FIGO Generic Postpartum

Haemorrhage Protocol
and Care Pathways

First published - March 2022

1
FIGO Generic Post-Partum Haemorrhage
Protocol and Care Pathways
Foreword
Globally, postpartum haemorrhage (PPH) remains the largest direct cause of maternal death.
Competent maternity care providers can achieve effective prevention and treatment of PPH
through an evidence-based, coordinated approach. It is also vital to have a well-resourced and
enabling environment and access to essential medicines.

MSD for Mothers* through Concept Foundation (CF) and WACI Health are supporting ministries of
health in several African countries, to update their Essential Medicines List (EML) in line with World
Health Organization (WHO) PPH recommendations for the use of uterotonics including tranexamic
acid (TXA) and heat-stable carbetocin (HSC). FIGO, in partnership with ICM through the Improve
Access to essential medicines to reduce PPH morbidity and mortality Project (IAP), is contributing
to this work by partnering with national member societies and associations to update their
protocols/guidelines for PPH prevention and treatment, and to develop job aids for health facility-
based maternal care providers.

During the IAP project (2021 – 2022), we developed a generic PPH protocol and clinical pathway
using the WHO PPH recommendations. This provides examples of key definitions, early
identification of risk, estimation of blood loss, choice of uterotonics, prevention and treatment at
various levels of care, effective multidisciplinary teamwork, communication, and referral – all of
which can inform a systematic approach to developing policy for PPH management in health
facilities.

FIGO and ICM were supported by national obstetrics and gynaecology societies and midwives’
associations to engage with ministries of health and establish PPH expert working groups (EWG)
in each country. The focal persons from each professional society/association met virtually every 1
– 2 weeks with the international coordination team to plan for in-country activities.

Two virtual, multi-stakeholder workshops with the identified PPH EWG were facilitated. Workshop
1 aimed to raise awareness of the WHO PPH recommendations, discuss, and appraise current
national PPH guidelines and protocols, and develop a plan to adapt the FIGO generic PPH
protocol and clinical pathway to meet the needs of the context. Digital feedback forms were
developed, and comments were collected during, and two weeks following the workshop. FIGO
incorporated the recommendations into the generic PPH protocol and clinical pathway and
returned the document to the PPH EWG for review and validation by the Ministry of Health.

The objectives of workshop 2 were to present the country adapted PPH protocol, discuss the use
and dissemination of the adapted protocol and to agree on the content and format of job aids,
which could support maternity care providers better to prevent and treat PPH. The international
team encouraged national government health promotion departments and graphic designers to be
involved and contributed a FIGO design consultant for additional expertise. The PPH EWG gave
feedback following the same process as the first workshop. FIGO and ICM further supported their
member societies/associations to design and plan for dissemination of the job aids.

The design of the meetings and workshops ensured engagement and ownership of key maternal
health stakeholders involved with policy development, education, and clinical practice. Other

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 2

countries can also adapt the generic PPH protocol and clinical care pathway and develop relevant
job aids using a similar multidisciplinary approach led by professional societies and associations.

Combined with focused health system interventions, (procurement and supply of quality
uterotonics etc.), it is anticipated that the IAP project interventions will contribute to prevention of
PPH morbidity and mortality.

Charles Anawo Ameh PhD, MPH, FWACS (OBGYN), FRSPH, SFHEA, FRCOG
Reader/Associate Professor
FIGO Technical lead FIGO IAP
Head Emergency Obstetric Care and Quality of Care unit
Deputy Head International Public Health department
Liverpool School of Tropical Medicine
United Kingdom

Florence West RNM, MIPH, PhD

ICM Midwife Advisor
The Hague, the Netherlands

*The activities in this publication were supported by funding from MSD, through its MSD for Mothers initiative and are
the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, U.S.A.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 3

Table of contents
Background ...................................................................................................................................................... 5
Introduction ...................................................................................................................................................... 6
Roles and responsibilities .......................................................................................................................... 6
The place of training and job aids ............................................................................................................. 7
Monitoring and evaluating PPH clinical guideline implementation ............................................................ 7
Definitions ........................................................................................................................................................ 7
WHO PPH guidelines ....................................................................................................................................... 8
PPH Prevention ................................................................................................................................................ 9
Treatment of PPH ........................................................................................................................................... 12
Minor PPH: blood loss 500 – 1000 ml without clinical shock .................................................................. 12
Situation-Background-Assessment-Recommendation ............................................................................ 14
Major PPH: Blood loss more than 1000 ml and ongoing bleeding or clinical shock ............................... 19
Conservative surgical techniques ............................................................................................................ 20
Secondary PPH .............................................................................................................................................. 21
Annex 1: Characteristics of potential uterotonics4 .................................................................................... 21
Annex 2: WHO recommendations: Uterotonics for the prevention and treatment of postpartum
haemorrhage .................................................................................................................................................. 22
A. Uterotonics for the prevention and treatment of postpartum haemorrhage4 ....................... 22
B. Recommendations for the prevention of PPH 5 .................................................................. 23
C. Recommendations for treatment of PPH5 .......................................................................... 24
Annex 3: SBAR communication and referral tool* ..................................................................................... 26
Annex 4: B-Lynch surgical technique for control of massive postpartum haemorrhage ..................... 27
Annex 5: Modified Early Obstetric Warning score chart ........................................................................... 28
References ..................................................................................................................................................... 29

Figure 1: Deciding which uterotonic to take ............................................................................................. 10

Figure 2: PPH prevention flow chart ........................................................................................................ 11
Figure 3: Flow chart for PPH treatment at BEmOC facility ...................................................................... 16
Figure 4: Flow chart for major PPH treatment at BEmOC facility ............................................................ 17
Figure 5: Flow chart for major PPH treatment at CEmOC facility............................................................ 18

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 4

Background
Globally, postpartum haemorrhage (PPH) remains the largest direct cause of maternal deaths.
Effective prevention and treatment of PPH can be achieved by an evidence-based, coordinated
approach by the main care providers of women during childbirth – Obstetrician & Gynaecologists,
and Midwives.

