DESK REVIEW:

POSTPARTUM HEMORRHAGE

Department of Community Medicine

Faisalabad Medical University (PMC), Faisalabad
Session 2017-2022

Submitted by: Aisha Batool (Roll # 083)

4th Year MBBS

Introduction:

Postpartum Hemorrhage (PPH) is a health condition in

women which is defined as loss of blood, 500ml or more, within 24 hours
after giving birth. PPH is one of the leading causes and is the most
significant reason behind death of mothers after delivery in developing
countries. Not just that, it is the primary cause of approximately one
quarter of all maternal deaths at global level. Most of these deaths resulting
from PPH occur within the first 24 hours after labor; majority of which can
be avoided by using utero-tonics, prophylactically, during the third stage of
labor and by appropriate case management. If we upgrade healthcare
services provided to women during the process of childbirth in order to
prevent and treat PPH, it will bring us a step closer to the achievement of
the Millennium Development Goals.

Situational Analysis:

Postpartum hemorrhage (PPH) is a prominent

cause behind maternal morbidity and mortality, accounting for about
one‐third of all pregnancy‐related deaths in Africa and Asia.
Data shows that the pregnancy-related mortality ratio in women around
the world is 17.3 deaths per 100,000 live births. National statistics help
conclude that close to 11.4% of these maternal deaths are caused by this
problem under consideration i.e. postpartum hemorrhage. In
industrialized countries, PPH is placed in the top 3 spots in the list of
causes of maternal mortality, others being embolism and hypertension. In
a developing world like ours, maternal mortality rates exceed 1000 women
per 100,000 live births, and World Health Organization (WHO) data
statistics suggest that 60% of maternal deaths in developing countries are
due to PPH, which makes upto 100,000 deaths per year. [2] A Practice
Bulletin from the American College of Obstetricians and Gynecologists
places the estimate at 140,000 maternal deaths per year or in other way, 1
woman every 4 minutes.
In Pakistan, case study for all the different causes of maternal mortality in
public and private hospitals highlights postpartum hemorrhage as the
main cause of death after childbirth.2
Even highly skilled obstetricians can be incompetent when dealing with
women in these life-threatening situations, without access to life-saving
medicines and sterilized blood transfusion sources. This happens even in
our well-equipped hospitals located in the major cities of Pakistan.

Summary of Situational Analysis:

Following are the key points

summarizing our situational analysis:-
PPH accounts for 11.4% of the total number of maternal deaths
 calculated per 100,000 live births.
In developed countries, PPH is one of the top 3 events leading to
maternal deaths in labor, along with embolism and hypertension.
In developing countries of Asia and Africa, one third of women die
during the course of labor because of PPH.
In Pakistan, it is the main cause of death in pregnant women.

High Risk factors:

In a large scale population-based

investigation, the most significant of all risk factors, summarized
using multivariable analysis approach, were as follows:

• Retained placenta.
• Failure to progress during the second stage of labor.
• Placenta accreta.
• Lacerations.
• Instrumental delivery.
• Large-for-gestational-age (LGA) newborn.
• Hypertensive disorders.
• Induction of labor.
• Augmentation of labor with oxytocin.
• Prolonged labor.
• Retained placenta products.
• Chorioamnionitis.
• Oxytocin used in labor.
• Preeclampsia/eclampsia.
• Multiple gestations.
• Hydramnios.
• Halogenated anesthesia.
• Previous episode of uterine atony.
• Increasing maternal.
• Obesity and raised Body Mass Index (BMI).
Disease Causation Model:
As it is a non-communicable
disease it presents the Wheel causation model of disease. This is a
non-communicable disease which relies upon biological factors,
environmental, social factors and others.

● Genetic Factors: It is shown through studies that it does

have genetic predisposition.

● Physical Factors: These include those points about the

general health of the mother or any associated symptom
that she is suffering from e.g. anemia, general body
weakness, maternal obesity etc.
● Biological Factors: Prolonged labor, multifetal gestation,
retained placenta, oxytocin induced labor, antepartum
hemorrhage, hydramnios all make it to the top of list for
several biological factors that precipitate PPH.
● Social Factors: These are the factors that affect patients of
 all ailments in a way or another, mainly poverty, inadequate
health services, instrumental delivery, low iron diet,
inappropriate delivery methods.

Strategic Approach:

LOGICAL BASIS PREVENTIVE STRATEGIES PUBLIC HEALTH PROBLEM

Natural course of disease Pathological model Postpartum hemorrhage

Interventions:

LEVEL OF PREVENTION MODES OF INTERVENTION LIST OF INTERVENTIONS

Primordial Avoid risk factors in the Awareness campaign about

target population as a general dietary health of women of
through awareness. fertility age as a whole.

Primary Health Promotion High risk awareness

campaign among pregnant
women especially in rural
areas, about diet and
importance of hospital birth.

Secondary Early diagnosis and Train doctors and

treatment of prophylaxis.
paramedics for such
situations and provide
equipment at low cost
making sure every facility has
them.

Tertiary Limit disability caused by Train staff, provide best

PPH and rehabilitation. services at the facilities
 handling cases, provide
service of counselling.

