick et al.
2002)

Highlights

Active management of the third stage of labor (AMTSL) is a key evidence-based practice
for preventing postpartum hemorrhage (PPH).

Physiologic Versus Active

Management
Physiologic or "expectant" management of the third stage involves:

• Waiting for signs that the placenta is separating from the uterine wall (for
example, a gush of blood and/or the uterus becomes firm and globular and
rises in the abdomen)
• Allowing the placenta to deliver spontaneously

The components of active management of the third stage are:

1. Administration of a drug that causes the uterus to contract (uterotonic)

2. Delivering the placenta by controlled cord traction with counter-traction on
the fundus of the uterus
3. Uterine massage after delivery of the placenta to maintain contraction
All three components of AMTSL are essential to prevent PPH.
Did you know?

Physiologic or "expectant" management of the third stage of labor is common practice

in the US and Canada.

Effectiveness of AMTSL: The

Evidence
Between 1988 and 1998, four good-quality, large-scale, randomized controlled
studies were conducted in well-resourced maternity hospitals. (Prendiville et al.
1988; Rogers et al 1998; Bagley 1990; Khan et al. 1997). These studies compared the
effects of active and expectant management of the third stage of labor. In all four
studies, active management was associated with:

• A decrease in PPH (up to 70%)

• A decrease in the length of the third stage

A systematic review and meta-analysis (Cochrane Library) found that AMTSL was
associated with:

• Approximately 60% reduction in occurrence of PPH and severe (>1000 ml)

PPH
• Decreased need for blood transfusion

• Decreased postpartum anemia (hgb <9 g/dL)

• Approximately 80% reduction in the use of therapeutic uterotonic drugs*

*Drugs that cause the uterus to contract

Joint Statement by FIGO and ICM

In November 2003, the International Confederation of Midwives (ICM) and the
International Federation of Gynecologists and Obstetricians (FIGO) launched a joint
initiative on the Prevention of Postpartum Hemorrhage.

Highlights

"Active management of the third stage of labour should be offered to women since it
reduces the incidence of postpartum hemorrhage due to uterine atony."
Cost Savings of AMTSL
A study calculating the cost savings of using AMTSL rather than expectant
management of labor for a population of mothers giving birth to babies in Latin
America and sub-Saharan African settings (specifically Guatemala and Zambia)
found a positive net benefit from AMTSL.

• In Guatemala researchers found a savings of $18,000 (with 100 lives saved)

and in Zambia, a savings of $145,000 (with 467 lives saved) for 100,000
births.
• Costing considerations included types and amounts of supplies for AMTSL,
for expectant management, and for management of PPH.
• Life years saved or disability adjusted life years averted were not included,
although these would likely be substantial because deaths prevented are
among relatively young women.

AMTSL: The Procedure

Controlled cord traction with counter-pressure to the uterus

AMTSL is a three-part process.

1. Routinely administer a uterotonic drug within one minute of the birth of the baby.
(SOGC 2004)
2. Then, during the next strong uterine contraction, apply controlled cord traction on
the umbilical cord.

• Controlled cord traction involves gently, but firmly pulling downward towards
the floor once the uterus has contracted, while pushing at the same time on
the abdomen just above the pubic bone.
3. Following the delivery of the placenta, gently, but firmly massage the uterus
through the abdomen in order to stimulate contractions and decrease vaginal blood
loss.

• The uterus should be massaged to ensure the uterus remains contracted.

Did you know?

Some have feared that controlled cord traction might be associated with inversion
(when the upper part of the uterus is pulled through the cervix) of the uterus or
separation of the cord from the placenta.

However, in five major controlled trials on AMTSL, no cases of uterine inversion or cord
separation were recorded.
Uterotonic Drugs - Oxytocin
Oxytocin is a posterior pituitary extract that causes the uterus to contract
repeatedly.

• The injectable uterotonic drugs given in AMTSL have been evaluated by the
Cochrane Review. (MacDonald et al. 2003)
• Although syntometrine (oxytocin plus ergometrine) resulted in a significant
but small reduction in PPH compared to oxytocin, it was consistently
associated with an increased incidence of such side effects as nausea,
vomiting, headache, and increased blood pressure.
• Although oxytocin is somewhat heat-sensitive, field studies by WHO found no
light-sensitivity and no loss in potency after twelve months of refrigerated
storage, and about 14% loss after one year at 30 degrees centigrade. (WHO
1993)

Highlights

Oxytocin is the uterotonic of choice when it is available, because of its effectiveness,

relative low incidence of side-effects, light stability, and relative heat stability.

