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​​​Prevention of Primary Postpartum Hemorrhage

System Readiness

  1. Construct a sterile tray that provides rapid access to instruments used to surgically treat PPH (Lyndon et al., 2015).
  2. Construct a sterile tray that provides rapid access to a hysterectomy tray (Lyndon et al., 2015).
  3. Conduct regularly scheduled simulation drills for practicing response to obstetric hemorrhage (Lyndon et al. 2015).
  4. Adopt and maintain an obstetrical hemorrhage emergency management plan which includes the activation of maternal hemorrhage response team as clinically needed (Lyndon 2015).

Time of Admission

Identify and manage patients with special consideration:

  • Placenta previa/accrete.
  • Bleeding disorder.
  • Anemia.
  • Those who decline blood products (ACOG, 2012; Lyndon et al., 2015).
  • Anticoagulant use (Nakajima, 2016).

Assess hemorrhage risk on admission, throughout labour, postpartum and at every handoff (ACOG, 2012; Lyndon et al., 2015):

  • If medium risk: Type and Screen and review hemorrhage protocol.
  • If high risk: Type and crossmatch 2 units of PRBCs, review hemorrhage protocol and notify OB provider and/or anesthesia (Lyndon et al., 2015).

Third Stage of Labour (Leduc et. al, 2009)

[Note #4 and #7 for specific recommendations related to Caesarean section]

  1. Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. AMTSL involves interventions to assist in expulsion of the placenta with the intention to prevent or decrease blood loss. Interventions include use of uterotonics, clamping of the umbilical cord, and controlled traction of the cord.
  2. Oxytocin (10 IU), administered intramuscularly, is the preferred medication and route for the prevention of PPH in low-risk vaginal deliveries. Care providers should administer this medication after delivery of the anterior shoulder.
  3. Intravenous infusion of oxytocin (20 to 40 IU in 1000 mL, 150 mL per hour) is an acceptable alternative for AMTSL.
  4. An IV bolus of oxytocin, 5 to 10 IU (given over one to two minutes), may be used for PPH prevention after vaginal birth, but is not recommended at this time with elective Caesarean section.
  5. Ergonovine can be used for prevention of PPH, but may be considered second choice to oxytocin due to the greater risk of maternal adverse effects and the need for manual removal of a retained placenta. Ergonovine is contraindicated in patients with hypertension.
  6. Ergonovine, 0.2 mg IM, and misoprostol, 600 to 800 g given by the oral, sublingual, or rectal route, may be offered as alternatives in vaginal deliveries when oxytocin is not available.
  7. Carbetocin, 100 g given as an IV bolus over one minute, may be used instead of continuous oxytocin infusion in elective Caesarean section for the prevention of PPH and to decrease the need for therapeutic uterotonics.
  8. For women delivering vaginally with one risk factor for PPH, carbetocin 100 g IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin.
  9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping.
  10. For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to six months of age conferred by delayed cord clamping.
  11. There is no evidence that in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH.
  12. Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH.

[Note: refer to Leduc et. al, 2009 for additional guidelines related to the treatment of postpartum hemorrhage.]

Secondary Postpartum Hemorrhage

  • Prompt and careful examination of the birth canal, including both inspection and palpation, to identify and repair lacerations of the perineum, vagina, or cervix, that result in visible or concealed hemorrhage (Andersen & Hopkins, 2008).
  • Repeat risk factor assessment at time of delivery and at least once per shift in the postpartum period. Treat multiple risk factors as high risk. Modify plan of care based on risk category (Lyndon et al., 2015).
  • Continue to monitor the patient for signs and symptoms of secondary PPH.
  • Development and implementation of protocols for the management of the third stage of labour include the use of uterotonic agents to prevent PPH. Protocols for management of ongoing PPH will also address the other possible etiologies of PPH in addition to uterine atony, including retained placenta, genital tract trauma, and defects in coagulation. Adherence to protocols for third stage management and for PPH will improve patient outcomes.

Conduct Clinical and System Reviews (see details below)

Given the broad range of potential causes of hemorrhage, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Clinical and System Reviews, Incident Analyses

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.
  2. Use appropriate analytical methods to understand the contributing factors.
  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for analysis methods are included in Resources for Conducting Incident and/or Prospective Analyses section of the Introduction to the Hospital Harm Improvement Resource.

Chart audits are recommended as a means to develop a more in-depth understanding of the care delivered to patients identified by the HHI. Chart audits help identify quality improvement opportunities.

Useful resources for conducting clinical and system reviews: