| | Postpartum hemorrhage today: ICM/FIGO initiative 2004–2006 published online 13 July 2006. Abstract Postpartum hemorrhage (PPH) is the main cause of maternal mortality. Yet, even though solutions have been identified, governments and donor countries have been slow to implement programs to contain the problem. While poverty and low educational level remain the underlying cause of PPH, the current literature suggests that active management of the third stage of labor can prevent it. The International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) are attempting to address the chronic PPH crisis by educating their members on best practices and on troubleshooting where resources are inadequate. Some studies found oxytocin to be preferable to misoprostol in settings where active management is the norm. However, secondary clinical effects may prove more troublesome with oxytocin than with misoprostol, and misoprostol may prove to be more practical and equally effective in low-resource settings. Two new interventions are also proposed, the anti-shock garment and the balloon tamponade. “Women are not dying because of a disease we cannot treat. They are dying because societies have yet to make the decision that their lives are worth saving.” (Mahmoud Fathalla, President of the International Federation of Gynecology and Obstetrics (FIGO), World Congress, Copenhagen, 1997) 1. Introduction  The wife of Shah Jahan of India, Empress Mumtaz, had 14 children and died of postpartum hemorrhage (PPH) in 1630. So great was Shah Jahan's love for his wife that he built the world's most beautiful tomb–the Taj Mahal–in her memory [1]. Far away to the north, another country was taking a very different, three-tiered approach. The Swedish Collegium Medicum was established in 1663; the Swedish clergy created an information system that, by 1749, provided the first national vital statistics registry in Europe; and by 1757, training was approved for midwives of all parishes in Sweden. The resulting infrastructure, a comprehensive midwifery system backed by physician expertise and a system for reporting outcomes, is considered responsible for reducing maternal mortality in Sweden from 900 to 230 per 100,000 live births between 1751 and 1900 [2]. To this day, Sweden has one of the lowest MMRs in the world. In 2006, each nation must decide whether it will build monuments to hardship and suffering or take steps to avoid misery. Although fully 10 years remain until the target date of 2015, it is already predicted that the Millennium Development Goal No. 5, to reduce the MMR (MMR) by 75%, will not be reached. Maternal mortality is currently estimated at 529,000 deaths per year, a number that translates into a global ratio of 400 maternal deaths per 100,000 live births [3]. Another way to characterize these deaths is to say that, because of childbearing, 1 woman dies every minute of every hour of every day. Most of the deaths and disabilities attributed to childbirth are avoidable. Indeed, 99% of maternal deaths occur in developing countries that have inadequate transport systems, limited access to skilled caregivers, and poor emergency obstetrical services [4]. It is a given that each mother and newborn require care that is close to where they live, respectful of their culture, and provided by persons with enough skill to act immediately should a complication occur. The challenge that remains internationally is not technological, but strategic and organizational [4]. Postpartum hemorrhage is the most common cause of maternal mortality and accounts for one-quarter of all maternal deaths worldwide [5]. The optimal solution for the vast majority–if not all–deaths caused by PPH is prevention, both before delivery by assuring that women are sufficiently healthy to withstand PPH, and at the time of delivery with appropriate labor management. To their credit, the International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) are engaging their membership in a worldwide campaign to address the PPH tragedy. 2. Definition and incidence The World Health Organization (WHO) has examined studies on PPH published between 1997 and 2002 to arrive at more precise definitions of PPH and estimates of its incidence [6]. Available resources, however (data from 50 countries, 116 studies, and 155 unique data sets) were not adequate. Definitions of PPH were lacking in 58% of the published studies, and in the population-based surveys, the rates ranged from 0.55% of deliveries in Qatar to 17.5% in Honduras. Preliminary findings suggest that excessive bleeding was reported to have occurred in 0.84% to 19.80% of deliveries, but most studies shunned the issues of defining and diagnosing PPH. One of the major problems is how to measure blood loss with accuracy. Published data are scant, and a gold-standard method is lacking. Clinical visual estimation of blood loss is not reliable [7], and as is often the case, necessity becomes the mother of invention. In the rural areas of Tanzania, the use of “kangas” has been adopted as a valid instrument [8]. Convenient because it is produced and sold locally, the precut kanga is a rectangle of local cotton fabric measuring 100 cm×155cm. When 3–4 kangas are soaked during a delivery, the trained traditional birth attendant is entrusted to transfer the woman to a health center. Even when a good measurement method is in place, defining PPH simply as a blood loss greater than 500mL does not take into account the underlying health factors responsible for the blood loss, and since the quantity of blood lost is often less important than the effect it has on the woman, it has been suggested that a useful definition takes into account any blood loss that causes a major physiologic change (e.g., a fall in blood pressure) that threatens the woman's life. 3. PPH: when, why, and where? Sixty percent of all maternal deaths occur during the postpartum period, and one source suggests that 45% of these deaths occur in the first 24h after delivery [9]. The risk of dying from PPH depends not only on the amount and rate of blood loss but also on the health of the woman [10]. Poverty, unhealthy lifestyle, malnutrition, and women's lack of control over their reproductive health are some of the broad issues that, unfortunately, have come to be accepted as inevitable and unchangeable. In a busy urban maternity hospital, in the country where the Taj Mahal stands witness to this problem, nurses in a labor ward may not complete a patient's case notes because she is of a low caste and, thus, deprive her of the safeguards afforded other women [3]. But India's problems are merely symbolic of what faces both high- and low-resource countries [3], [4], [11]. Two-thirds of the women who incur PPH have no identifiable clinical risk factors such as multiple pregnancy or fibroids [12]. In this regard, PPH is a veritable equal-opportunity occurrence. However, it is not an equal-opportunity killer. It is the poor, malnourished, unhealthy woman delivered away from medical care who will die from it. On the other hand, the woman who is fortunate enough to be delivered near a well-staffed and well-supplied medical facility will most likely survive the three usual delays: delay in recognizing a complication and seeking help; delay in accessing transportation to reach a medical facility; and delay in receiving adequate and comprehensive care upon arrival to the medical facility. About 95% of all maternal deaths in 2000 were equally distributed between Asia (253,000) and sub-Saharan Africa (251,000) [13], but with greater risks in Africa because it has a smaller population. With more than 900 maternal deaths per 100,000 live births, sub-Saharan Africa has for decades been the region with the highest MMR. In this region, the number births attended by skilled health personnel and life expectancy at birth strongly correlate with maternal mortality. As an example, the increased ability to measure maternal mortality in Afghanistan has revealed a suspected but heretofore unconfirmed reality. The retrospective cohort study of women of reproductive age conducted in four districts from four provinces by the Centers for Disease Control and Prevention reported an astounding maternal mortality of 1900 per 100,000 live births [14]. Another group of authors describes reasons for such a high MMR in the Afghanistan province of Herat: “[C]onditions for individual and community health often depend on the protection and promotion of human rights. The findings of this study identify a number of human rights factors that contribute to preventable maternal deaths in Herat Province. These include access to and quality of health services, adequate food, shelter, and clean water, and denial of individual freedoms such as freely entering into marriage, access to birth control methods and possibly control over the number and spacing of one's children.” [15] In many other countries, PPH accounts for more than half of maternal deaths, rather than for the quarter worldwide. For example, it has been reported to be 43% in Indonesia, 53% in the Philippines, and 53% in Guatemala [4]. Within given countries certain populations are also at increased risk. In Latin America, for example, the Pan American Health Organization has identified three main reasons for a higher maternal mortality among indigenous populations: (1) The professional teams in charge of maternity care underrate or are ignorant of traditional cultural practices; (2) health teams and pregnant women often communicate poorly, a principal factor behind low maternal enthusiasm for maternity care; and (3) public policies for consensus building and intercultural dialogue on maternal health are in conflict with established objectives and goals and the allocation of resources [16]. 