Practical approaches to managing postpartum haemorrhage with limited resources

Practical approaches to managing postpartum haemorrhage with limited resources

Best Practice & Research Clinical Obstetrics and Gynaecology xxx (xxxx) xxx Contents lists available at ScienceDirect Best Practice & Research Clini...

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Best Practice & Research Clinical Obstetrics and Gynaecology xxx (xxxx) xxx

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Practical approaches to managing postpartum haemorrhage with limited resources Susan Fawcus, MBBCh, MA (oxon), FRCOG, Professor Emeritus and Senior Scholar * Department of Obstetrics and Gynaecology, University of Cape Town, H floor Old Main building, Grooteschuur Hospital, Anzio road, Observatory, Cape Town, 7925, South Africa

a b s t r a c t Keywords: Postpartum haemorrhage Limited resources Home birth Task shifting In-facility treatment Emergency transport

Mortality from postpartum haemorrhage (PPH) is higher in low resource settings due to increased incidence, higher case fatality rates and poor general health of the population. The challenges of managing PPH with limited resources are presented. Feasible interventions for preventing and treating PPH for home births are described. Given that maternity care is organised around levels of care in low resource settings, guidance is provided for what measures can be performed to manage PPH at different levels of care (clinic, community health centre, district hospital, regional and central hospital); and by which cadre (midwife, clinical officer, general doctor, specialist). Effective management of PPH requires on-going training and emergency drills. Reducing mortality from PPH is not possible without available urgent transport from home to facility and between levels of care. In addition, the essential building blocks of the health system must be functional to enable effective management of PPH. © 2019 Published by Elsevier Ltd.

Introduction Low income countries and settings with limited resources have higher proportions of maternal deaths from postpartum haemorrhage (PPH) compared to high income countries. Globally haemorrhage accounts for 27.1% of all maternal deaths with wide variations across regions; for example 36.9% * Corresponding author. E-mail address: [email protected] 1521-6934/© 2019 Published by Elsevier Ltd.

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(24.1e51.6) in North Africa compared to 16.3% (11$1e24$6) in developed regions [1]. Near miss rates from PPH are higher in low resource settings with high PPH mortality [2]. A systematic review attempted to measure the incidence of PPH globally. Although the data was limited with objective assessment of blood loss being more common in high resource settings, and the data being facility based; the review estimated the incidence of PPH (>500 mls) to be 6.6% of all births, and of severe PPH (>1000 mls) to be 1.86%. Of note, rates were higher in Africa with a PPH rate of 10.45%, compared to other regions and higher in rural areas compared to urban areas [3]. This suggests that higher mortality from PPH in low resource settings is due to both a higher incidence of PPH together with poorer outcomes from PPH. There is insufficient data on case fatality rates from PPH in different settings to corroborate this. There is less data on incidence of haemorrhage following caesarean delivery (CD), but systematic reviews demonstrates higher rate of PPH>1000 mls in women having CD [3,4]. There are many medical and surgical modalities of treatment available to treat postpartum haemorrhage as well as for resuscitation with blood products and circulatory support in an intensive care environment. However the capacity to perform these interventions and the enabling environment for them to be done is severely constrained in settings with limited resources and where the majority of births may occur at home [5,6]. It is important that evaluation of effectiveness of different treatment modalities for PPH, including settings with limited resources, report on core outcomes that are standardised. These have been recently developed by a Delphi consensus that identified 12 core outcomes (blood loss >500 mls and >1000 mls; shock; coagulopathy; hysterectomy; organ dysfunction; maternal death; blood transfusion; use of additional haemostatic intervention; transfer for higher level of care; women's sense of wellbeing, acceptability and satisfaction with the intervention; breastfeeding; and adverse effects) [7]. Not all of these can be measured in settings with limited resources. There are systematic reviews on effectiveness of measures to manage PPH, the most comprehensive being the Cochrane reviews by Gallos in 2018 for prevention, and Mousa in 2014 for treatment [8,9]. They cover home and facility settings. The scope of this chapter is not primarily focussed on evaluating the evidence for different modalities of treatment for PPH, but rather on applying what is known and included in international guidelines, such as those from WHO, NICE, RCOG, ACOG and FIGO, to settings with limited resources [10e14].