Competent care providers can decrease PPH mortality by assessing for risk in the antenatal
period, monitoring progress of labour and active management of third stage of labour (AMTSL). It
is also vital to have a well-resourced and enabling environment and access to essential medicines.

In recent years, the World Health Organization (WHO) revised and published guidance to prevent
and manage PPH. These include:

 WHO. (2012): Recommendations for the prevention and treatment of PPH.

 WHO. (2017): Recommendation on Tranexamic Acid for the treatment of PPH.
 WHO. (2018): Recommendations on the use of uterotonics for the prevention of PPH.
 WHO. (2019): Essential Medicines List (EML).

For these recommendations to have a positive impact on PPH prevention and treatment, a system-
wide approach is needed.

MSD for Mothers have supported Concept Foundation (CF) and WACI Health during a two-year
project to update countries national policy/protocols in line with the WHO Recommendations
2017/18, as well as updating their EML to reflect the recommended use of TXA and heat-stable
carbetocin.

FIGO, in partnership with ICM, is joining CF and WACI Health to extend this effort for the next 18-
months through the Improve access to essential medicines to reduce PPH morbidity and mortality
(IAP) project from January 2021 to August 2022. FIGO and ICM will partner with their member
societies/associations in these countries to develop appropriate tools so that frontline clinicians are
able to implement the WHO Recommendations in health facilities.

The FIGO/ICM collaboration will work with policy makers, health care providers and supply chain
experts to support increased availability of quality uterotonics and the anti-fibrinolytic drug,
tranexamic acid (TXA).

The IAP project aims to facilitate adoption of updated WHO PPH Recommendations (2017 &
2018), at a country level into practice through dissemination of updated clinical guidelines and
protocols. The expected outcomes of the project are:

1. Normative clinical standards are in place to support the implementation of effective

practices at different levels of health care.
2. WHO Recommendations are translated from guidelines into clinical protocols and
appropriate implementation resources for PPH prevention and treatment.
3. Dissemination efforts to facilitate replication and scale-up of the approach.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 5

Introduction
It has been estimated that 295,000 (UI 279,000 to 340,000) maternal deaths occurred globally in
2017. Most of these deaths (86% or 254,000) occurred in sub-Saharan Africa (SSA) and Southern
Asia (SA). Sixty-three percent of all maternal deaths globally are due to direct causes, most
(27.1%) of these are due to haemorrhage. Haemorrhage is the primary underlying cause of 24.5%
and 30.3% maternal deaths respectively in SSA and SA respectively. Sixty-two percent of all
deaths due to haemorrhage globally occur in the postpartum period (62% in SSA and 86% in SA).
The majority of postpartum haemorrhage (PPH) maternal deaths could be avoided by the use of
prophylactic uterotonics during the third stage of labour.

To meet the ambitious maternal health targets of the Sustainable Development Goals, specifically
SDG 3.1: reduce the global maternal mortality ratio to less than 70/100,000 live births by 2030.
Practical steps are needed to scale up the implementation of evidence-based interventions to
prevent and treat PPH.

Following the publication of updated WHO PPH recommendations by the World Health
Organization in 2017 and 2018, there is limited application of these, as well as limited knowledge
of effective uterotonics for PPH prevention and treatment.

This clinical protocol for the prevention and management of post-partum haemorrhage has been
developed in line with the World Health Organization PPH guidelines, to improve awareness of
uterotonic options and a translation of the guidelines to facilitate evidence based clinical practice.

Purpose
The purpose of this guideline is to support Skilled Health Personnel in providing care based on
best practice and best available evidence to identify, prevent and manage PPH. Specifically, this
clinical protocol will increase the capacity for

 Identification of high-risk groups and instituting measures to prevent/minimise post-partum

haemorrhage.
 Clear and timely communication between surgical, anaesthetic and haematology/blood
transfusion services.
 Prompt resuscitation and supportive measures including replacing the blood loss.
 Investigating the cause for and arresting the haemorrhage.
 Instituting appropriate monitoring.

Roles and responsibilities

This guideline defines the roles and responsibilities of midwives, medical interns, medical officers,
obstetric registrars, obstetricians, anaesthetists, and staff involved in the care of women with post-
partum haemorrhage in both basic and comprehensive Emergency Obstetric Care (EmOC) health
facilities.6

These guidelines should be implemented along with current WHO guidelines that highlight women-
centred care to optimise the experience of labour and childbirth for women and their babies
through holistic, human rights and evidence based approach (WHO recommendations: Intrapartum
care for a positive childbirth experience and WHO labour care guide).7,8

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 6

The place of training and job aids
These guidelines should be incorporated into continuous professional development programmes
for Skilled Health Personnel9 providing maternity services. The guidelines should also be used to
update job aids to facilitate implementation.

 Regular drills and skills training are essential in the management of PPH.
 Trainees should be allowed dedicated and protected time for training.
 Simulation of obstetric procedures and emergencies can only augment, not replace, the
learning that occurs by caring for actual patients.
 In-house training is cheap and associated with improved outcomes.
 Funding should be available for training to reduce the cost of medical litigation as a result of
substandard care.
 Teamwork is essential for proper coordination of the management.
 Above all, patients and their relatives must be kept fully informed at all stages of
management.

Monitoring and evaluating PPH clinical guideline implementation

The implementation of the country-adapted PPH clinical protocol should be monitored at all levels
of care where maternity services are provided. Clinical audits or criterion-based audits can be used
based on clearly defined review criteria and indicators, locally agreed. A good starting point are the
relevant standards and indicators described in the WHO document ‘Standards for improving quality
of maternal and newborn care in health facilities’.10

Definitions
Postpartum haemorrhage is defined as estimated blood loss of more than 500 ml* within 24
hours of a vaginal birth or 1000 ml after caesarean section, or any blood loss sufficient to
compromise haemodynamic stability. In women with lower body mass (less than 60kg), a lower
level of blood loss may be clinically significant. 11
PPH can be minor (500-1000 ml) or major (more than 1000 ml). A severe PPH following Lower
Segment Caesarean Section (LSCS) involves the loss of 1500 ml or more.
Massive PPH involves the loss of 2000 ml or more of blood from the genital tract within 24 hours
of the birth of the baby or when the woman is haemodynamically compromised or showing signs of
shock as a result of obstetric haemorrhage of any amount over 500 ml.
A blood loss can be considered a Massive Obstetric Haemorrhage in cases where either four
units of blood have been transfused and further units are required, regardless of blood loss or
there is a blood loss >2000 ml.
Secondary PPH is defined as excessive blood loss from the genital tract after 24 hours following
delivery, until six weeks post-delivery.

* 1 unit of packed red blood cells is approximately 280-450 ml.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 7

Visual estimates of blood loss are very inaccurate, there is also a tendency to underestimate blood
loss associated with a surgical procedure.
The physiological increase in circulating blood volume during pregnancy means that signs of
hypovolaemic shock become less sensitive in pregnancy. Following PPH, a fall in blood pressure
is usually a late sign. In women with normal haemoglobin levels, blood loss of 500-1000 ml may
not be associated with any change in pulse rate and blood pressure. There is usually an increase
in pulse and respiratory rate with blood loss of up to 1500 ml (30% loss in blood volume), the
woman is usually pale and cold. With blood loss of more than 1500-2000 ml (up to 40% loss in
blood volume) or more, in addition to raised pulse and respiratory rate, the blood pressure falls
(hypotension). Additionally, signs associated with reduced perfusion of the skin, brain and skin
such as cold clammy skin, confusion/agitation/drowsiness, and reduced urine output become
evident.

These clinical signs associated with specific blood loss volumes above are more reliable than
visual estimation. Swabs and clots can be weighed for a more accurate estimate of blood loss.

WHO PPH guidelines

This protocol has been developed based on three WHO PPH guidelines, the summary of key
recommendations from these guidelines are provided in Annex 2.

 WHO (2012): Recommendations for the prevention and treatment of PPH

 WHO (2017): Recommendation on Tranexamic Acid for the treatment of PPH
 WHO (2018): Recommendations on the use of uterotonics for the prevention of PPH

The main change in the 2012 WHO PPH guideline, is the use of tranexamic acid (indication,
timing, and dosing) - Table 1

Table 1: The main change in recommendation on TXA in the WHO 2012 PPH
recommendation.13

Indication Timing Dosing

WHO 2012 TXA Use of TXA is For atonic uterus, use TXA if IV(slowly):1g
Recommendation recommended for the oxytocin and other
treatment of PPH if uterotonics fail to stop the Repeat after 30 minutes if
oxytocin and other bleeding. bleeding continues.
uterotonics fail to stop
the bleeding or if it is
thought that the
bleeding may be partly
due to trauma.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 8

 WHO 2017 TXA Use TXA in all cases of Use TXA within 3 hours and Fixed dose of 1g in 10 ml
Recommendation PPH, regardless of as early as possible after (100mg/ml) IV at 1 ml per
(updated) whether the bleeding is the onset of PPH. Do not minute (i.e., administered over
due to genital tract initiate TXA more than 3 10 minutes)
trauma or other causes. hours after birth, unless Second dose of 1g IV if
being used for bleeding that bleeding continues after 30
restarts within 24 hours of minutes or if bleeding restarts
completing the first dose within 24 hours of completing
(see dosing). the first dose.

PPH Prevention
Minimising the risk of PPH starts during the antenatal period, by the identification and treatment of
anaemia, identify any women with increased risk of PPH (Table 2) and plan for their delivery. Risk
factors for developing PPH may present antenatally or intrapartum, so care plans should be
modified as these risks emerge. 11 Women with known risk factors should be delivered in health
facilities with capacity for blood transfusion and surgery.

During the 3rd stage of labour, one of the following uterotonics, carbetocin, misoprostol,
ergometrine/methylergometrine and oxytocin and ergometrine fixed-dose combination, should be
administered (Figure 1 and Figure 2). The characteristics of these uterotonics are provided in
Annex 1.
Oxytocin (10 IU, IM/IV) is the recommended uterotonic of choice (vaginal and caesarean birth). If
oxytocin is unavailable or the quality cannot be guaranteed, the other uterotonics above can be
used. The use of carbetocin (100 micrograms, IM/IV) is only recommended for the prevention of
PPH for all births in contexts where its cost is comparable to other effective uterotonics. It is
expected that heat-stable carbetocin (HSC) will be available in many low and lower-middle income
countries, this is likely to address the issues of effectiveness, quality and affordability.
Any uterotonic that contains ergometrine could be used in the absence of oxytocin in contexts
where hypertensive disorders can safely be excluded. Non Skilled Health Personnel should only
administer misoprostol (oral 400 or 600 microgram). 4
Injectable prostaglandins such as carboprost or sulprostone are not recommended for PPH
prevention.
Postpartum abdominal uterine tone assessment for the early identification of uterine atony is
recommended for all women.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 9

Figure 1: Deciding which uterotonic to take

Are skilled health personnel Heat-stable carbetocin (100 μg.

who can administer injectable Trained community health IM/IV) in contexts where its cost
uterotonics available? No is comparable to other effective
workers and lay health
workers can administer uterotonics.
misoprostol (400 μg or 600
μg PO)
Yes OR

Ergometrine / methylergometrine
(200 μg. IM/IV), in contexts
Is oxytocin available? where hypertensive disorders
No can be safely excluded prior to
Oxytocin is not available, or its use.
its quality cannot be
Yes guaranteed
No
OR
Is oxytocin of sufficient quality?
Fixed-dose combination of
oxytocin and ergometrine, in
contexts where hypertensive
Yes disorders can be safely excluded
prior to its use.

