Postpartum Hemorrhage Toolkit

In 2003, the International Federation of Gynecology and Obstetrics (FIGO) and the International Confederation of Midwives (ICM) issued a joint statement that has prioritized universal access to active management of the third stage of labor (AMTSL) to respond to the urgent need to make real progress in reducing maternal mortality globally.

This toolkit is designed to provide useful, practical information and materials for: (1) health care providers so that they can prevent postpartum hemorrhage (PPH) through AMTSL and manage the most common causes of PPH; (2) health management teams and health facility managers so that they can ensure that all of the necessary supplies and equipment are available to practice AMTSL; and (3) policy makers so that they can advocate for necessary policy change to assure that active management of the third stage of labor is available to all women giving birth. The toolkit is not intended to be a comprehensive source for all materials related to prevention of postpartum hemorrhage, but rather focuses on selected tools that may be most useful to providers and policy makers.

Description of the toolkit

The toolkit provides selected essential, practical materials for adopting interventions for prevention, management, and treatment of postpartum hemorrhage.

The toolkit is available online only. When accessed online, relevant documents can be downloaded and adapted, as necessary, for country-specific use. The toolkit is designed to serve as a library reference document for midwifery, obstetric, and other professional and training associations, universities, Ministry of Health resource centers, and other centralized reference centers that provide support to maternal health care providers and distribute professional information to members. This document is designed with the view that as additional research findings become available, updates and additional information can be downloaded to supplement existing materials.

The toolkit is comprised of six sections:

Section A: WHO, FIGO, ICM statements / recommendations for prevention of PPH

This section provides:

A copy of statements made by WHO, FIGO, and ICM supporting AMTSL.
A copy of recommendations made by WHO for the prevention of PPH.
Go to Section A

Section B: Evidence base for active management of the third stage of labor

This section provides a summary of research and copies of articles published in peer-reviewed journals that provide an evidence base to:

Support offering AMTSL to every woman at every vaginal birth.
Promote oxytocin as the uterotonic of choice for AMTSL when injectable uterotonic drugs are available.
Support use of misoprostol for the prevention and treatment of PPH.
Practice controlled cord traction to facilitate expulsion of the placenta.
Delay cord clamping for 2-3 minutes after birth of the baby.
Go to Section B

Section C: Steps for Expanding Prevention of Postpartum Hemorrhage (PPH)

This section provides a set of tools to assist country programs that are selecting strategies and interventions to scale-up AMTSL. These tools will help country programs:

Identify areas that need to be strengthened in policy, practice, in- and pre-service education, uterotonic drugs and logistics, and monitoring and evaluation.
Select facility- and community-based interventions to prevent PPH.
Select training and non training interventions for scaling up AMTSL activities at the community and facility levels.
Go to Section C

Section D: Clinical care and guidelines for prevention and treatment of postpartum hemorrhage

This section provides a step-by-step description of AMTSL, a brief overview of comprehensive interventions to prevent PPH, WHO guidelines for management of the most common causes of PPH, and updates on new advances for treatment of PPH in low resource settings.

Clinical care and treatment guidelines for prevention of postpartum hemorrhage presented in this section are based on the World Health Organization manual “Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors (MCPC) (2003).

Go to Section D

Section E: Medications and logistics for active management of the third stage of labor

This section contains key reference articles on the research that has been conducted regarding the advantages and disadvantages of the various drugs that may be used for active management of the third stage of labor. In addition, the document “Prevention of Postpartum Hemorrhage: Drug Management Issues in the Active Management of the Third Stage of Labor” details the logistic and management issues of the appropriate drugs and presents in table format the storage requirements and advantages and disadvantages of each drug.

This section provides:

A copy of WHO/PATH’s “Essential Medicines for Reproductive Health: Guiding principles for their inclusion on National Medicines Lists.
Guidelines for selection of uterotonic drugs for use in AMTSL.
Guidelines for storage, transport, procurement, and documentation of uterotonic drugs used in AMTSL.
An update on oxytocin in Uniject and use of time-temperature-indicators (TTI) for ensuring potency of oxytocin.
Fact sheets on uterotonic drugs.
Go to Section E

Section F: Presentations

This section provides PowerPoint slide presentations on:

Promoting evidence-based care
Evidence for active management of the third stage of labor
Steps of AMTSL
Selection of uterotonic drugs for AMTSL
Pathway to national scale-up of AMTSL
In addition to the PowerPoint slides, a link is provided for downloading the CD-ROM “Active Management of the Third Stage of Labor: A Demonstration.” Please note that a CD-ROM is included in the hard copy of the toolkit.