The context of limited resource settings These are summarised in Box 1 and discussed in the text that follows. Limited resources occur in the context of poverty, socio-economic deprivation of the community and weak health systems [15,16]. The population served may have a high disease burden due to increased prevalence of anaemia, undernutrition, HIV and infectious diseases and the women may be disempowered in patriarchal societies. Access to health facilities may be problematic due to long distances and difficult terrain for transport with poor roads and infrastructure. In such settings a large proportion of women deliver at home, either by choice for cultural reasons, and/or distrust or fear of health facilities; or due to inadequate access to the nearest facility. For many women the delivery will be not attended by a skilled attendant [5]. Unlike in well-resourced settings, in low resource settings PPH is not predominantly due to uterine atony but ruptured uterus from obstructed labour, traumatic vaginal delivery, and unsafe CDs all feature as important causes of PPH [17]. The health system deficiencies listed in Box 1 will now be elaborated on: (a) Insufficient numbers of health workers. This may be an absolute national shortage of health professionals, or inequitable distribution between rural and urban areas or private and public sectors. (b) Insufficient availability of appropriately skilled birth attendants and other cadre of health workers. Whereas specialist obstetricians and trainees, specialist anaesthetists and professional midwives constitute the core maternity workforce in well-resourced countries, the situation is different in low resource settings where service delivery requires considerable task shifting [18]. For example, general doctors (medical officers) perform the majority of CDs and anaesthesia for Please cite this article as: Fawcus S, Practical approaches to managing postpartum haemorrhage with limited resources, Best Practice & Research Clinical Obstetrics and Gynaecology, j.bpobgyn.2019.03.009

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Box 1 The context of limited resource settings

Social determinants of PPH outcomes.      

High burden of disease Poverty Long distances to facilities with inaccessible terrain High proportion of home births Disempowered women Out of pocket payments for health care

Pattern of PPH.  Different pattern of PPH with trauma featuring commonly in addition to uterine atony; both compounded by sepsis Weak Health systems.  Insufficient numbers of health workers, with limited training and supervision  Insufficient availability of appropriately skilled birth attendants and other cadre of health workers.  Limited equipment  Limited availability of essential medications  Ineffective cold chain  Limited availability of blood products  Limited availability of back up resources such as blood banks, intensive care units, laboratories, interventional radiology  Insufficient emergency transport for referral.

CDs, midwives direct labour ward care with nurse aides performing observations, lay health workers perform counselling and testing for HIV, traditional birth attendants may conduct home births and community health workers may perform postnatal care. In addition where numbers of doctors are limited, other cadre of provider such as the clinical officers in Tanzania, Malawi and Mozambique take over specific functions such as CD surgery and anaesthesia [19]. Task shifting with adequate training and support is a beneficial way of dealing with skills shortages; and is sometimes preferred by communities because this cadre may have better understanding of local culture and are more likely to remain in the local area. However, there are certain skills related to PPH which are often lacking: hysterectomy which can be life esaving is a specialist skill; and assisted vaginal delivery for prolonged second stage. If performed in the correct circumstances, this can reduce the incidence of second stage CDs, known to be associated with severe PPH [20]. Concern has been expressed that operative vaginal delivery skills are disappearing particularly in low resource settings [21]. In addition, involvement of a multidisciplinary specialist team including obstetric specialist, anaesthetic specialist, haematologist and interventional radiologist is lacking in settings with limited resources. (c) Limited equipment. Essential equipment such as blood pressure measuring devices; point of care haemoglobinometers or anaesthetic machines may be lacking or non-functional due to inadequate maintenance.