Use oxytocin (10 IU, IV or IM)

OR

Misoprostol
(400 μg or 600 μg PO)

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 10

Figure 2: PPH prevention flow chart

PPH Prevention
Birth personnel type

3rd stage of labour: after delivery of baby

Skilled Health Personnel

Yes No

Oxytocin 10IU, IV/IM (vaginal and caesarean births), Misoprostol (400 micrograms or
if unavailable or if quality cannot be guaranteed one 600 micrograms, orally)
of the following can be used following the decision
process above in figure 11, based on clinical eligibility
and availability:
Uterotonic

 Heat stable carbetocin (100 micrograms IM/IV)

 Misoprostol (400 micrograms or 600 micrograms, orally)
 Ergometrine/methylergometrine (200 micrograms,
IM/IV)2
 Oxytocin and ergometrine fixed-dose combination
(5IU/500 micro grams, IM)2

Birth asphyxia
Cord clamping

No Yes

Late cord clamping (1-3mins) but Early cord clamping (<1min)

initiate essential newborn care

Skilled Health Personnel

Yes No
Placenta

Controlled cord traction (CCT) for No CCT

both vaginal and caesarean births

1. Carboprost is not recommended for prevention of PPH

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 11
2. In contexts where hypertensive disorders can be safely excluded prior to its use
Treatment of PPH
Minor PPH: blood loss 500 – 1000 ml without clinical shock
This management plan is for PPH with blood loss 500-1000 ml without clinical shock. Additionally,
a smaller blood loss associated with clinical signs of shock, hypotension (systolic BP drop of
30mmHg), tachycardia (pulse rate rise of more than 30bpm), tachypnoea (respiratory rate more
than 30 cycles/min) or oliguria (less than 30 ml of urine/hour) can also be managed following these
steps.

Alert labour ward in-charge/coordinator, first line obstetric (medical intern/medical

Intravenous
officer) andaccess one grey
anaesthetic cannula
staff (if in a comprehensive EmOC facility)

The most senior skilled health personnel available should lead the management. The team leader
will be responsible for key procedures, clear communications, and allocation of tasks
(interventions, equipment and documentation, monitoring and communication with the family).
Clear information should be provided to the woman and her partner about what is happening from
the onset.

Conduct a primary survey

 Assess Airway, Birthing and Circulation

 Fluid replacement
 Establish intravenous access with 16G cannula and commence crystalloid infusion, for
example Hartmans solution, normal saline
 Urgent venepuncture: FBC, Group and Save, Coagulation screen including fibrinogen
 Monitor vital signs: pulse, respiratory rate, blood pressure every 15 minutes. A modified
early obstetric warning score (MEOWS) will aid monitoring, prompt action and escalating
promptly when abnormal scores are observed.

Conduct a secondary survey

Look out for the Four T’s (Tone, Tissue, Trauma and Thrombin) and associated risk factors (Table
2). The most common cause of PPH is uterine atony with placenta site bleeding, genital tract
trauma or both. The initial evaluation is differential uterine atony from genital track lacerations.

Table 2: Risk factors and causes of obstetric haemorrhage

The Four T’s Risk factors/notes

Tone: abnormalities of uterine contraction

Overdistension of uterus Polyhydramnios, multiple gestation,
macrosomia

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 12

 The Four T’s Risk factors/notes
Intra-amniotic infection Fever, prolonged rupture of membranes
Functional/ anatomical distortion of uterus Rapid labour, prolonged labour, fibroids,
placenta praevia, uterine anomalies

Uterine relaxants e.g. magnesium sulfate / Terbutaline, halogenated anaesthesia,

nifedipine Glyceryl trinitrate (GTN)
Bladder distension May prevent uterine contractions
Tissue: retained products of conception
Retained cotyledon or succenturiate lobe

Retained blood clots

Trauma: genital tract injury
Lacerations of the cervix, vagina or Precipitate labour, instrumental delivery
perineum
Vaginal and paravaginal haematoma

Extensions, lacerations at CS Malposition deep engagement

Uterine rupture Previous uterine surgery

Uterine inversion High parity, excessive cord traction

Thrombin: abnormalities of coagulation

Pre-existing states e.g. Von Willebrand History of hereditary coagulopathies or liver

Haemophilia disease
Acquired in pregnancy: Bruising, Elevated blood pressure
Gestational thrombocytopenia, PET with
HELLP
DIC: IUD, severe infection, abruption, Coagulopathy
amniotic fluid embolus,
Severe PIH/PET
Therapeutic anticoagulation DVT/PE treatment

Clinical considerations
 Empty bladder – leave catheter in place and commence fluid balance chart
 Assess uterine tone and perform uterine massage as necessary “rub up a contraction”,
bimanual compression if required.
 Uterotonic medications see Figure 2. Note that dose of misoprostol for treatment is 800
micrograms sublingual.
 Tranexamic acid (TXA) should be used in all cases of PPH, regardless of whether the bleeding
is due to genital tract trauma or other causes within 3 hours of birth.
 TXA should be administered at a fixed dose of 1g in 10 ml (100 mg/ml) IV at 1ml per
minute(i.e., administered over 10 minutes), with a second dose of 1g IV if bleeding continues
after 30 minutes or if bleeding restarts within 24 hours of completing the first dose.14

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 13

 The reference point for the start of the 3-hour window for starting TXA administration is time of
birth. If time of birth is unknown, the best estimate of time of birth should be used as the
reference point.
 The use of TXA should be avoided in women with a clear contraindication to antifibrinolytic
therapy (including TXA) for example known thromboembolic event during pregnancy.

 TXA should be part of the standard comprehensive PPH treatment package, including
medical (uterotonics), non-surgical and surgical interventions in accordance with WHO
guidelines or adapted local PPH treatment protocols.
 Early use of IV TXA (as early as possible after clinical diagnosis of PPH and only within 3
hours of birth) in addition to standard care is recommended for women with clinically
diagnosed PPH following vaginal birth or caesarean section.
 The point estimates of effect of TXA use beyond 3 hours on death for trauma6 and for PPH
were both in the direction of harm, albeit not statistically significant for women with PPH. In
view of this evidence, WHO recommends against the use of TXA more than 3 hours after
birth.
 Treatment delay in use of TXA appears to reduce benefit. The benefit appears to decrease
by 10% for every 15-minute delay, with no benefit seen after 3 hours.

TXA Health system considerations

TXA should be readily available at all times in the delivery and postpartum areas of facilities
providing emergency obstetric care.

TXA is relatively cheap in most contexts, easy to administer, often available in health care settings
due to its use in trauma and surgery, has a shelf life of 3 years, and can be stored at room
temperature (15–30C) in many places.

