Resource Library

On 6 March, 2024, the Postpartum Hemorrhage Community of Practice (PPH CoP) hosted a webinar on implementation considerations for new WHO recommendations for PPH. This document provides a summary of the key points that presenters made during the conversation.

You can watch the webinar recording here and view the slides in English or French.

In 2023, the World Health Organization (WHO) convened a Guideline Development Group to update an existing recommendation on assessing postpartum haemorrhage (PPH) and consider using a care bundle to treat PPH. This decision was based on new evidence on the subject that had become available. This document issues an updated recommendation on the assessment of PPH and a new recommendation on the use of a treatment bundle for the management of PPH.

Highlights

• Recommendations of objective measurement of postpartum blood loss to improve the detection and treatment of PPH in women experiencing vaginal birth.
• Recommendation of a standardized and timely approach to PPH management, consisting of objective quantification of blood loss and a treatment care bundle, supported by an implementation strategy in women experiencing vaginal birth.

How to Use

The primary audience for this document includes health-care professionals responsible for developing national and local health-care protocols and policies, as well as managers of maternal and child health programmes, and policy-makers in all settings. The recommendations will also be useful to those health workers directly providing care to women giving birth, such as obstetricians, midwives, nurses and general practitioners.

Summary

In recognition of the growing need for global action to improve the quality of PPH care, the World Health Organization (WHO) worked together with several stakeholders to develop this Roadmap, outlining global-level research, normative, implementation, and advocacy goals, activities, and milestones from 2023 to 2030, to address key PPH priorities and fast-track progress towards the SDG 3.1 target. This Roadmap establishes an innovative, solution-driven, and customised strategic framework that centres PPH high-burden country maternal health goals and priorities, and points investments into critical areas of health systems, with special emphasis on LMICs.

Highlights

• The Roadmap outlines the key priorities and strategies to combat PPH burden and associated adverse outcomes as agreed by the stakeholders at the 2023 Global PPH Summit, structured around four interlinked strategic areas (research, norms and standards, implementation, and advocacy) that are necessary to catalyse efforts and fast-track attainment of country goals to avert maternal death.
• Under each strategic area, the Roadmap describes activities and put forward specific actions and deliverables for the period 2023 to 2030.
• Implementation of the Roadmap and progress toward key milestones will be monitored through a common measurement platform, to be developed as one of the initial milestones in the Roadmap.
• Planned dissemination activities include translation into all six official UN languages and publication in peer-reviewed journal articles.

How to Use

Successful implementation of this Roadmap will require concerted and coordinated efforts from all stakeholders. WHO will serve as an initial catalyst for key activities in the short-term, including through helping to establish structure for global leadership and governance around the Roadmap. WHO will also work closely with Ministries of Health, relevant national agencies, and national professional associations to develop normative materials that are adapted for local contexts to kick-start implementation. However, longer-term actions will require commitments from additional stakeholder groups.

Worldwide, more than half a billion women of reproductive age are anaemic. Each year, about 70 000 women who give birth die from postpartum haemorrhage. Almost all deaths are in low-income or middle-income countries. We examined the association between anaemia and the risk of postpartum haemorrhage.

Highlights

• We did a prospective cohort analysis of data from the World Maternal Antifibrinolytic-2 (WOMAN-2) trial. 
• The trial enrolled women with moderate or severe anaemia giving birth vaginally in hospitals in Pakistan, Nigeria, Tanzania, and Zambia.
• Anaemia is strongly associated with postpartum haemorrhage and the risk of death or near miss. 
• Attention should be given to the prevention and treatment of anaemia in women of reproductive age.

How to Use

The paper explores the crucial link between maternal anaemia and postpartum haemorrhage, while demonstrating the potential of tranexamic acid as a lifesaving intervention.

Driving Global Adoption: A Comprehensive Guide for Implementing WHO’s Revised Recommendation on Uterotonics for PPH Prevention, Leveraging Smiles for Mothers’ Experience in Nigeria

Highlights

• The program supported the 3 states to implement costed roadmaps for the adoption and roll-out of medicines aligned with WHO recommendations on the use of uterotonics to prevent postpartum hemorrhage, including introducing a new uterotonic, heat-stable Carbetocin.
• The Smiles for Mothers program is committed to improving the quality of care for the prevention of PPH in public health facilities and reducing mortality due to PPH using a system-strengthening approach that covers patient literacy and community awareness, supply chain management, and service delivery. 
• Over the two-year implementation period from 2020 to 2022, significant progress was made, and the Smiles for Mothers Playbook is a culmination of that journey.

How to Use

The playbook serves as a valuable reference tool for healthcare professionals, policymakers, and stakeholders involved in maternal health initiatives. It provides guidance on the adoption and rollout of the WHO recommendations on uterotonics for the prevention of PPH, including the introduction of heat-stable Carbetocin.

Summary

This three-year, cluster-randomized trial involved teaching providers the early detection of PPH coupled with the proposed WHO first-response bundle for postpartum hemorrhage (PPH), and then evaluating the bundle—a sequence of care components delivered in total, in rapid succession, without waiting for any individual component to work.

Highlights

• The WHO PPH first-response bundle includes massage, uterotonic, tranexamic acid, IV fluids, and examination. While each individual component had been studied in the past, the bundle approach had not.
• The research project modeled the Helping Mothers Survive training approach—low-dose, high-frequency—to build the capacity of health care professionals through a single-day training for the PPH clinical bundle.
• The E-MOTIVE trial demonstrated that after near-universal uptake of the bundle by providers, use of the bundle significantly reduced bleeding and improved maternal health outcomes related to PPH – a 60% reduction in severe PPH outcomes.