When given intramuscularly, oxytocin acts within two and one-half minutes.

Uterotonic Drugs - Ergometrine

Intramuscular injection

Ergometrine:

• Is inexpensive

• Is effective for two to four hours

• Takes six to seven minutes to become effective when given intramuscularly

However, ergometrine:

• Causes a tonic (continuous) contraction rather than repeated contractions

and relaxation as oxytocin does
• Is neither heat- nor light-stable and so requires an effective cold chain for
storage
• Carries an increased risk of hypertension, vomiting, and headache (compared
to oxytocin)
• Is contraindicated in women with high blood pressure
Highlights

Ergometrine is an effective uterotonic, but oxytocin is preferable, if available.

Did you know?

Oral ergometrine should NOT be used for AMTSL.

Onset of action for oral ergometrine is too long to be effective for AMTSL.

Uterotonic Drugs - Misoprostol

Misoprostol is a prostaglandin. Misoprostol:

• Is both heat- and light-stable

• Does not require an injection because it can be given orally, bucally (in the
cheek), vaginally, or rectally
• Has a positive safety profile

When well-stored oxytocin or ergometrine or safe injection facilities are not

available, oral misoprostol is an acceptable alternative.

Misoprostol may play an important part in a strategy to reduce PPH in countries

where most births occur in the home. A study involving 1,620 rural women in India,
published in The Lancet in 2006, concluded that oral misoprostol was associated
with significant decreases in the rate of acute postpartum hemorrhage and mean
blood loss. (Derman 2006)

Did you know?

The US Pharmacopeia Expert Committee concluded that misoprostol is safe and

effective in preventing PPH and considered this indication as an an accepted off-label
use.
Comparison of Blood Loss in
Different Types of Management of
Third Stage of Labor

• In a study that compared active versus physiologic management of the third

stage of labor, the incidence of PPH with physiologic management was 18%.
(Prendiville et al. 1988)
• Also, a WHO review that compared the effectiveness of misoprostol
versus "conventional injectable uterotonics"* for AMTSL found
2.7% incidence of PPH among women given conventional injectable
uterotonics versus 3.6% incidence of PPH among women given misoprostol.
(Gulmezoglu et al. in Cochrane Review 2004)
*Oxytocin, ergometrine, and ergometrine-oxytocin are grouped together as
"conventional injectable uterotonics."

Nipple Stimulation
Although nipple stimulation has been shown to stimulate the body's own oxytocin
production (which is known to stimulate uterine contractions), no studies to date
have been able to demonstrate that nipple stimulation can effectively reduce
postpartum blood loss or the incidence of PPH.

Breastfeeding should always be encouraged immediately postpartum and thereafter,

because the nipple stimulation of suckling:

• Increases the body's own oxytocin production

• Incurs many other benefits on both mother and baby

Vigilant Monitoring: The Fourth Stage
of Labor
The mother is at greatest risk for PPH immediately after the birth; therefore, a
woman should be vigilantly monitored during the first hours after birth.

• A woman's vaginal blood loss, pulse, blood pressure, and the firmness of her
uterine fundus should be monitored every 15 minutes for the first two
hours; then hourly for hours three and four; and then four-hourly until 12
hours after delivery of the placenta.
• During this time also ensure that the mother is clean, warm, comfortable, and
in contact with her baby.
• The woman should also be encouraged to urinate frequently to prevent a full
bladder, which can prevent effective uterine contractions and thus result in
hemorrhage.
• Teach the mother about danger signs, and tell her that if any occur, she
should let a skilled attendant know immediately.

Highlights

The delivery of the placenta does not mark the end of risk for bleeding, but rather may
be the point when problems most commonly begin.

Because the first hours after birth are so important to the woman´s health and survival,
some people term this "the fourth stage" so that it will receive the attention it deserves.

Program Considerations
• In order for active management of the third stage of labor (AMTSL) to be
successful, providers must be trained in the basic knowledge and skills that
are necessary to perform this practice safely and effectively.
• Some uterotonics are heat-sensitive, light-sensitive, or both. So, if their
quality and stability are to be protected, it is essential that these drugs be
protected from heat and light.
• Policy must allow - and provide legal backing for - nurses, midwives, doctors,
and anyone else assisting at births to give a uterotonic drug and perform all
steps of AMTSL.
• Key indicators should be used to measure the success of any program.
Country-Level Implementation
Prevention of postpartum hemorrhage (PPH) should never be carried out alone as a
vertical program, but rather as part of an integrated package of care provided to
mother and newborn during labor, birth, and the postpartum period.