4. Existing evidence for PPH prevention In September 2004, Litch [17] provided a summary of the evidence in favor of active management of the third stage of labor. The following excerpt summarizes these data: “From 1988 to 1998, four large randomized controlled studies conducted in well-resourced maternity hospitals (two in the United Kingdom, one in the United Arab Emirates and one in Ireland) 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 and the length of third stage of labor…A Cochrane Library systematic review and meta-analysis also concluded that active management of the third stage in the setting of a maternity hospital was superior to expectant management in reducing blood loss, incidence of postpartum hemorrhage and duration of the third stage; it was also associated with reduced postpartum anemia, decreased need for blood transfusion, and less use of additional therapeutic uterotonic drugs.” [17] To a certain extent, the same caveat holds for the use of prostaglandins, since at least two Cochrane reviews have addressed the issue of misoprostol, a prostaglandin E1 analogue, as a choice for use in the prevention and treatment of PPH. A 2003 review suggests that 800μg of misoprostol administered rectally may be a “first-line” drug for the treatment of primary PPH, but that further randomized controlled trials are required to identify the best drug combinations, route, and dose for the treatment of PPH; and a 2004 review reports that “[n]either intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the active management of the third stage of labor, especially for low-risk women. Future research on prostaglandin used after birth should focus on the treatment of postpartum hemorrhage rather than prevention where they seem to be more promising” [18]. Even a WHO multicenter randomized trial left some issues unresolved. It concluded that 10 IU of oxytocin (intravenous or intramuscular) was preferable to 600μg of oral misoprostol in the active management of the third stage of labor at hospitals where active management was the norm [19]. The possibly troubling “secondary effect” of oxytocin on manual removal of the placenta needs clarification, as a 2004 Cochrane Review suggested that, with the prophylactic use of oxytocin, “the risk of manual removal of the placenta may be increased” [20]. In high-resource countries, where embolism rather than PPH is the major cause of maternal mortality, hemorrhage requiring hysterectomy is considered one of the most life-threatening conditions experienced by women during the perinatal period [21]. Retained placenta represents a serious complication requiring manual removal, and such a “secondary outcome” could be critical to consider when deciding on third-stage management protocols. Because the picture is not yet entirely clear, practitioners should continually update themselves regarding available options, and health care agencies and governments planning units should be equally vigilant about determining the best approach to adopt according to the available resources. Although the literature suggests that active management using standard oxytocic drugs can reduce PPH incidence by 40% [22], this method is far from ideal in low-resource countries where many births are supervised by traditional birth attendants away from medical facilities and where the lethal PPHs are occurring. The WHO study did not investigate whether misoprostol was better than placebo. Two recent trials of misoprostol, however, suggest favorable results with this agent in low-resource countries. One, a field intervention trial in Tanzania following home births, demonstrated that 1000μg of misoprostol administered rectally by traditional birth attendants to women who lost 500mL of blood or more decreased the need for referral and/or further treatment compared with a nonintervention group [23]. The other, a randomized, double-blind, placebo-controlled trial conducted among women attended by midwives at local health centers in Guinea–Bissau, concluded that 600μg of misoprostol routinely administered sublingually after delivery reduced the frequency of severe PPH [24]. Both studies suggest that the safety of delivery is greater with misoprostol use, even when the women are attended by practitioners not “skilled” by the WHO/ICM/FIGO definition. An even more bolder method to deal with PPH was tried in Indonesia, where 1811 women were offered counseling about PPH prevention and misoprostol use by trained and supervised volunteers. This study demonstrated that misoprostol was safely used in a self-directed manner by the study participants who were delivered at home in the intervention area [25]. Although misoprostol is available in most Asian and American countries, its use is restricted in many countries because of the fear that it will be used as an abortifacient. There is no access to this agent in most of Africa and much of the Middle East, and only three countries, Brazil, Egypt, and France, have approved its use in obstetrics [26]. Given the potential benefits of misoprostol towards the major goal of the Millennium Development Goal No. 5–reducing maternal mortality–and the fact that WHO has added it to its list of “essential medicines” [27], there appears to be a role for FIGO, ICM, and the research community in closing the gaps in research as well as opening the barriers to the availability of this medication. 