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(d) Limited availability of essential medications. Stock outs or insufficient supplies of essential uterotonic drugs may occur, especially at primary care level. Also there have been some reports describing poor quality oxytocin [22]. (e) Ineffective cold chain. Inability to maintain fridge temperatures would impact on the storage of uterotonic drugs such as oxytocin and ergometrine; and would impair the storage of on-site emergency blood products (f) Limited availability of blood products. All hospitals performing CD require an on-site supply of ‘emergency blood’; group specific (eg OPOS) or universal donor (ONEG) blood. This is limited to 2e4 units red cells which may be inadequate for a case of massive obstetric haemorrhage when additional units and clotting factors are required. Rural hospitals may be remote and far away for blood banks to replace supplies or provide additional supplies. This may be compounded by reduced pools of blood donors such as in populations with high HIV prevalence (g) Limited availability of back up resources such as blood banks, intensive care units (ICUs), laboratories, interventional radiology. Blood banks and ICUs should be available at tertiary hospitals which many of the population do not have access to. Interventional radiology services for uterine artery embolization are rarely available in low resource settings. (h) Insufficient emergency transport for referral. Many women with severe PPH may need to be referred to a facility with greater expertise and the facilities to manage them. Immediate and urgent transport may be limited due to lack of resources, long distances or difficult terrain. Inequity in maternal health outcomes and in resource allocation for maternal health globally and regionally is an infringement of the human rights of women and communities [23]. Although this chapter describes how to manage PPH in such settings, a human rights or public health approach would advocate strongly for such inequities to be addressed and reversed.

Prevention and management of Pph for home birth Home birth is the location where the impact of limited resources is greatest for managing PPH. Addressing the social determinants of anaemia, recurrent infectious diseases and poor nutritional status would enable women to withstand PPH blood loss at delivery better. Similarly, in areas of high HIV prevalence such as in Southern Africa, access to anti-retroviral therapy improves women's general health status. This is beyond the scope of this chapter. Similarly, promoting better health financing systems so women do not have to pay out of pocket for delivery care or transport to a facility, are both essential prerequisites for managing PPH effectively. In some countries in South America, India and Sub-Saharan Africa, voucher systems have been used to secure local transport for women in labour from home to a facility, with drivers who will be reimbursed later by the scheme [24,25]. Encouraging universal facility delivery confers benefits in terms of ability to both prevent and treat PPH. However it may be impossible due to inaccessible facilities, overcrowded facilities, costs of care, distrust of facilities with fear of health care workers, and lack of transport. Despite these challenges there are interventions, which can address some of these problems, and enable PPH to be prevented and managed more effectively at community level [16]. They are listed in Box 2 and described in the following text. 1. Interfacing with traditional birth attendants (TBAs) to recognise them as an extension of the health service who are trusted by women and recognised by the health facility [26]. TBAs cannot be considered as skilled birth attendants. However, if viewed as community health workers, they can play a major role in identifying pregnant women, encouraging healthy diet in pregnancy and encouraging facility delivery where feasible, and recognising those for whom it is essential (eg women with previous CD or previous PPH). It is preferable that the actual birth should be attended to by a skilled birth attendant (SBA) with ready access to a facility or in a facility [27]. 2. Women's groups facilitated by a community worker to encourage birth preparedness and devise community solutions for transport. Such groups can also alert women as to who will Please cite this article as: Fawcus S, Practical approaches to managing postpartum haemorrhage with limited resources, Best Practice & Research Clinical Obstetrics and Gynaecology, j.bpobgyn.2019.03.009

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Box 2 Strategies to improve management of PPH for home births.  Prevention of anaemia antenatally  Interfacing with traditional birth attendants (TBAs) to recognise them as an extension of the health service who are trusted by women and recognised by the health facility.  Facilitation of facility birth.  Women's groups facilitated by a community worker to encourage birth preparedness and devise community solutions for transport.  Maternity waiting areas adjacent to facilities  Home administration of uterotonics to prevent and treat PPH.  Simple measures to identify and treat PPH after home birth  Available emergency transport for urgent referral of women with PPH at home