Country-Level Implementation

• Policy support

• National standards

• Training/education

• Logistics

• Birth preparedness

• Community mobilization

• Measuring program success

Policy Support
• A core competency of the skilled attendant is to "manage the third stage of
labor actively." (WHO/ICM/FIGO 2004)
• Policy must allow - and provide legal backing for - nurses, midwives, doctors,
and anyone else assisting at births to give a uterotonic drug and perform all
steps of active management of the third stage of labor (AMTSL).
o This may require expansion of the role of the nurse or midwife.
• Professional associations, such as midwifery associations, should actively
promote AMTSL for all births in the public and private sectors.

Highlights

All skilled providers must have authorization to perform AMTSL.

National Standards
• AMTSL must become part of the national guidelines/standards for Safer
Motherhood and the management of all normal births
• National standards can be based on international guidelines/standards from
WHO/UNICEF/UNFPA/World Bank
Training/Education
For AMTSL to be successful, providers must be trained in the basic knowledge and
skills that are necessary to perform this practice safely and effectively.

Staff should be:

• Aware of potential side effects and cautions for use of the drugs

• Able to counsel and educate patients effectively about AMTSL, its purpose,
and potential side effects
Training will also need to include:

• Proper infection prevention practices, including safe needle disposal

• The management of any complications that might occur

• Training in AMTSL will need to be competency-based, using objective

assessment tools to ensure that competency is achieved prior to clinical
implementation

Highlights

Besides being part of inservice training programs for all care providers who are involved
with caring for women during labor and birth, AMTSL should be incorporated into the
basic preservice education of all skilled providers prior to licensure and beginning
practice.

Logistics: Drug Management and

Storage Requirements
Some uterotonics are heat-sensitive, light-sensitive, or both. So, if their quality and
stability are to be protected, it is essential that these drugs be protected from heat
and light.

• Program managers must choose the uterotonic that is appropriate to their

specific conditions.
o If there is no cold chain or no way to protect from light, perhaps
ergometrine would not be the drug of choice.
o Or perhaps more than one type of uterotonic will be available in the
system.
• Procurement standards must be set based upon the number of facilities,
deliveries, program expansion, and product usage.
 • Management information systems must be in place so that consumption
patterns can be monitored.
• Storage of the drug, if injectable, will require an effective cold chain, although
short, monitored time at ambient temperature does not seem to adversely
affect the potency of oxytocin as it does the potency of
ergometrine. (Rational Pharmaceutical Management Plus 2004)

Highlights

Even well-trained service providers cannot provide quality care unless effective
uterotonic drugs are on hand to give to the mother immediately after the baby is born.

Considerations in the Selection of a

Uterotonic
Birth Preparedness and Community
Mobilization
• To function effectively, an AMTSL program requires preparedness before birth
as well as mobilization of communities.
• Responsibility for birth preparedness needs to be shared by women, families,
communities, providers, facilities, and policymakers.

Measuring Program Success

A mother, father, and newborn in Guatemala

How can you tell if your program has been successful?

Depending on available resources, and whether you want to measure output,

outcome, or impact, some indicators that may be used to monitor success in a
country or in a district include percentage of:

• Births in the past six months in targeted facilities with AMTSL

• Targeted facilities where service delivery staff have been trained in AMTSL
and uterotonics (oxytocin) are available
• Targeted facilities where oxytocin is available

• Percentage of deaths of women of reproductive age (WRA) due to PPH

• Proportion of maternal mortality due to PPH

Overcoming Challenges in
Introduction of an AMTSL
Intervention/Protocol
A clinic in Afghanistan

Widespread implementation of AMTSL in developing countries requires:

• Consideration of training, drug, and policy issues

• The availability of syringes and needles

• Injection safety practices and safe disposal policies

• The mobilization of communities to demand and access services

• The presence of a skilled attendant at all births

The practice of AMTSL must be an integrated part of any strategy to reduce
maternal mortality and provide quality maternal and newborn care services.

Highlights

In order to address concerns and overcome many challenges that might arise:

Advocacy, with presentation of the evidence, among stakeholders, including

policymakers, educators, hospital/clinic managers, drug suppliers, care providers, and
community members should precede widespread implementation of AMTSL.

Emerging Issues
Preventing PPH at Home Births: The Expanded Role of Misoprostol

• An emerging consideration is the use of the uterotonic misoprostol, after

delivery of the baby when a skilled attendant is not available and/or a safe
injection is not possible.
• Misoprostol may be given:

o By women (self-administered) who give birth without a skilled

attendant, or
o By traditional birth attendants
• Studies are being conducted to confirm the safety, effectiveness, and
feasibility of such an approach.