5. Ongoing initiatives to prevent PPH Every childbearing woman is potentially at risk for PPH, but biologic and/or physiologic considerations are only part of the picture. Heathcare workers should assume a stronger attitude of service and responsibility in the larger public health issues, empowering women to seek help in a transformed health care culture. Moreover, when caring for indigenous populations and minority groups forgotten or subjugated by a dominant culture, more sensitive approaches respecting pregnancy and birth as social and cultural events should be adopted. Incorporating traditional practitioners, e.g., the partera in Central America, into the health care team would be an important step forward. It is crucial that physicians, midwives, and nurses work with communities and women's groups to bridge existing gaps in care. An international group of researchers and experts that included representatives of ICM and FIGO met in August 2003 in Ottawa, Canada, to craft the Ottawa Statement on the prevention of PPH and offer new options for its treatment. At the last World Congress of FIGO in Chile, in 2003, President Arnaldo Acosta announced that FIGO, in partnership with ICM, would launch an initiative to promote active management of the third stage of labor (AMTSL) to prevent PPH, and increase the knowledge of nurses, midwives, and physicians in the medical and surgical treatment of PPH. Both FIGO and ICM are collaborating with the Program for Appropriate Technology for Health to conduct the Prevention of Postpartum Hemorrhage Initiative. Launched in October of 2004, this project has created tool kits and educational modules to implement AMTSL and has also provided small grants to countries, so that FIGO- and ICM-member associations and societies may collaborate to spread the use of AMTSL. These initiatives have been prompted, in large part, by the fact that past efforts did not substantially decrease maternal mortality and morbidity. Procedures for PPH prevention and treatment are well known and proven to be beneficial, but they are not readily available to many health workers and pregnant women. 6. Joint statement and action plan launched in 2004 by ICM/FIGO “Management of the third stage of labor should be offered to women since it reduces the incidence of postpartum hemorrhage due to uterine atony.” Active management of the third stage of labor consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include •Administration of uterotonic agents; •Controlled cord traction; and •Uterine massage after delivery of the placenta, as appropriate. Every birth attendant must have access to needed supplies and equipment and acquire the knowledge, skills, and critical judgment to carry out active management of the third stage of labor. 6.1. How to use uterotonic agents Warning! Do not give ergometrine or syntometrine (which contains ergometrine) to women with pre-eclampsia, eclampsia, or high blood pressure. 6.2. How to perform controlled cord traction •Clamp the cord close to the woman's perineum (once pulsation stops in a healthy newborn) and hold it in one hand; •Place the other hand just above the woman's pubic bone and stabilize the uterus by applying counter-pressure during controlled cord traction; •Keep a slight tension on the cord and wait for a strong uterine contraction (2–3min); •With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta. Continue to apply counter-pressure to the uterus; •If the placenta does not descend during 30–40 s of controlled cord traction, do not continue to pull on the cord:○Gently hold the cord and wait until the uterus is well contracted again; ○With the next contraction, repeat controlled cord traction with counter-pressure. Never apply cord traction (never pull) without applying counter-traction (push) above the pubic bone on a well-contracted uterus. •As the placenta is being delivered, hold it in two hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery; •If the membranes tear, gently examine the upper vagina and cervix wearing sterile or disinfected gloves, and use a sponge forceps to remove any pieces of membrane that are present; •Carefully examine the placenta to ensure that none of it is missing. If a portion of the maternal surface is missing, or there are torn membranes with vessels, suspect retained placenta fragments and take appropriate action [27]. 6.3. How to perform uterine massage •Immediately massage the fundus of the uterus abdominally until the uterus is contracted; •Palpate for a contracted uterus every 15min and repeat uterine massage as needed during the first 2h; •Ensure that the uterus does not become relaxed (soft) or “boggy” after you stop uterine massage. In all of the above actions, explain the procedures and actions to the woman and her family. Continue to provide support and reassurance throughout. 7. Important changes to consider in active management protocols There is evidence suggesting that immediate cord clamping may reduce the quantity of red blood cells a newborn receives, possibly causing short- and long-term problems. Because prior concerns about polycythemia have not been documented [28], the collaborative ICM/FIGO group decided not to include early cord clamping in the active management protocol. This decision means that the present definition of active management promulgated by ICM/FIGO differs from that described in earlier publications. FIGO now also advises that if oxytocin or misoprostol are unavailable, skilled birth attendants should use physiologic (or expectant) management of the third stage. This means that, to avoid maternal overexertion, they should not begin cord traction before the uterus has contracted and the placenta's expulsion has begun. This is best described as allowing the mother to expel her own placenta without interference from the practitioner. 