The clinical care pathway will depend on the type of facility where the diagnosis of PPH is made –
a primary care/facility with Basic Emergency Obstetric Care capacity (BEmOC) (Figure 3 and
Figure 4) or a hospital with Comprehensive Emergency Obstetric Care facility (CEmOC) (Figure 5).

Situation-Background-Assessment-Recommendation
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework
for communication between members of the health care team about a patient's condition. 15,16

S = Situation (a concise statement of the problem)

State clearly:

What is your grade

Where you are calling from

Which patient you are calling about: name and age

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 14
Why are you calling?
B = Background (pertinent and brief information related to the situation)

State the admission diagnosis and date of admission

State any important history

Give a brief summary of the treatment to date

A = Assessment (analysis and considerations of options — what you found/think)

State the findings of the initial assessment

State the most recent vital signs: respiratory rate, heart/pulse rate, B/P, temperature,
oxygen saturations, AVPU (Alert, Voice/or new confusion, Pain or Unresponsive), Blood
sugar

What is the state of the uterus?

RWhat
= Recommendation
is the state of the(action requested/recommended — what you want)
placenta?

What
State is
clearly
your assessment
what your recommendation
of lacerations? is or what do you want?

SBAR allows for an easy and focused way to set expectations for what will be communicated and
how between members of the team, which is essential for developing teamwork and fostering a
culture of patient safety.

There is moderate evidence for improved patient safety through SBAR implementation, especially
when used to structure communication over the phone16. A tool for SBAR implementation is
provided in Annex 3: SBAR communication and referral tool*.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 15

Figure 3: Flow chart for PPH treatment at BEmOC facility
 Estimated blood loss 500- Call for HELP and ALERT: Labour ward in-  Most senior to lead care
charge/coordinator, first line obstetric (clinical
1000 ml  Allocate tasks
officer, medical intern/medical officer)
 Blood loss with change in
RR, PR and BP

Assess ABC  Repeat oxytocin and administer sublingual

misoprostol 800 micrograms if
 Airway: Confirm airway open, patent and breathing (RR) unresponsive within 10mins (uterus
 If symptomatic: Oxygen 15L/min via facemask still atonic)1
 Circulation: PR, BP  Administer TXA within 3 hours of birth: 1g
 Establish venous access: 2 wide bore cannula (16 G) in 10 ml (100 mg/ml) IV at 1 ml per
minute2
 Fluid replacement: warmed crystalloid infusion-2L fast, and
transfuse as soon as possible  Oxytocin 40 units in 500 ml sodium
 Insert urethral catheter, empty the bladder, open fluid balance chloride 0.9% at 125 ml/hr
chart
 Monitor vital signs (pulse rate, respiratory rate and blood Secondary survey:
pressure) every 15 mins (MOEWS chart)
 Tissue: Check if placenta delivered and complete.
Bleeding stopped after 30 minutes?
CCT, manual removal of placenta.

 Tone: boggy soft during bimanual examination =

No Yes atonic uterus. Rub up contractions. Perform
bimanual compression.

 Tears: Check for perineal and cervical tears and

Administer a second dose of TXA 1g IV if bleeding continues repair
after 30 minutes or if bleeding restarts within 24 hours of
completing the first dose. Bleeding stopped?

No Yes

REFER TO CEmOC facility with Situation Background,

Assessment Recommendation (SBAR) report (Annex 3)

 External aortic compression

 Apply non-pneumatic anti-shock garment

1 IVoxytocin peak onset of action is immediate and peak concentration after 30 minutes while IM oxytocin onset
of action is 3-7 minutes and duration of action is up to 1 hour (Annex 1).

2TXA should be avoided in women with clear contraindication to antifibrinolytic therapy such as a known
thrombotic event during pregnancy

Uterine packing is not recommended for the treatment of PPH due to uterine atony

Women should remain in the delivery suite for 24 hours after major PPH has been resolved or after transfer
from ICU/ITU
FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 16
Figure 4: Flow chart for major PPH treatment at BEmOC facility
 Estimated blood loss CALL for HELP! A multidisciplinary team
 Most senior to lead care
>1000 ml should be alerted: Labour ward in-
charge/coordinator, first line obstetric  Allocate tasks
 Blood loss with change in
(medical intern/medical officer), obstetric
RR, PR and BP

Assess ABC  Full blood count, coagulation screen, renal

and liver function tests
 Airway: Confirm airway open, patent and breathing (RR)
 If symptomatic: Oxygen 15L/min via facemask  Group and cross match 4 units of packed
red cells/fresh whole blood
 Circulation: PR, BP
 Establish venous access: 2 wide bore cannula (14-16 G)  Transfuse if bleeding is more than 1.5L and
 Fluid replacement: Warmed crystalloid infusion-2L fast, and bleeding is continuing
transfuse as soon as possible
 Insert urethral catheter, empty the bladder, open fluid  Repeat oxytocin and 800 micrograms
balance chart misoprostol if unresponsive within 10
 Monitor vital signs (Pulse rate, respiratory rate and blood mins (uterus still atonic)1
pressure) every 15 mins (MOEWS chart)  Administer TXA within 3 hours of birth: 1g in
Secondary survey: 10 ml (100 mg/mL) IV at 1 ml per
minute2
 Tissue, Tone, Tears, Thrombin
 Oxytocin 40 units in 500 ml sodium chloride
0.9% / ringers lactate at 125 ml/hr
 Continuously assess blood loss

1. Tissue: Placenta 2. Tone: boggy soft 3. Tears: check for 4. Thrombin

delivered? during bimanual perineal and cervical
examination = Uterine tears
Atony

No or
incomplete No tears Yes based on
on Yes
history. Prepare
inspection to refer to
Yes No
Repair CEmOC

 Controlled cord traction

 Rub up contractions
 If undelivered after 30mins
of birth: Manual
 Expel blood clots from
placenta removal2 uterus
 Bimanual uterine
compression

If persistent bleeding/shock

Administer a second dose of TXA 1g IV if bleeding  External aortic compression

continues after 30 minutes or if bleeding restarts within 24
 Apply non-pneumatic anti-shock garment
hours of completing the first dose.
 Uterine Balloon Tamponade (UBT)

 Uterine packing is not recommended

Refer to CEmOC facility (capacity for
 IV oxytocin peak onset of action is immediate and peak surgery and blood transfusion with Situation
concentration after 30 minutes while IM oxytocin onset of Background, Assessment Recommendation
FIGO action is 3-7 minutes
Postpartum and duration
Haemorrhage of action
Clinical is up to and Care Pathways
Protocol (SBAR) report (Annex 3) 17
1hour (Annex 1).
 Administer broad spectrum antibiotics1
Figure 5: Flow chart for major PPH treatment at CEmOC facility
 Estimated blood loss >1000 ml CALL for HELP! A multidisciplinary team should be  Most senior to lead
 Blood loss with change in RR, alerted: Labour ward in-charge/coordinator, first line care
PR and BP obstetric (medical intern/medical officer), obstetric  Allocate tasks
consultant and anaesthetic staff

 Full blood count, coagulation screen, renal and liver

Assess ABC function tests

 Airway: Confirm airway open, patent and breathing  Group and cross match 4 units of packed red
(RR) cells/fresh whole blood
 If symptomatic: Oxygen 15L/min via facemask
Transfuse if bleeding is more than 1.5L and
 Circulation: PR, BP bleeding is continuing
 Establish venous access: 2 wide bore cannula
(14-16 G)
 Repeat oxytocin and 800 micrograms misoprostol if
 Fluid replacement: Warmed crystalloid infusion- unresponsive within 10 mins (uterus still atonic)1
2L fast, and transfuse as soon as possible
 Administer TXA within 3 hours of birth: 1 g in 10 ml (100
 Insert urethral catheter, empty the bladder, open
mg/ml) IV at 1 mL per minute2
fluid balance chart
 Monitor vital signs (Pulse rate, respiratory rate  Oxytocin 40 units in 500ml sodium chloride 0.9% /
and blood pressure) every 15 mins (MOEWS ringers lactate at 125 ml/hr
chart)  Continuously assess blood loss

Secondary survey:
Bleeding stopped after 30 minutes?
Tissue: Check if placenta delivered and complete. CCT,
manual removal of placenta.

Tone: boggy soft during bimanual examination= atonic uterus.

No Yes Rub up contractions. Perform bimanual compression.

Tears: Check for perineal and cervical tears and repair

Administer a second dose of TXA 1 g IV if bleeding Bleeding stopped?

continues after 30 minutes or if bleeding restarts within 24
hours of completing the first dose.

Non-surgical methods
No Yes
 External aortic compression
 Apply non-pneumatic anti-shock garment
2
TXA should be avoided in women with clear
 Uterine Balloon Tamponade (UBT) contraindication to antifibrinolytic therapy such as a
known thrombotic event during pregnancy
Surgical methods
3
 Examination under anaesthesia Involve experienced surgeons with vascular
expertise.
 Repair tears
 Apply brace sutures* 4
Resort to sub-total hysterectomy sooner rather than
 Stepwise devascularisation and internal iliac artery ligation. 3
later
 Hysterectomy.4
TXA should be administered IV ONLY

1
IV oxytocin peak onset of action is immediate and peak concentration after 30 minutes while IM oxytocin onset of action is 3-7
minutes and duration of action is up to 1hour (Annex 1).

*Have a copy of BLYNCH suture on display in the operation theatre (Annex 4)

NASG garment instructional video here. UBT instructional video here.

FIGO
WomenPostpartum
should remain inHaemorrhage Clinical
the delivery suite for 24 hoursProtocol andhas
after major PPH Care
beenPathways
resolved or after transfer from ICU/ITU 18
Major PPH: Blood loss more than 1000 ml and ongoing bleeding or
clinical shock

Call for help! Request Labour Ward in-charge/Coordinator, medical officer/Obstetric

Registrar and Anaesthetist and alert Consultant Obstetrician and Consultant Anaesthetist.

The most senior skilled health personnel available should lead the management. The team leader
will be responsible for key procedures, clear communications, and allocation of tasks
(interventions, equipment and documentation, monitoring and communication with the family).

Conduct a primary survey

 ABC: assess airway and breathing; oxygen 15L/min via face mask
 Evaluate circulation
 Position the patient flat
 Give immediate clinical treatment:
o Uterine massage “rub up a contraction”, bimanual compression if required
o Empty bladder – leave catheter in place and commence fluid balance chart
o Uterotonic medications – see Figure 4
o Establish two 14-16g cannula, take bloods for full blood count, coagulation screen, renal
and liver baseline and cross match packed red cells (4 units).
o Volume replacement: involves restoration of both blood volume and oxygen carrying
capacity.
o As rapidly as possible give 2L of warmed Hartmann’s solution or normal saline, followed by
whole blood as soon as available.
o Blood transfusion as soon as blood is available, following blood transfusion clinical
protocol. Not that near patient estimation of Hb can be misleading.
o Controlled cord traction if placenta has not yet been delivered – remove any clots or
remaining tissue
o Continuously assess blood loss – weigh swabs and clots and keep a contemporaneous
estimate of blood loss.
o Monitor vital signs: pulse, respiratory rate, blood pressure every 15 minutes. A modified
early obstetric warning score (MEOWS) will aid monitoring, prompt action and escalating
promptly when abnormal scores are observed.17,18. Annex 5: Modified Early Obstetric
Warning score chart.

Conduct a secondary survey (Table 2)

Care pathway

 If pharmacological measures fail to control the haemorrhage, surgical interventions should

be initiated sooner rather than later.
 Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most
women where uterine atony is the only or main cause of haemorrhage.

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 19

  Conservative surgical interventions may be attempted as second line, depending on clinical
circumstances and available expertise.
 It is recommended that a laminated diagram of the brace suture technique be kept in
theatre.(Annex 4)
 Resort to hysterectomy sooner rather than later (especially in cases of placenta accreta or
uterine rupture).
 Ideally and when feasible, a second experienced clinician should be involved in the
decision for hysterectomy.

Conservative surgical techniques

A description of the B-Lynch suture technique is provided here. See Annex 4: B-Lynch surgical
technique for control of massive postpartum haemorrhage.

The B-Lynch suture allows for even tension, free drainage of the uterine cavity and facilitates
involution. With this technique it is easy to confirm haemostasis, that the uterine cavity is empty,
confirm no decidual tear/trauma.