definitely require facility birth and the importance of being transferred to a facility if labour is prolonged. Prolonged labour is a major risk factor for PPH. Women's groups have been found to be beneficial for improving maternal and perinatal health outcomes in Nepal and Malawi [28]. Maternity waiting areas. These are lodging facilities adjacent to health facilities where women can await labour so as to bypass the issue of trying to secure transport in labour or for an emergency [29]. This is particularly important for women who live far from the nearest facility and for whom a high risk birth is anticipated. Home administration of uterotonics to prevent and treat PPH. Despite policies for facility delivery or home delivery by a skilled birth attendant, many women deliver at home, often in more remote rural settings [5]. TBAs can be trained to administer a uterotonic agent after birth of the baby to prevent PPH. Since they are not skilled birth attendants they should not be trained to perform controlled cord traction [10]. A recent Cochrane network meta-analysis on the use of uterotonics compared to placebo for prevention of PPH, demonstrated that oxytocin, ergometrine, carbetocin and misoprostol and combinations are all effective for the prevention of PPH [8],. Misoprostol alone has the lowest efficacy, while ergometrine and misoprostol have higher side effect profiles. Given that at home, TBAs do not measure blood pressure or assemble injections, the two most realistic medications for home administration by a TBA are the uniject pre-assembled syringe unit with 10 IU oxytocin or oral misoprostol 400 to 600 mcgms. The latter has advantages that it does not need to be refrigerated. There are observational studies to show these practices are feasible in low resource settings in Nigeria and Bangladesh [30,31]. In the future heat stable carbetocin could be considered for home use if affordable and pre-assembled injection units can be manufactured. Management of PPH after home birth. This is described in papers on Home based life-saving skills [16,32]. Various locally appropriate ways to recognise PPH have been suggested such as observing flooding and clots, or soaking two ‘kangas’ (rectangular cloth worn as a skirt or shawl) [32]. Effective management of PPH at home is not possible but some interventions are available: administration of the above uterotonics, baby suckling at breast to stimulate endogenous oxytocin and bladder voiding [14,16,32]. Aortic compression has been practised by some TBAs in this situation. Transport for women with PPH at home. Rapid transport to a hospital is required for women who have PPH at home. Severe PPH can lead to death within 2 h. More widespread use of mobile phones has improved means of communication greatly compared to fifteen years ago and it is now easier to summon help. However, in many low resource settings, there are limited numbers of ambulances, very few have trained paramedics and the terrain may be difficult for vehicles to traverse. Motor cycle ambulances may be more realistic. The women's groups described previously can be a mechanism for women planning in advance a method of emergency transport from their village, if it becomes necessary after home birth with PPH [28]. Utilisation of the Non Pneumatic anti- Shock Garment (NASG) which reduces shock and maintains circulation to vital organs during transit has been shown in observational studies and one cluster RCT to enable women with PPH to survive the transfer [33].

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Facility based management of Pph with limited resources This section will cover management of PPH after vaginal delivery and at/after CD in facilities of a health system with limited resources. High quality evidence of effectiveness for many aspects of PPH treatment is lacking. Most reviews focus on prevention and medical management, with few trials on surgical modalities [8,9],. For the latter, guidance comes from case series and expert opinion described in the international guidelines described earlier [10e14]. Also, evidence for the optimum sequence of interventions, and referral issues is lacking, and again guidance comes from these guidelines and health system experiences in low resource settings [34]. In low income countries with limited resources, maternity care is frequently organised around levels of care: clinic (CHC), district hospital (DH), regional hospital (RH) and tertiary hospitals (TH). These correspond to levels of expertise and the extent of resources with, for example CHCs being staffed by midwives and nurses, DHs by general doctors or clinical officers, and RHs/THs by specialists. Only THs would have certain facilities such as intensive care units (ICUs) and in resource poor countries interventional radiology may not be available at any level. There are criteria which specify what conditions should be managed at which level of care. Given that most pregnant and labouring women access care at primary care level which is closest to their home, referrals will always be necessary with an accompanying transport system. Those with risk factors require referral onward which may be nonurgent (e.g. to attend next high risk clinic at regional hospital) or very urgent such as for postpartum haemorrhage or eclampsia. These models of care were first introduced by Philpott in the 1970s [34]. Subsequently, WHO distinguished between BEOC (Basic Emergency Obstetric Care) at clinic level and CEOC (Comprehensive Emergency Obstetric Care) which corresponds to the referral hospital [35].