Preventive Approach:

The Pathological prevention Method is

the most suitable method in this condition. The Pathological prevention
model for disease control costs following:
• Primary prevention which is going to deal with the limitation of the
risk factors for the disease occurrence.
• Secondary prevention which is going to deal with the early diagnosis
and treatment.
• Tertiary prevention will limit the disability caused by the conditions.
 1. Primary Prevention:
It is impossible to predict which women are more likely to have a
PPH. Many factors may contribute to uterine atony or
lacerations. Addressing these factors may help prevent PPH
and reduce the amount of bleeding a woman may have.
Taking a preventive approach can save women’s lives.
Despite the best efforts of health providers, women may still
suffer from PPH. If PPH does occur, positive outcomes depend on
how healthy the woman is when she has PPH (particularly her
hemoglobin level), how soon a diagnosis is made, and how quickly
effective treatment is provided after PPH begins.
• The first step in controlling the post-partum hemorrhage is
educating the women about the disease and the methods by which
this condition can be minimized.
• Encouraging the mother to go to hospital for deliveries instead of
home deliveries.
• Educating the mother to eat the food rich in Iron.
• Discouraging use of instruments during delivery.
• Discouraging using oxytocin for inducing delivery.
• Administration of a uterotonic drug within one minute after the
baby is born.
• Develop a birth preparedness plan. Women should plan to give birth
with a skilled attendant who can provide interventions to prevent
PPH (including AMTSL), and can identify and manage PPH, and refer
the woman for additional treatment if needed.
• Develop a complication-readiness plan that includes recognition of
danger signs and what to do if they occur, where to get help and
how to get there, and how to save money for transport and
emergency care.
• Routinely screen to prevent and treat anemia during pre-conceptual,
antenatal, and postpartum visits. Counsel women on nutrition,
focusing on available iron and folic acid-rich foods, and provide
iron/folate supplementation during pregnancy.
• Help prevent anemia by addressing major causes, such as malaria
 and hookworm:
- For malaria, encourage use of insecticide.
- treated bed nets,
- provide intermittent preventive treatment during pregnancy to
prevent asymptomatic infections among pregnant women living in
areas of moderate or high transmission of Plasmodium falciparum,
and ensure effective case management for malaria illness and anemia.
- For hookworm, provide treatment at least once after the first
trimester.
• In cases where the woman cannot give birth with a skilled
attendant, prevent prolonged/obstructed labor by providing
information about the signs of labor,
• When labor is too long, and when to come to the facility or
contact the birth attendant.

Prevent harmful practices by helping women and their families to

recognize harmful customs practiced during labor (e.g. providing
herbal remedies to increase contractions, health workers giving
oxytocin by intramuscular [IM] injection during labor).

2. Secondary prevention:
The main target of secondary prevention is to diagnose early
and provide quick treatment. This can be done by arranging
training workshops and providing proper equipment and
teaching how to use them.
3. Tertiary prevention:

Tertiary prevention will limit the disability caused by the condition. This is also
done by training the staff for management of a patient of PPH in the best
possible way. Suitable diet plans and hospital stays for observation are some of
these solutions.

Feasibility Matrix:
IDENTIFIED TECHNICAL RESOURCES EFFECTIV EQUIT GENDE SUSTAINABILIT
INTERVENTION FEASIBILIT E Y R Y
S Y IMPAC
T

Case finding L L L L L M

General M M M M M M
Awareness

High risk L L H L M L
awareness

Antenatal care M M M H M M

Control using M M H H H H
oxytocin

Skilled M M M M H M
healthcare
worker

Preventive Goals:

• The main preventive goal is to decrease the incidence of postpartum

hemorrhage in women so that mortality and morbidity rate can be
controlled among pregnant women.
 • To increase the awareness among female about going to hospital for
delivery.
• To discourage the use of instruments during delivery.
• To ensure the safe delivery of the baby and safety of the mother.
• To control the use of oxytocin for inducing labor.
• Prevent harmful practices by helping women and their families to
recognize harmful customs practiced during labor (e.g. providing
herbal remedies to increase contractions, health workers giving
oxytocin by intramuscular [IM] injection during labor).

Final Recommendation:

● Address the factors that cause uterine atony and laceration that lead to PPH
in one way or another.
● In case PPH does occur, early diagnosis by well-trained and well-equipped
staff can limit the consequences, so train and equip gynecologists,
obstetricians and paramedics about handling such situations efficiently.
● Educate women about their nutritional intake especially during pregnancy,
about the signs of labor to prevent prolonged labor and counselling them to
opt for hospital delivery. Awareness campaigns can be a good solution.
● Discourage the use of instruments and oxytocin during delivery.
● Develop a complication-readiness plan that includes recognition of danger
signs and what to do if they occur, where to get help and how to get there,
and how to save money for transport and emergency care.
● Routinely screen to prevent and treat anemia during pre-conceptual,
antenatal, and postpartum visits.

Reference:
1. International Confederation of Midwives , International Federation of Gynaecology &
Obstetrics. Joint statement Prevention and treatment of Post-partum haemorrhage.
New advances for low resource settings. 2006. Available at: www.figo.org/docs/pph.
2. Derman RJ, Kodkany BS, Goudar SS, Gellar SE, Naik VA, Bellad MB et al. Oral
misoprostol in preventing postpartum haemorrhage in resource-poor communities: a
randomized controlled trial.Lancet 2006;368:1248-53.
3. Hofmeyr GJ, Walraven G, Gulmezoglu AM, Maholwana B, Alfirevic Z, Villae J.
Misoprostol to treat postpartum haemorrhage: a systematic review. BJOG
2005;112:547-53.
4. Jaferey SN. Maternal Mortality in Pakistan compilation of available data. J Pak Med
Assoc 2002; 52: 539-44.
5. United Nations.Millenium Development goals; NY UN:2000. Available at:
http//www.un.org/millennium goals.
6. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of the causes
of maternal death: a systematic review. Lancet 2006; 367:1066-74.