Postpartum Haemorrhage

In many studies on maternal mortality postpartum haemorrhage (PPH) is the predominant cause of death. PPH is thus a major challenge in programmes aiming at reducing maternal mortality. There are two major lines of thinking in the management of PPH.

Still, the first line of thinking addresses the problem of bleeding after delivery by trying to avoid drugs and just try to use “natural methods”. The proponents of this line of thinking argue that drugs may be disposable and not necessary if proper handling of the birthing process takes place. Examples of such handling is putting the newborn baby to the nipples and stimulating it to suck, whereby endogenous oxytocin will be released from the pituitary, giving uterine contraction and less risk of PPH.

This approach has been tested in settings, where it has been used by traditional birth attendants (Bullough et al. 1989). It has been found inefficient even if theoretically attractive and potentially appropriate.

The second line of thought is promoting active management of third stage of labour, comprising three different components:

a) injection of oxytocin;
b) early cord clamping;
c) controlled cord traction.

It has been convincingly demonstrated that the use of oxytocin injection significantly reduces the risk of PPH (Prendiville et al . 1999). There is a widespread consensus that early cord clamping and controlled cord traction contribute to the prevention of PPH, though this has not been subject to scientific scrutiny. The principal problem here is that the drug (oxytocin) is seldom readily available for routine use during labour.

A substitute for oxytocin is methylergometrine. Its use to pregnant women with hypertension is not recommended but the risks of deteriorating vasospastic disease should be balanced against the potential benefit of achieving a uterine contraction in case of impending or obvious PPH. The major drawback with methylergometrine is, however, that it is unstable in daylight and in adverse environmental circumstances. Studies have indicated that much of its effect is lost under the circumstances prevailing in most low-income countries (de Groot 1996). There is no doubt that oxytocin should be promoted as the drug of choice in preventing and treating abundant bleeding after delivery.

Oxytocin injection requires syringe and needle, which are largely unavailable in many settings in rural areas. There is also a risk of re-utilization of used syringes and needles in areas where HIV infection is prevalent. In order to overcome this hurdle we have tested the device “UniJect” in Angola for its appropriateness to prevent PPH. The preliminary results clearly indicate that this device, filled with 10 IU of oxytocin, used intramuscularly immediately after expulsion of the newborn significantly reduces the prevalence of PPH (da Silva et al ., unpublished). The acceptability of this routine among midwives and parturient women is good (Jangsten et al ., unpublished) and a mass production of this oxytocin-filled device is a promising new appropriate technology for the years to come.

A new interesting technology for PPH prevention has recently emanated. The prostaglandin E₁ analogue misoprostol is subject to a multicentre trial to test its advantages/disadvantages in relation to oxytocin given as described above. Preliminary results from several smaller studies indicate that misoprostol is not of greater benefit than oxytocin for the prevention of PPH. However, misoprostol can be given orally, vaginally or rectally and is heat-stable and not requiring injection (syringe and needles) and will for that reason remain as an attractive and potentially appropriate method for the prevention of PPH. Presumably there is much more to be said about misoprostol as an appropriate obstetric technology, since appropriate dosage has not been researched completely (Bugalho et al . 1995). It is further probable that other prostaglandin analogues will appear, since the need for a cheap, temperature-stable and orally active prostaglandin, like misoprostol, is obvious.

A forgotten highly appropriate management principle in PPH is manual compression of the abdominal aorta, a technique that by and large seems to be forgotten in big textbooks. It is described in some literature (Bergström et al . 1994) and should be given renewed attention. It can be used immediately after delivery as a bimanual technology, using one hand at the level of the umbilicus to compress the abdominal aorta between the closed fist and the vertebral column, and using the other hand in the groin to confirm that the pulsations of the femoral artery are vanishing. It can also be used as an internal preoperative procedure, by which the assistant compresses the abdominal aorta above the uterine level and below the liver level across the bowels. In either case the maternal blood flow will be efficiently stopped above the aortic bifurcation, which implies reduced or stopped blood flow to the uterine artery with ensuing reduced uterine bleeding. Direct compression of the abdominal aorta is presumably much more efficient than packing the vagina with cloth, since this does not control the arterial blood flow above the lesion or from the non-contracted uterus.

Even if the clinical experience of applying compression of the abdominal aorta is massive, the efficacy of this manoeuvre is seldom addressed in scientific studies (Kinsella et al . 1990, Riley & Burgess 1994, Keogh & Tsokos 1997).