Prevention of PPH in facility birth At all levels of care general measures to prevent PPH are similar. They include risk assessment during antenatal care, prevention of anaemia, safe labour ward practices to prevent prolonged labour and sepsis which are risk factors for PPH, conducting operative vaginal delivery for prolonged second stage where indicated rather than perform second stage CD, avoiding unnecessary CDs and conducting them safely to prevent PPH at CD. Where feasible it is important to ensure women with conditions such as placenta praevia and abruptio placenta known to be associated with PPH deliver at referral hospitals. Active management of the third stage of labour (AMTSL) reduces the incidence of PPH by 60% and should be feasible at all levels of care where there are skilled birth attendants. Administration of an uterotonic after delivery, delayed cord clamping and controlled cord traction are all components of AMTSL [10]. According to a recent Cochrane network meta-analysis and WHO guidance; oxytocin 10 IU iv/im remains the uterotonic of choice after vaginal delivery due to efficacy, low side effect profile and the fact it can be used for other purposes such as induction of labour [8,36]. Concerns have been expressed about the need for refrigeration, reports of poor quality oxytocin and occasional stock outs. This means alternative uterotonics are necessary for prevention in such situations. The review indicates that carbetocin, a longer acting oxytocin preparation is equally effective and can be an alternative, but hitherto its price in low resource settings has been prohibitive. The recently published CHAMPION trial which shows non inferiority of heat stable carbetocin for prevention of PPH after vaginal delivery has important implications for resource poor settings since, unlike oxytocin, it does not require refrigeration [37]. If the cost is reduced, this could become the uterotonic of choice for prevention where resources are limited. Equally effective to prevent PPH are ergometrine and the oxytocin/ergometrine combination; however they have a greater side effect profile. They elevate BP and therefore are contraindicated in women with pre-eclampsia and for women where the equipment for monitoring BP is not available which may occur in resource poor settings. Misoprostol, although not as effective as the uterotonics mentioned above and causes unpleasant shivering for women, nevertheless is superior to