Go to Section F

How to use the toolkit

POPPHI Prevention of postpartum hemorrhage: Toolkit Components

By clicking on the links below you can download the various components. If you would like to have a clear definition of medical terms used in the toolkit documents, it is advisable to download the Glossary of terms document before downloading other documents.

Glossary of terms: PDF
Glossary of terms: Word
Acrobat Reader 6.0 or higher is required to open the files.

Although the Microsoft Word documents have the advantage that they can be edited, the formatting is unstable (Microsoft defaults to the setting of the computer on which the file is opened) and may require a great deal of reformatting when you open the document on your computer. It is advisable to review the formatting in all Microsoft documents, specifically the bullet points, before printing the document. The Acrobat (PDF) documents will not undergo formatting changes, but they cannot be edited

Section A: WHO, FIGO, ICM statements / recommendations

Document 1: October 2006 MPS Technical Update: Prevention of postpartum hemorrhage by active management of the third stage of labor

English PDF (245K)

Document 2: WHO/MPS Recommendations for the prevention of postpartum hemorrhage (October 2006)

English PDF (1,459K)

Document 3: 2006 ICM/FIGO Joint Statement: Prevention and treatment of postpartum hemorrhage – New advances for low resource settings

English PDF (189K)

Français PDF (201K)

Español PDF (195K)

Document 4: FIGO/ICM Joint Statement: Management of the third stage of labor to prevent postpartum hemorrhage

English PDF (129K)

Français PDF (156K)

Español PDF (135K)

Document 5: Declaration of support for FIGO/ICM global effort to prevent PPH

English PDF (102K)

Français PDF (131K)

Español PDF (144K)

Section B: Evidence base for active management of the third stage of labor

This Section is divided into 7 parts and once downloaded should be combined together for the complete document.

Authors / publishers for the articles available for downloading have given permission for reproduction. If you would like a copy of any of the other articles listed as additional resources, please contact the author/publisher directly.

Please note that page numbers for the complete articles may not follow the order of articles posted for this section.

Introduction

English PDF (75K)

Part 1: Support for offering AMTSL to every women at every vaginal birth

Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management of the third stage of labour. British Medical Journal. 1988; 297: 1295–1300.

English PDF (608K)

Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active versus expectant management of third stage of labour: the Hinchingbrooke randomized controlled trial. Lancet 1998; 351: 693-699.

English PDF (199K)

Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software.

http://www.cochrane.org/reviews/en/ab000007.html

Cotter A, Ness A, Tolosa J. Prophylactic oxytocin for the third stage of labour. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD001808. DOI: 10.1002/14651858.CD001808.

http://www.cochrane.org/reviews/en/ab001808.html

McCormick ML, Sanghvi HCG, Kinzie B, McIntosh N. Averting maternal death and disability: Preventing postpartum hemorrhage in low-resource settings. International Journal of Gynecology and Obstetrics. 2002; 77: 267-275.

English PDF (298K)

Miller S, Lester F, Hensleigh P. Prevention and treatment of postpartum hemorrhage: New advances for low-resource settings. Journal of Midwifery & Women’s Health. 2004; 49: 283-292.

English PDF (33K)

Part 2: Support for oxytocin as the uterotonic of choice for AMTSL when injectable uterotonic drugs are available

McDonald S, Abbott JM, Higgins SP. Prophylactic ergometrine-oxytocin versus oxytocin for the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Oxford: Update Software.

http://www.cochrane.org/reviews/en/ab000201.html

Elbourne D R, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labour (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Oxford: Update Software.

English PDF (26K)

Part 3: Support for administering misoprostol for prevention of PPH

Carpenter JP. Misoprostol for Prevention of Postpartum Hemorrhage: An Evidence-Based Review by the US Pharmacopeia, Rockville, Maryland: United States Pharmacopeia, 2001.

English PDF (629K)

Gülmezoglu M et al. WHO multicentre randomised trial of misoprostol in the management of the third stage of labour. The Lancet. 2001; 358: 689-695.

English PDF (237K)

Gulmezoglu AM, Forna F, Villar J, Hofmeyr GJ. Prostaglandins for prevention of postpartum hemorrhage (Cochrane Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software.

http://www.cochrane.org/reviews/en/ab000494.html

Misoprostol and Postpartum Hemorrhage (PPH) Research, April 2007, Version 7

English PDF (63K)

Part 4: Support for delaying cord clamping

IYCFC Unit, Nutrition Section, UNICEF HG. WHO/UNICEF Guidance on management of the third stage of labor and timing of cord clamping: Are we throwing the baby out with the bath water? August 2003.

English PDF (22K)

Part 5: Research on CCT

Khan GQ, John IS, Wani S, Doherty T, Sibai BM. Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial. American Journal of Obstetrics and Gynecology 1997; 177: 770-774.

