Abstract
Postpartum hemorrhage (PPH) is the largest contributor to maternal mortality, occurring in between 1 and 5% of deliveries. Prophylactic uterotonics are widely recommended to prevent atonic hemorrhage. Rapid recognition of PPH and identification of hemorrhage etiology is essential to reduce mortality and morbidity. Treatment is etiology-specific and comprises a range of medical, mechanical, temporizing and surgical procedures. Important developments from trauma and emergency medicine around massive hemorrhage protocols are newly implemented for PPH, and the evidence base for PPH medical management is expanding, with clinical trials ongoing. Improving the management of PPH in limited-resource settings will require continued attention to ensure the availability of low-cost accessible prevention and treatment options, in addition to a focus on skilled care providers.
Acknowledgements
The authors would like to thank L Keith, for his invaluable comments on the manuscript; A Lalonde, FIGO; E Main, CMQCC; and A Weeks, University of Liverpool, for their discussions of relevant innovations in PPH management; and E Butrick and M Curtis for their editing assistance.
Financial & competing interests disclosure
S Miller is a member of the CMQCC and the FIGO Safe Motherhood and Newborn Health Committee. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Key issues
• Postpartum hemorrhage (PPH) is the leading contributor to maternal mortality, occurring in 1–5% of deliveries.
• Prophylactic uterotonic administration during the third stage of labor is critical for reducing the incidence of PPH.
• Oxytocin is the preferred uterotonic for prevention and treatment of PPH. Where oxytocin is not available or feasible, administration of other injectable uterotonics or oral misoprostol is recommended for prevention; and ergometrine, oxytocin-ergometrine or a prostaglandin (including misoprostol) is recommended for treatment.
• Treatment for PPH is etiology-specific; prompt identification of cause of bleeding is necessary and appropriate and appropriate definitive treatment should be initiated as soon as possible. Conservative treatment measures should be attempted prior to surgical intervention to reduce the need for hysterectomy.
• Guidelines around resuscitation are changing due to trauma and critical care research suggesting better patient outcomes with higher fresh frozen plasma to red blood cells ratios.
• Randomized controlled trials evaluating the effectiveness of tranexemic acid and fibrinogen concentrate on PPH are currently underway, with results expected within the next few years.
• Institutionalization of standard PPH management protocols combined with a checklist approach and facility preparedness for obstetric emergencies may improve timely implementation of evidence-based PPH management.
• High-fidelity simulations (drills) of acute, severe hemorrhage improve team performance and communication for treatment of PPH.
• Research is needed on the community-level distribution or self-administration of uterotonics, particularly misoprostol, and other management options for PPH where skilled attendants are not available.
• Greater attention to the development of health personnel and task-shifting is required in low-resource areas to ensure adequate availability of health personnel.