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placebo and again does not need refrigeration so would have a role where there is a non-functional cold chain or a health provider who cannot give an injection or measure BP [8,36]. The appropriate uterotonic for preventing PPH at CD has been less studied, although available evidence suggests that it is similar to that for vaginal delivery. However there is a proviso; pharmacokinetic studies by obstetric anaesthetists and some mortality case series have demonstrated hypotension when doses of oxytocin greater than 5IU are given by a rapid intravenous (iv) bolus [38]. In low resource settings, the anaesthetic for CD is not given by a specialist anaesthetist but by a general doctor, nurse or non-doctor anaesthetist such as the clinical officers in Tanzania, Malawi or Mozambique. Such cadre may find it difficult to manage severe hypotension especially if the woman is already hypotensive from regional anaesthesia. Therefore, anaesthetic and professional organisations ‘expert opinion’ recommends that rapid boluses over 5 IU should not be given; but rather doses 5 IU be administered as a slow iv bolus accompanied by an infusion. Another approach is to give the uterotonics at CD by the intramuscular route [39]. Research is needed on the efficacy of HS carbetocin for prevention of PPH at CD. It is important that more research and a consensus is reached on the use of uterotonics at CD so guidance can be standardised. This is very important for non-specialist doctors giving anaesthesia working in low resource settings. Facility treatment of PPH with limited resources This section on treating PPH with limited resources will be subdivided by level of care so as to indicate what can be done at the different levels and by whom; this is summarised in Table 1. Primary care delivery site/BEOC (community health centre, midwife obstetric unit) Recognition of PPH after vaginal delivery is done visually by the attending nurse noting excessive bleeding and supported by recognition of shock by BP and pulse monitoring. For non-professional nurse aides, the use of coloured coded early warning charts or the CRADLE device which measures shock index and has a colour coded warning system where a red light flashes for shock (Pulse > 1.7 x the systolic BP) may all aid in problem recognition [40,41]. Impaired level of consciousness can be assessed by the AVPU system (Alert, Responds to Voice, responds to Pain, Unconscious) which is simpler to use than the Glasgow coma scale [42]. At this level, the following medications can be given sequentially to treat uterine atony: 20 IU oxytocin infusion followed by ergometrine or ergometrine/oxytocin combination (if able to exclude hypertension) plus tranexamic acid (TXA). An alternative uterotonic agent would be oral misoprostol. Injectable progesterones such as carboprost are not available at this level of care and their side effect profile cautions against their use at this level. Heat stable carbetocin has not yet been extensively researched for treatment of PPH. Since the WOMAN trial only reported in 2017, its use may not have been assimilated into local protocols. TXA was shown by the WOMAN Trial to be effective in reducing PPH mortality if given within 3 h of bleeding [43e45]. It is important that it is on the Essential Drugs List for primary care clinics. Manual removal of placenta can be performed at clinic level by a skilled health care worker. It is part of the signal functions of a BEOC facility [35]. The Release trial showed no benefit from intra-umbilical oxytocin injection for placental removal [46,47]. In women with on-going bleeding despite the above treatments, referral to a hospital becomes imperative and this has to be organised by the attending midwife. BEOC facilities refer all women to hospital who have had blood loss over 500 mls. Balloon tamponade using a device made from a condom or surgical glove plus catheter or a specifically designed product (if affordable) can be inserted in a CHC [48,49]. Case series have supported the use of uterine balloon tamponade in management of PPH from atonic uterus [50]. However, only one randomised controlled trial has been performed which suggest poor outcome in the tamponade group [51]. It was a small trial with several confounders. Currently balloon tamponade should be considered as a method to temporise rather than treat, should not delay further necessary treatments, and may be valuable as temporising treatment during referral. Please cite this article as: Fawcus S, Practical approaches to managing postpartum haemorrhage with limited resources, Best Practice & Research Clinical Obstetrics and Gynaecology, j.bpobgyn.2019.03.009


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Table 1 Management of PPH at different levels of care in low resource settings.




District Hospital CEOC

Regional/tertiary Hospital/CEOCþ

Nurse aide Midwife Clinical Officer Doctor a 24 h delivery facility Point of care haemoglobin

Midwife Clinical officer General doctor (non-specialist)

Midwife General doctor Specialist obstetrician Specialist/other disciplines Delivery facility plus inpatient stay Blood bank Operating theatre Radiology department Intensive care unit Fluid resuscitation Blood transfusion (emergency and crossmatched blood) Fresh frozen plasma and other blood products Cell salvagea Ventilatory support BEOC/CEOC treatment plus: Repair third degree tear Subtotal (STAH) or total hysterectomy Intensive care unit Uterine artery embolization/ interventional radiologya


Fluid resuscitation with Intravenous crystalloids BP, pulse and urine output monitoring. Non-pneumatic anti-shock garment (NASG) for referral


Bimanual compression Aortic compression Oxytocin, ergometrine, misoprostol. Tranexamic acida Repair simple genital tract tears Manual Removal of placenta (no anaesthesia) Balloon tamponade (BT)


Delivery facility plus inpatient stay Group specific blood stored in fridge Simple X ray facility Operating theatre Fluid resuscitation Blood transfusion (group specific or universal donor) stored in fridge Fresh dried plasma (clotting factors) Cell salvagea Inotropes NASG for referral BEOC treatment plus: Injectable prostaglandins? MROP under anaesthesia Repair complex vaginal/perineal/ cervical tears Laparotomy for PPH: Uterine compression sutures±BT Uterine artery ligation/ devascularisation Repair of simple uterine rupture Uterine tourniquet STAHa

only if resource or skill available.