English PDF (375K)

Part 6: Research on nipple stimulation / suckling and postpartum hemorrhage

Bullough CHW, Msuku RS, Karonde L. Early suckling and postpartum haemorrhage: Controlled trial in deliveries by traditional birth attendants. The Lancet. September 2, 1989: 522-525.

English PDF (473K)

Part 7: PPH risk factor analysis

Tsu, V. Postpartum haemorrhage in Zimbabwe: a risk factor analysis. British Journal of Obstetrics and Gynaecology. 1993; 100: 327-333.

English PDF (564K)

List of additional references

English PDF (48K)

English Word (90K)

Section C: Steps for Expanding Prevention of Postpartum Hemorrhage (PPH) Initiatives

N.B. POPPHI is working with a broader postpartum hemorrhage (PPH) community to fine tune the tune the indicators used for active management of the third stage of labor (AMTSL) and community-based prevention of PPH. The proposed overarching result is to increase the use of AMTSL for births to prevent PPH.

Indicators can be accessed at: http://www.pphprevention.org/monitoring_evaluation.php

This Section is divided into 6 parts and once downloaded should be combined together for the complete document

Part 1: Planning tool for expanding AMTSL

English PDF (397K)

English Word (558K)

Part 2: Evaluation of training strategies for management of the third stage of labor

English PDF (341K)

English Word (554K)

Part 3: Community-based strategies for prevention and treatment of PPH

English PDF (886K)

English Word (738K)

Part 4: MNH / JHPIEGO. Preventing postpartum hemorrhage: From research to practice.

http://accesstohealth.net/toolres/pdfs/ACCESSpphconfrptEN.pdf

Part 5: Community education fact sheet for preventing PPH

English PDF (129K)

English Word (109K)

Part 6: Country examples
Report of a POPPHI visit to the Quality Assurance Project sites in Niger, West Africa (April 2008)

English PDF (6,710K)

Section D: Clinical care and guidelines for prevention and treatment of postpartum hemorrhage

This Section is divided into 5 parts and once downloaded should be combined together for the complete document

Part 1: Active management of the third stage of labor (AMTSL) – a detailed description

English PDF (1,655K)

English Word (1,959K)

Part 2: Causes and prevention of postpartum hemorrhage (PPH)

English PDF (505K)

English Word (299K)

Part 3: Management of vaginal bleeding after childbirth

English PDF (172K)

English Word (192K)

Part 4: Management of shock

English PDF (97K)

English Word (94K)

Part 5: New advances in treatment of PPH – Anti-shock garment, balloon condom catheter

http://www.medscape.com/content/2004/00/48/40/484023/484023_fig.html

Section E: Medications and logistics for active management of the third stage of labor

(This Section is divided into 9 parts and once downloaded should be combined together for the complete document)

Part 1: Essential Medicines for Reproductive Health: Guiding principles for their inclusion on National Medicines Lists
English PDF (1,165 K)

Part 2: Selection of uterotonic drugs for use in AMTSL
English PDF (483K)

English Word (277K)

Part 3: Stability of injectable uterotonic drugs
English PDF (1,208K)

Part 4: Stability of oral uterotonic drugs
English PDF (513K)

Part 5: Fact sheets on uterotonic drugs
English PDF (577K)

English Word (516K)

Part 6: Drug management issues for uterotonics used in AMTSL
English PDF (201 K)

Part 7: Creating Access to Misoprostol: Steps to Availability
English PDF (103K)

Français PDF (68K)

Part 8: Innovations – Oyxtocin in Uniject
English PDF (136 K)

Innovations– Time Temperature Indicators

English PDF (257 K)

Part 9: Fact sheet for providers on augmentation of labor
English PDF (199K)

English Word (136K)

Presentations

Presentation 1: Promoting evidence-based care

English PPT (394 K)

Presentation 2: Evidence for active management of the third stage of labor

English PPT (610 K)

Presentation 3: Steps for AMSTL

English PPT (2,152 K)

Presentation 4: Uterotonic drugs for AMTSL

English PPT (419 K)

Presentation 5: Pathway to national scale-up of AMTSL

English PPT (2,752 K)

CD-ROM: Active Management of the Third Stage of Labor: A Demonstration

This animated demonstration is available in English, French, and Spanish.

English version
Versión español
Version française
Note: The online version can be easily viewed on most computer systems, but may take longer to load via slower/dial-up Internet connections. If necessary, you may be prompted to install a free Macromedia Flash™ Player plug-in on your computer. The installation process is easy and should take only a few moments to complete. The CD-ROM version is available in English. Please contact us if you would like a copy.

Written by
Prof. S. Whitehall MSc
View all articles
Written by Prof. S. Whitehall MSc

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