Requirements19

 Lloyd Davis or frog-legged position essential

 The uterus must be exteriorised
 Basic surgical competence required
 Bi-manual compression to test for potential success
 Transverse lower segment incision should be made
 Uterine cavity checked, explored, and evacuated
 A 70-mm half circle guarded needle (code: w3709) mounted on a 90-cm monocryl No. 1
(Ethicon, Somerville, N.J.) or Catgut suture is appropriate
 Apply suture correctly with even tension (no shouldering)
 Allow free drainage of blood, debris, and inflammatory material
 Check bleeding control vaginally, using swabs and instruments

After application, the uterus should be exteriorised and the surgeon demonstrates to the assistant
bimanual compression and ante version. The second assistant checks the vagina to ensure that
bleeding is controlled and the surgical technique will work.

Causes of failure include the following:

 Placenta percreta
 Wrong technique causing uterine necrosis
 Uncontrolled DIC
 No pre-operative investigations done
 Poor technique i.e. not properly applied
 Delayed application

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 20

Secondary PPH
In women presenting with secondary PPH, an assessment of vaginal microbiology should be
performed (high vaginal and endocervical swabs) and appropriate use of antimicrobial therapy
should be initiated when endometritis is suspected.

A pelvic ultrasound may help to exclude the presence of retained products of conception, although
the diagnosis of retained products is unreliable. Surgical evacuation of retained placental tissue
should be undertaken or supervised by an experienced clinician.

Annex 1: Characteristics of potential uterotonics4

Characteristics Brief description (14,15)

Oxytocin Synthetic cyclic peptide form of the naturally occurring posterior pituitary hormone

Binds to oxytocin receptors in the uterine myometrium, stimulating contraction of this

uterine smooth muscle by increasing the sodium permeability of uterine myofibrils.

Carbetocin Long-acting synthetic analogue of oxytocin with agonist properties

Binds to oxytocin receptors in the uterine smooth muscle, resulting in rhythmic

contractions, increased frequency of existing contractions, and increased uterine
tone.

Misoprostol Synthetic analogue of natural prostaglandin E1

Has oxytocic properties, inhibits gastric acid and pepsin secretion, and enhances
gastric mucosal resistance to injury.

Injectable Injectable prostaglandins (systemic) trialled for PPH prevention include

prostaglandins prostaglandin F2 analogues (carboprost), prostaglandin E2 (dinoprostone) and
prostaglandin E2 analogues (sulprostone)

Ergometrine Ergometrine and methylergometrine are ergotalkaloids that increase uterine muscle
tone by causing sustained uterine contractions

Oxytocin plus Fixed-drug combinationa–oxytocin (5 IU) plus ergometrine (500 microgram)

ergometrine

Misoprostol plus See misoprostol and oxytocin

oxytocin
Combination agents not in synthetic (fixed-dose) or naturally occurring forms

Characteristics Pharmaco-kinetics(14,15)

Oxytocin Intravenous (IV): almost immediate action with peak Half-life: 1–6
concentration after 30 minutes minutes

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 21

 Intramuscular (IM): slower onset of action, taking 3–7
minutes, but produces a longer-lasting clinical effect of up
to 1 hour

Carbetocin IV: sustained uterine contractions within 2 minutes, lasting Half-life: 40

for about 6 minutes and followed by rhythmic contractions minutes
for 60 minutes

IM: sustained uterine contractions lasting for about

11minutes and rhythmic contractions for 120 minutes

Misoprostol Absorbed 9–15 minutes after sublingual, oral, vaginal or Half-life: 20–40
rectal use minutes

Oral and sublingual routes have the advantage of rapid

onset of action, while the vaginal and rectal routes result
in prolonged activity and greater bioavailability.

Injectable IM: 15–60 minutes to peak plasma concentration Half-life:

prostaglandins 8minutes

Ergometrine IM: onset of action within 2–3 minutes, lasting for about Half-life: 30–120
3 hours minutes

IV: onset of action within 1 minute,

Lasting 45 minutes (although rhythmic contractions may
persist for up to 3 hours)

Oxytocin plus See oxytocin and ergometrine Half-life: 1–6

ergometrine minutes
Half-life: 1–6 minutes IM: latent period for the uterine (oxytocin) and
response is about 2.5 minutes; uterotonic effects last for 30–120 minutes
around 3 hours (16) (ergometrine)

Misoprostol plus See misoprostol and oxytocin

oxytocin

Annex 2: WHO recommendations: Uterotonics for the

prevention and treatment of postpartum haemorrhage

A. Uterotonics for the prevention and treatment of postpartum haemorrhage4

Context Recommendation Category of
recommendation

Efficacy and 1. The use of an effective uterotonic for the prevention Recommended
safety of of PPH during the third stage of labour is
uterotonics for recommended for all births. To effectively prevent
PPH PPH, only one of the following uterotonics should be
prevention used:
 oxytocin (Recommendation 1.1)
 carbetocin (Recommendation 1.2)
 misoprostol (Recommendation 1.3)

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 22

 Context Recommendation Category of
recommendation

 ergometrine/methylergometrine
(Recommendation 1.4)
 oxytocin and ergometrine fixed-dose combination
(Recommendation 1.5).

1.1 The use of oxytocin (10 IU, IM/IV) is recommended for Recommended
the prevention of PPH for all births.

1.2 The use of carbetocin (100 micrograms, IM/IV) is Context-specific

recommended for the prevention of PPH for all births in recommendation
contexts where its cost is comparable to other effective
uterotonics.

1.3 The use of misoprostol (either 400 micrograms or 600 Recommended

micrograms PO) is recommended for the prevention of
PPH for all births.

1.4 The use of ergometrine/methylergometrine (200 Context-specific

micrograms, IM/IV) is recommended for the prevention of recommendation
PPH in contexts where hypertensive disorders can be
safely excluded prior to its use.

1.5 The use of a fixed-dose combination of oxytocin and Context-specific

ergometrine (5 IU/500 micrograms, IM) is recommended recommendation
for the prevention of PPH in contexts where hypertensive
disorders can be safely excluded prior to its use.