A NASG can be employed for unstable patients being transferred. Observational studies show reduction in PPH mortality, but a cluster RCT showed a non-significant decline in mortality but unfortunately was underpowered. It did show significantly faster recovery from shock [33]. Some clinics organise their supplies so all items needed to manage a PPH are in a box; the “PPH box” to facilitate speedy management. District hospital/CEOC (first referral level hospital) DHs do not have a blood bank but stock ‘emergency blood’; usually a minimum of two units of O Negative and possibly O positive units in a designated fridge. In the absence of a blood bank there would be no supply of fresh frozen plasma or other blood products. An alternative low cost source of clotting factors is Fresh dried plasma, which is powdered plasma that can be stored on a pharmacy shelf for up to 2 years, and after reconstitution with sterile water can be infused to replace clotting factors. In some circumstances this supply of blood products is too limited for resuscitating a woman with massive haemorrhage. Intraoperative cell salvage could be used at DHs for bleeding at CD and laparotomy if they are supplied with the equipment for collection and a leucocyte depletion filter to prevent amniotic fluid embolism [52,53]. However its use is not as widespread as it could be. Novel ways of supplying remote facilities (clinics and DHs) with blood products have been tried in some counties such as Rwanda and involve flying the supplies by drone. This type of technology could greatly assist in resource poor settings [54]. At DHs, there is access to an operating theatre for manual removal of placenta, exploration of the uterus for retained placental fragments and for repair of complex vaginal or cervical tears [55,56].

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However, the skill for repair of third or fourth degree tear is not usually available, and such women would need to be referred, with vaginal packing to control bleeding if required. Caesarean deliveries are performed at DHs. In some resource-poor settings the same doctor who performs the anaesthesia also does the surgery. This situation is not safe and all attempts should be made for DHs to be sufficiently staffed to have two doctors in theatre for a CD. This is particularly important for a situation where there is PPH at CD; the one doctor must be resuscitating while the second is controlling the bleeding at surgery. The ASOS trial has drawn attention to the fact that CD is the most commonly performed surgery globally with haemorrhage being a major surgical complication in African countries [57]. This highlights the imperative to improve surgical safety at CD. Since there is a theatre facility, laparotomy can be performed for ongoing PPH (including PPH at/ after CD) when vaginal/cervical tears and retained products have been excluded. The skills for conservative surgical measures to control bleeding should be available at DHs. These include Uterine compression sutures, mass uterine artery ligation and Balloon tamponade plus uterine compression sutures (‘uterine sandwich’) [58,59]. Simple repair of a ruptured uterus can also be performed. However the skills for total or subtotal hysterectomy are unlikely to be available at a DH. For an irreparable uterine rupture, morbidly adherent placenta or intractable uterine atony, total or subtotal hysterectomy is the only measure than can save the life. If the skill is not available, a uterine tourniquet can be placed around the uterus, compressing the uterine arteries, the abdomen packed, closed and the patient transferred urgently to a RH or TH where hysterectomy can be performed [60,61]. A NASG may improve condition during transfer [33]. Regional hospital plus central hospitals At this level, specialist skill for repair of third and fourth degree tears [62]; and for hysterectomy is available, including management of placenta praevia and morbidly adherent placenta [63e65]. Intensive care facilities for critical care management postoperatively including ventilation should be available. An on-site blood bank and haematology service enables blood component therapy to be target driven not formulaic [66]. The applicability of promoting the use of point of care TEG or ROTEM for evaluating clot formation in resource-poor settings is currently being evaluated [66]. Given the need to save blood in the context of limited supplies, intraoperative cell salvage can also be employed at this level [52]. However the above requirements for RH/THs often do not occur in low resource settings. RHs may not have an ICU or blood bank and there may be no specialists, due to concentration of specialist in urban areas. Where there are specialists, the services tend to be better staffed but often are overloaded with referrals. Of note, interventional radiology for uterine artery embolization is not an intervention that would be available in RHs in most resource poor settings and also may not be available at THs in many countries [53]. Whereas in well-resourced settings, massive obstetric haemorrhage mobilises a multidisciplinary team to collectively manage the PPH, in resource poor settings this is not usually possible, leaving a limited team of obstetric specialist plus anaesthetist to manage the problem, with junior staff.