8. The role of national professional organizations The following points outline the 10 key actions that are being promoted worldwide by FIGO/ICM to prevent PPH and manage it when it occurs: (1)Disseminate the joint statement to all national associations of midwives and societies of obstetrician–gynecologists, and encourage the national groups to disseminate it to their members. (2)Obtain support for the joint statement from agencies in the field of maternal and neonatal health care, such as UN and non-UN development agencies. (3)Recommend that this Global Initiative on the prevention of PPH be integrated into the midwifery curricula of medical and nursing schools. (4)Recommend that the Global Initiative be adopted by health policy makers and politicians. (5)Every mother giving birth anywhere in the world will be offered active management of the third stage of labor for the prevention of PPH. (6)Every skilled attendant will have training in active management of the third stage of labor and in techniques for the treatment of PPH. (7)Every health facility where births take place will have adequate equipment and supplies of uterotonic drugs, as well as protocols in place for the prevention and treatment of PPH. (8)There will be blood transfusion facilities in all centers that provide comprehensive health care (secondary and tertiary levels of care). (9)Physicians will be trained in simple conservative techniques such as compression sutures and devascularization [29]. (10)Promising new drugs and technologies for the prevention and treatment of PPH, such as the tamponade technique, are being evaluated. National professional associations also have an important and collaborative role to play in the following areas: •Advocacy for skilled care at birth; •Public education about the need for adequate prevention and treatment of PPH; •Publication of the statement in national midwifery, obstetric, and medical journals as well as in newsletters and on Web sites; •Dealing with legislative and other barriers that impede the prevention and treatment of PPH—which includes confronting poverty and malnutrition as well as incorporating active management of the third stage of labor into pre-service and in-service curricula for all skilled birth attendants; •Incorporating active management of the third stage of labor in national standards and clinical guidelines, as appropriate; •Working with national pharmaceutical regulatory agencies, policymakers, and donors to ensure that adequate supplies of uterotonics and injection equipment are available. In order to assess the situation and send aid where strategically feasible, FIGO/ICM developed a detailed questionnaire on: •The cost and availability of oxytocics around the world, who is allowed to use them and under what circumstances, how they are stored, and the plans and obstacles to place utertonics in the hands of those who need them; •The present practice protocols of the various societies with regards to management of the third stage and the training available; •The working definition of active management of the third stage in every country; •The key actions the member associations are undertaking or are willing to undertake. Results will be presented at the FIGO World Congress in 2006 in Kuala Lumpur. 9. Two new tools: the anti-shock garment and the tamponade test 9.1. The anti-shock garment A new type of anti-shock garment has been developed, which reverses the effect of shock on the body's blood distribution. It is best described as a giant blood pressure cuff that applies external counter-pressure to the legs and abdomen. Based on the principle that the brain, heart, and lungs of a person in shock incur a loss of oxygen because blood accumulates in the lower abdomen and legs, the anti-shock garment returns blood to the vital organs, thus stabilizing body pressure until a hospital can be reached. The Cochrane Review reveals no evidence that using medical anti-shock trousers (or pneumatic anti-shock garments) for circulatory support reduces mortality length of hospitalization, or length of stay in the intensive care unit for patients with trauma, and these garments may even increase these indicators [30]. However, the Cochrane Review cautions about the poor quality of the trials and data. Moreover, a trial of the nonpneumatic anti-shock garment (NASG) is presently conducted in Egypt, Nigeria, and Mexico by Suellen Miller, from the Women's Global Health Imperative. Preliminary results from the pilot Egypt study suggest that, compared with women in the control group in whom the NASG was not used, bleeding decreased by 50% in women experiencing various forms of obstetrical hemorrhage (e.g., ruptured ectopic pregnancy, postabortion complications, or PPH) in whom the NASG was used [32]. The use of this device could be critical to decrease MMRs by avoiding the second delay in low-resource settings—reaching a health facility. 10. The tamponade test The following is a summary of a written description of the tamponade test by Dr. Sabaratnam Arulkumaran, Professor and Head of the Division of Obstetrics and Gynecology at St. George's Hospital Medical School in London, England. A survey in the UK showed that hysterectomy was the most common surgical procedure in women who did not respond to a combination of uterotonic drugs [31]. As invasive surgery following a PPH can cause additional blood loss and a long convalescence, alternative procedures are being sought, and the tamponade test is a nonsurgical approach (Fig. 1). If used as soon as uterotonics are found ineffective, the tamponade test could both reduce the amount of blood lost and indicate whether definitive surgery is needed within minutes. It may be useful in women incurring PPH of nontraumatic causes, and when there is no retained tissue in the uterus. It is hypothesized that total blood loss and the need for blood transfusion, laparotomy, and even hysterectomy–with their related risk–may be avoided by a modern version of this old technique. 10.1. Rationale for the tamponade test The first-aid technique to stop a vessel from bleeding following an injury is to apply a tourniquet, or else apply pressure proximally to the bleeding vessel. Applying sufficient pressure to compress the blood vessel often brings resolution—the bleeding has stopped when the bandage is removed several hours later. This technique works because the pressure on the blood vessel is greater than the pressure within the vessel. If pressure is applied long enough, the blood may clot and form a permanent seal. Blood flows into the uterus with a pressure of 120/80mm Hg, for a mean arterial pressure of 90mm Hg. The spiral arteriolar arrangement in the uterus might lower the arterial pressure with which the blood enters the uterus. When the placenta separates, the venous sinuses and the spiral arterioles are exposed and bleeding occurs from the placental bed. If uterine atony continues after oxytocics are given, bimanual compression is undertaken while local trauma is ruled out as the source of bleeding. Exploration under anesthesia is often undertaken to remove products that may be retained within the uterus and to determine whether any trauma to the uterus or lower genital tract may be the source of bleeding. If the bleeding is due to uterine atony, i.e., the failure of the living ligatures to stop the bleeding, a tamponade test would help decide whether the uterine tamponade itself would be therapeutic, or whether laparotomy is needed. 10.2. History In the past, uterine tamponade was achieved by packing the uterus with cotton gauze, a technique which had several disadvantages. General, spinal, or epidural anesthesia was needed, and because the packing was done blindly, it was not known whether it filled the entire uterine cavity. Moreover, the fear of perforation often led to inadequate packing; and whether the packing was effective was not known for several minutes, as the blood had to soak the pack before reaching the cervix. To overcome some of these difficulties, a sterile plastic bag was first introduced into the uterus, and then packed with gauze; but the process was cumbersome, took time, and was not always effective [32]. The interest of the medical community for uterine tamponade has been revived by the appearance of the balloon tamponade. 10.3. How balloon tamponades are used Several reports describe the successful treatment of PPH using a hydrostatic balloon tamponade, either alone or in combination with additional surgical methods [33], [34]. The most commonly used balloon has been the Sengstaken–Blakemore tube, used by surgeons for decades to arrest bleeding from esophageal varices. Fig. 1 shows the SOS Bakri Tamponade Balloon Catheter. It is the aim of FIGO to lobby to make these devices less expensive than they are presently. Steps to their use are as follows: When uterotonics and uterine massage do not stop the bleeding, the patient is checked for local trauma or retained tissue in the uterus. Then, under spinal, epidural, or general anesthesia, a balloon catheter (sterilized by gas or by soaking in 2% glutaraldehyde solution for 20min) is inserted into the uterine cavity. A vaginal examination or direct visualization to identify the cervix facilitates insertion. For direct visualization, a vaginal speculum is introduced and the anterior lip of the cervix is secured with a sponge forceps. When the Sengstaken–Blakemore stomach device is used, the distal tube is cut and removed to facilitate insertion and retention in the uterine cavity and the balloon part, held with another sponge forceps, is inserted into the uterine cavity. Once the balloon has been placed in the uterine cavity, an assistant is asked to fill it with warm sterile water or a warm saline solution. About 100–300mL could be used, but overfilling the balloon may cause it to bulge out of the cervix and be expelled. For this reason, the balloon wall should be distensible, but not so distensible that increasing pressure causes it to herniate through the cervix. In case reports, the volume used varies from 80 to 300mL. The practice has been to fill the balloon until it becomes visible in the cervix lumen. At this stage, if there is no bleeding through the cervix or through the drainage channel of the balloon catheter, the test result is pronounced successful and no further fluid is added. If the bleeding continues, the result is unsuccessful and surgery is needed. Further research is in progress to make catheter balloons more effective by measuring the inner pressure of the balloon part. When the pressure exceeds that of the patient's blood pressure, no additional fluid needs to be added and the bleeding should stop. If the bleeding does not stop and does not originate in the lower genital tract, then the need for surgery via laparotomy is indicated. Whether the tamponade will be successful is known within minutes. Once it is found to be successful, the uterine fundus is palpated abdominally and a mark is made with a pen as a reference line from which any uterine enlargement or distension would be noted during the period of observation. 