How to Use

This study is well positioned to help inform the WHO’s official recommendation about PPH, as well as potential endorsement of the capacity-building approach as the methodology to be used to implement the bundle.

WHO
March 2022

WHO recommends early use of intravenous Tranexamic Acid (TXA) within 3 hours of birth in addition to standard care for women with PPH. WHO is now alerting health care professionals about the risk of administration errors that can occur with Tranexamic Acid (TXA) injection (TXA has been mistaken for obstetric spinal anaesthesia used for caesarean deliveries resulting in inadvertent intrathecal administration).

TXA is a lifesaving medicine, however, this potential clinical risk should be considered and addressed. Review existing operating theatre drug handling practices to decrease this risk, i.e. store TXA away from the anaesthetic drug trolley, and preferably outside the theatre.

Key Takeaways

• Intrathecal TXA is a potent neurotoxin, with refractory seizures and 50% mortality.
• TXA should be administered at a fixed dose of 1g in 10 ml (100 mg/ml) IV at 1 ml per minute, with a second dose of 1g IV if bleeding continues after 30 minutes.
• The presentation of some of local anesthetics is similar to TXA (transparent ampoule containing transparent solution), which can erroneously be administered instead of the intended intrathecal anesthetic resulting in serious adverse effects.
• Obstetricians from several countries have reported inadvertent intrathecal TXA administration and related serious neurological injuries.

Overview

The primary audience for these recommendations includes health professionals who are responsible for developing national and local health-care guidelines and protocols (particularly those related to postpartum haemorrhage (PPH) prevention and treatment) and those involved in the provision of care to women and their newborns during labour and childbirth, including midwives, nurses, general medical practitioners and obstetricians, as well as managers of maternal and child health programmes, and relevant staff in ministries of health and training institutions, in all settings.

World Health Organization, UNICEF, and UNFPA, 2021.

This document was prepared to specifically assist national medicines regulatory authorities to understand the nature and extent of oxytocin quality issues and to provide key technical information and quality requirements for oxytocin products in dossier assessments. Furthermore, this document also presents recommendations on other regulatory actions needed to ensure that only quality-assured oxytocin products are authorized and made available to women.

Parry Smith WR, Papadopoulou A, Thomas E, Tobias A, Price MJ, Meher S, Alfirevic Z, Weeks AD, Hofmeyr GJ, Gülmezoglu AM, Widmer M, Oladapo OT, Vogel JP, Althabe F, Coomarasamy A, Gallos ID.
Cochrane Database of Systemic Reviews, 2020.

Authors conclude that the available evidence suggests that oxytocin used as first-line treatment of PPH is probably more effective than misoprostol with less side effects. Adding misoprostol to the conventional treatment of oxytocin probably makes little or no difference to effectiveness outcomes, and is also associated with more side-effects. The evidence for most uterotonic agents used as first-line treatment of PPH is limited, with no evidence found for commonly used agents, such as injectable prostaglandins, ergometrine, and Syntometrine®. 

Key Takeaways (based on 7 hospital-based trials, involving 3738 women in 10 countries)

• Misoprostol, as first‐line treatment uterotonic agent:
  • Probably increases the risk of blood transfusion compared with oxytocin.
  • May increase the incidence of additional blood loss of 1000 mL or more.
  • May result in increased risk of vomiting and fever compared with oxytocin.
• Misoprostol plus oxytocin:
  • Makes little or no difference to the use of additional uterotonics and to blood transfusion compared with oxytocin.
  • Cannot rule out an important benefit of using the combination over oxytocin alone for additional blood loss of 500 mL or more, additional blood loss of 1000 mL or more, maternal mortality, or severe morbidity.
  • Increases the incidence of fever and vomiting compared with oxytocin alone.
  • The combination makes little or no difference to vomiting compared with misoprostol alone.
  • Probably reduces the risk of blood transfusion and may reduce the risk of additional blood loss of 1000 mL or more compared with misoprostol alone.
  • The combination is compatible with a wide range of treatment effects for additional blood loss of 500 mL or more, maternal mortality or severe morbidity, use of additional uterotonics, and fever compared to misoprostol alone.

Overview

In 2019, the Executive Guideline Steering Group (GSG) for World Health Organization (WHO) maternal and perinatal health recommendations prioritized the updating of the existing WHO recommendations for intravenous (IV) versus intramuscular (IM) oxytocin for prevention of PPH after vaginal birth in response to the availability of new evidence.

The recommendation in this document thus supersedes the previous WHO recommendation for the prevention of PPH as published in the 2012 guideline, WHO recommendations for the prevention and treatment of postpartum haemorrhage.

Overview

In 2019, the Executive Guideline Steering Group (GSG) for the World Health Organization (WHO) maternal and perinatal health recommendations prioritized updating of the existing WHO recommendation: Umbilical vein injection of oxytocin for the treatment of retained placenta, in response to the availability of new evidence.

The recommendation in this document thus supersedes the previous WHO recommendations on “intraumbilical vein injection of oxytocin for treatment of retained placenta” as published in the 2012 guideline, WHO recommendations for the prevention and treatment of postpartum haemorrhage.