Appropriate training on PPH management With limited resources and expertise, algorithms and care pathways for PPH are useful teaching tools and guides for action [11,14,67]. Future developments in information technology may allow apps on mobile phones to guide management. Training needs to start with basic training of undergraduates in training schools. On-going in-service training on PPH needs to involve the whole team; medical staff (obstetric and anaesthetic) clinical officers, nurses and paramedics. Also some form of training for TBAs, and Community Health Workers, should be considered. There are number of programmes on training in obstetric emergencies which cover PPH as part of emergency obstetric care [68].

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Emergency scenario training (drills) has been shown to be beneficial in preparing teams for emergencies and together with emergency obstetric care training in SA and India, have been shown to reduce PPH deaths [69,70]. On-going outreach and support by specialists from RHs and THs to district level staff can maintain skills and ensure that the doctors and other staff at DHs have the necessary skills for managing PPH. In some countries, mentorship programmes have been implemented whereby specialist mentors at RHs/ THs provide telephonic support to new doctors at DHs for obstetric emergencies including PPH [71].

Emergency transport Given that in settings where resources are limited, care has to be organised around different levels of care, transport from home to facility and between institutions will be necessary. It is particularly critical for PPH which unlike other conditions progresses to death if not managed very quickly. Community systems for organising transport have already been described. Ambulances are scarce in resource-poor settings and not easily maintained. Limited staffing and expertise means that often an ambulance is merely a driver without a paramedic. Ideally a nurse or doctor should accompany a woman with PPH but staffing limitations do not always allow for this. This is a problem when shocked patients with PPH need transfer and is when the NASG can contribute. It can be applied by non-paramedic ambulance staff [33]. Air transport may be necessary in very remote areas and as mentioned previously drones for delivery or urgent supplies.

Organisation and management of the health system to achieve effective management with limited resources Managing PPH in poor resource settings is a major test for a health system. All the essential building blocks (information systems, health workforce, medical products and technologies, leadership and governance, healthcare financing, and service delivery) recommended by WHO need to be functional [72]. Organisation of levels of care and transport between them enables appropriate use of limited resources. Relationship building with communities, TBAs and CHWs facilitates access to care. Facility management plus drug and blood supply needs to be efficient and ensure appropriate utilisation of staff with task shifting. Allocation of resources (urban vs rural inequities; public vs private) needs to be more equitable in health planning. Training programmes and drills for PPH should be on-going and auditable within facilities. Auditing of PPH indicators/core outcomes will allow PPH management programmes to be evaluated; in particular case fatality and near miss rates from PPH.

Summary Review of the context of limited resources and poverty in low income settings and how it impacts on PPH deaths, demonstrates that it is an infringement of the rights of women, requiring advocacy at all levels. Nevertheless, there are many interventions (resuscitation, prevention and treatment) which can be performed at all levels of care, including at home, that can save lives despite limited resources. Obstetric specialists working in these settings should see they have three roles: advocating for improving resources for poor women, managing PPH effectively in their hospital and providing mentorship, outreach support and training to district facilities that refer to them.

Please cite this article as: Fawcus S, Practical approaches to managing postpartum haemorrhage with limited resources, Best Practice & Research Clinical Obstetrics and Gynaecology, j.bpobgyn.2019.03.009

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Practice points  The incidence and mortality of PPH are higher in limited resource settings.  Community initiatives involving community health workers, traditional birth attendants, women's groups and maternity waiting areas can facilitate access to care.  Uterotonic drugs can be administered to prevent and treat PPH at home birth, as well as in facility birth.  Despite limited resources, there are many interventions that can be performed at clinic and district hospital level to resuscitate and treat women with PPH.  District hospitals must be able to perform laparotomy and conservative surgical measures for intractable PPH.  Emergency transport, with temporising treatment for PPH, is essential to enable women to get to the highest level of care when required.

Research agenda  Resuscitation aides in limited resource settings.  Outcomes of Manual Removal of Placenta at clinic/BEOC level.  Efficacy of conservative surgical measures: balloon tamponade, uterine compression sutures, uterine tourniquet.  Referral mechanisms for women with severe PPH.  Task shifting for hysterectomy.

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