10.4. Care after tamponade The patient should be kept under constant surveillance after insertion of the tamponade balloon catheter. Her pulse, blood pressure, uterine fundal height, and signs of any vaginal bleeding or bleeding through the lumen of the catheter should be noted every half hour. Her temperature should be recorded every 2h and urinary output measured hourly via an indwelling Foley catheter. Since a foreign body is introduced and will remain in place for hours, the woman should receive broad-spectrum antibiotics from the time of insertion for up to 3days. At St. George's Hospital Medical School, ampicillin and metranidazole are administered intravenously on day 1, followed by 2 more days of oral antibiotics. If the woman is sensitive to penicillin, erythromycin or cephalosporin is prescribed. A low-dose infusion of oxytocin (40 IU in a liter of normal saline solution) is continued until the balloon is withdrawn to keep the uterus contracted. After 6–8h, if the uterine fundus remains at the same level, and there is no active bleeding through the cervix or the central lumen of the catheter, it is safe to remove the balloon provided that the woman is stable and adequate blood replacement has been provided. The balloon removal procedure is as follows: The mother is kept fasting in case surgery is needed under anesthesia. First, the balloon is deflated, but not removed for 30min, during which the oxytocin infusion is continued even if there is no bleeding. If there is still no bleeding after these 30min, the oxytocin infusion is stopped and the balloon catheter removed. In this way, if the woman starts bleeding when the balloon is deflated or the oxytocin stopped, the balloon can be inflated again. In the experience at St. George's Hospital Medical School with more than 30 cases, there were no cases when the balloon needed to be refilled [33]. Six hours seem to be sufficient for the placental bed to clot and stop bleeding. To date, no immediate problems such as bleeding or sepsis, or long-term complications such as menstrual problems or problems with conceiving, have been reported in women who underwent uterine tamponade. 10.5. The evidence for tamponade The largest case series consists of 16 consecutive cases in which the tamponade test was used as a last measure before embarking on a laparotomy [33]. The bleeding stopped immediately in 14 patients, and no additional intervention was required. Even when the bleeding did not stop, the quantity of bleeding was markedly reduced, allowing enough time to stabilize the two patients prior to surgery. The amount of blood collectively lost by the 16 patients was estimated at 50L, and together these women received 99 units of blood, 36 units of fresh-frozen plasma, 23 units of platelets, and 180mL of cryoprecipitate. Although more research is needed, it would seem that the tamponade test could have been introduced earlier to reduce bleeding in primary or secondary PPH; after a second-trimester miscarriage; and in some cases after a cesarean section—provided that there is no spontaneous or surgical trauma and no retained tissue in the uterus. The tamponade test could be particularly effective in reducing the MMR of low-resource countries, as it can be performed by staff of little training in small centers with minimal facilities. 11. The clinical classification of hypovolemic shock Mild shock occurs when about 20% of the blood volume is lost and there is decreased perfusion of nonvital organs and tissues (skin, fat, skeletal muscle, and bone), with pale, cool skin and a feeling of growing cold. Moderate shock occurs when 20–40% of the blood volume is lost and there is decreased perfusion of vital organs (liver, the gut, and kidneys), oliguria and/or anuria, a slight to significant drop in blood pressure, and mottling in the extremities, especially the legs. Severe shock occurs when 40% or more of the blood volume is lost and there is decreased perfusion to the heart and brain, restlessness, agitation, coma, cardiac irregularities, electroencephalographic abnormalities, and possibly cardiac arrest. 11.1. Hemorrhagic shock and the concept of the golden hour Severe, acute blood loss can lead to cardiovascular failure. Severity depends on body weight, hemoglobin levels, and body metabolism. For instance, a blood loss of 1.5L causes severe shock in a woman weighing 48kg but only a mild shock in a woman weighing 84kg. As more time elapses between the onset of severe shock and resuscitation, the percentage of surviving patients decreases because metabolic acidosis sets in. The golden hour is the time at which resuscitation must begin to ensure the best chance of survival. The probability of survival decreases sharply after the first hour if the patient is not effectively resuscitated. 11.2. An algorithm for action An algorithm has been suggested for the management of atonic PPH. It is called H.A.E.M.O.S.T.A.S.I.S. - H:
Ask for help - A:
Assess (vital parameters, blood loss) and resuscitate - E:
Establish etiology and check medication supply (syntometrine, ergometrine, bolus syntocinon) and availability of blood - M:
Massage uterus - O:
Oxytocin infusion, prostaglandins (intravenous, rectal, intramuscular, intra-myometrial) - S:
Shift to operating room, exclude retained products and trauma, bimanual compression - T:
Tamponade balloon, uterine packing - A:
Apply compression sutures - S:
Systematic pelvic devascularization (uterine, ovarian, quadruple, internal iliac) - I:
Intervention radiologist, uterine artery embolization if appropriate - S:
Subtotal or total abdominal hysterectomy
12. Conclusion Tourists flock to the Taj Mahal, unaware that the event symbolized by this monument still occurs continually around the world—in the shadows of a woman's blood-soaked dirt floor; of a desperate husband's rough cart dragged through bad roads, which does not arrive in time; of the sad eyes of a basic health unit nurse. Governments have been slow to prioritize women's health and donor countries have not shown sufficient commitment to dealing with maternal mortality; and yet, poverty reduction and education were supposed to be acknowledged as the keys to good health—the motto was to be that there is no health without education and no education without health [35]. To address the PPH issue, ICM and FIGO have launched a worldwide initiative to promote active management of the third stage of labor for all women. Further research is needed about the benefits and possible adverse effects of misoprostol, oxytocin, the anti-shock garment, and the balloon tamponade. Both organizations need governments, donor countries, and the public to support the campaign that will help address Millennium Development Goal No. 5. The professional associations are respectfully requested to join the ICM/FIGO coalition and contribute to the prevention and treatment of PPH. They can do so by working with their ministries of health on the broader issues of poverty, nutrition, women's status, and access to medication and education and persuade them to adopt the low-cost medico-surgical approaches just discussed. A community and national infrastructure designed in Sweden in the 1700s would still represent a giant's step toward FIGO's Millennium goal to save mothers, and the time appears to be right to seize the answers that have been staring us in the face for some time. References [1]. [1]Taj Mahal history and pictures available at: http://www.indianchild.com/taj_mahal.htm. [2]. [2]Hogberg U. The decline in maternal mortality in Sweden: the role of community midwifery. Am J Publ Health. 2004;94(8):1312–1319. [3]. [3]World Health Organization . In: Attending to 136 million births, every year: make every mother and child count: The World Report 2005. Geneva, Switzerland: WHO; 2005;p. 61. [4]. [4]AbouZahr C. Antepartum and postpartum hemorrhage. In: Murray CJ, Lopez AD editor. Health dimensions of sex and reproduction. Boston, MA: Harvard University Press; 1998;p. 172–181. [5]. [5]World Health Organization . In: Attending to 136 million births, every year: make every mother and child count: The World Report 2005. Geneva, Switzerland: WHO; 2005;p. 62–63. [6]. [6]Gulmezoglu AM. Postpartum hemorrhage (1997–2002). Monitoring and evaluation department of reproductive health and research. Geneva, Switzerland: World Health Organization; 2004 (25–26 May);. [7]. [7]Razvi K, Chua S, Arulkumaran S, Ratnam SS. A comparison between visual estimation and laboratory determination of blood loss during the 3rd stage of labor. Aust N Z J Obstet Gynaecol. 1996;36:152–154. MEDLINE [8]. [8]Prata N, Mbaruku G, Campbell M. Using the kanga to measure postpartum blood loss. Int J Gynecol Obstet. 2005;89:49–50. [9]. [9]Li XF, Fortney JA, Kotelchuck M, Glover LH. The postpartum period: the key to maternal mortality. Int J Gynecol Obstet. 1996;52:1–10. [10]. [10]Coombs CA, Murphy EZ, Laros RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol. 1991;77:69–76. MEDLINE [11]. [11]Kane TT, El-Kady AA, Saleh S, Hage M, Stanback J, Potter L. Maternal mortality in Giza, Egypt: magnitude, causes and prevention. Stud Fam Plann. 1992;23:45–57. MEDLINE [12]. [12]Available at: http://www.mnh.jhpiego.org/best/pphactmng.asp. [13]. [13]World Health Organization . Maternal mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva, Switzerland: WHO; 2004;. [14]. [14]Bartlett LA, Mawji S, Whitehead S, et al. Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002. Lancet. 2005;365(9462):864–870. Abstract | Full Text |
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PII: S0020-7292(06)00178-0 doi:10.1016/j.ijgo.2006.04.016 © 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Inc. All rights reserved. | |
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