1.6 Injectable prostaglandins (carboprost or sulprostone) Not recommended

are not recommended for the prevention of PPH.

Choice of 2. In settings where multiple uterotonic options are Recommended

uterotonics for available, oxytocin (10 IU, IM/IV) is the recommended
PPH uterotonic agent for the prevention of PPH for all births.
prevention
3. In settings where oxytocin is unavailable (or its quality Recommended
cannot be guaranteed), the use of other injectable
uterotonics (carbetocin, or if appropriate
ergometrine/methylergometrine, or oxytocin and
ergometrine fixed-dose combination) or oral misoprostol
is recommended for the prevention of PPH.
4. In settings where skilled health personnel are not Recommended
present to administer injectable uterotonics, the
administration of misoprostol (400 mcg or 600 mcg, PO)
by community health workers and lay health workers is
recommended for the prevention of PPH.

B. Recommendations for the prevention of PPH 5

a. The use of uterotonics for the prevention of PPH during the third stage of labour is
recommended for all births. (Strong recommendation, moderate-quality evidence)

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 23

 b. Oxytocin (10 IU, IV/IM) is the recommended uterotonic drug for the prevention of PPH.
(Strong recommendation, moderate-quality evidence)
c. In settings where oxytocin is unavailable, the use of other injectable uterotonics (if
appropriate ergometrine/methylergometrine or the fixed drug combination of oxytocin
and ergometrine) or oral misoprostol (600 μg) is recommended. (Strong
recommendation, moderate quality evidence)
d. In settings where skilled birth attendants are not present and oxytocin is unavailable,
the administration of misoprostol (600 μg PO) by community health care workers and
lay health workers is recommended for the prevention of PPH. (Strong
recommendation, moderate quality evidence)
e. In settings where skilled birth attendants are available, CCT is recommended for
vaginal births if the care provider and the parturient woman regard a small reduction in
blood loss and a small reduction in the duration of the third stage of labour as important.
(Weak recommendation, high-quality evidence)
f. In settings where skilled birth attendants are unavailable, CCT is not recommended.
(Strong recommendation, moderate-quality evidence)
g. Late cord clamping (performed after 1 to 3 minutes after birth) is recommended for all
births while initiating simultaneous essential newborn care. (Strong recommendation,
moderate quality evidence)
h. Early cord clamping (<1 minute after birth) is not recommended unless the neonate is
asphyxiated and needs to be moved immediately for resuscitation. (Strong
recommendation, moderate-quality evidence)
i. Sustained uterine massage is not recommended as an intervention to prevent PPH in
women who have received prophylactic oxytocin. (Weak recommendation, low-quality
evidence)
j. Postpartum abdominal uterine tonus assessment for early identification of uterine atony
is recommended for all women. (Strong recommendation, very-low-quality evidence)
k. Oxytocin (IV or IM) is the recommended uterotonic drug for the prevention of PPH in
caesarean section. (Strong recommendation, moderate-quality evidence)
l. Controlled cord traction is the recommended method for removal of the placenta in
caesarean section. (Strong recommendation, moderate-quality evidence)

C. Recommendations for treatment of PPH5

a. Intravenous oxytocin alone is the recommended uterotonic drug for the treatment of
PPH. (Strong recommendation, moderate-quality evidence)
b. If intravenous oxytocin is unavailable, or if the bleeding does not respond to oxytocin,
the use of intravenous ergometrine, oxytocin-ergometrine fixed dose, or a prostaglandin
drug (including sublingual misoprostol, 800 μg) is recommended. (Strong
recommendation, low-quality evidence)
c. The use of isotonic crystalloids is recommended in preference to the use of colloids for
the initial intravenous fluid resuscitation of women with PPH. (Strong recommendation,
low-quality evidence)

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 24

 d. The use of tranexamic acid is recommended for the treatment of PPH if oxytocin and
other uterotonics fail to stop bleeding or if it is thought that the bleeding may be partly
due to trauma. (Weak recommendation, moderate-quality evidence)*
e. Uterine massage is recommended for the treatment of PPH. (Strong recommendation,
very slow-quality evidence)
f. If women do not respond to treatment using uterotonics, or if uterotonics are
unavailable, the use of intrauterine balloon tamponade is recommended for the
treatment of PPH due to uterine atony. (Weak recommendation, very-low-quality
evidence)
g. If other measures have failed and if the necessary resources are available, the use of
uterine artery embolization is recommended as a treatment for PPH due to uterine
atony. (Weak recommendation, very-low-quality evidence)
h. If bleeding does not stop in spite of treatment using uterotonics and other available
conservative interventions (e.g. uterine massage, balloon tamponade), the use of
surgical interventions is recommended. (Strong recommendation, very-low-quality
evidence)
i. The use of bimanual uterine compression is recommended as a temporizing measure
until appropriate care is available for the treatment of PPH due to uterine atony after
vaginal delivery. (Weak recommendation, very-low-quality evidence)
j. The use of external aortic compression for the treatment of PPH due to uterine atony
after vaginal birth is recommended as a temporizing measure until appropriate care is
available. (Weak recommendation, very-low-quality evidence)
k. The use of non-pneumatic anti-shock garments is recommended as a temporizing
measure until appropriate care is available. (Weak recommendation, low-quality
evidence)
l. The use of uterine packing is not recommended for the treatment of PPH due to uterine
atony after vaginal birth. (Weak recommendation, very-low-quality evidence)
m. If the placenta is not expelled spontaneously, the use of IV/IM oxytocin (10 IU) in
combination with controlled cord traction is recommended. (Weak recommendation,
very-low-quality evidence)
n. The use of ergometrine for the management of retained placenta is not recommended
as this may cause tetanic uterine contractions, which may delay the expulsion of the
placenta. (Weak recommendation, very-low-quality evidence)
o. The use of prostaglandin E2 alpha (dinoprostone or sulprostone) for the management
of retained placenta is not recommended. (Weak recommendation, very-low-quality
evidence)
p. A single dose of antibiotics (ampicillin or first-generation cephalosporin) is
recommended if manual removal of the placenta is practised. (Weak recommendation,
very-low-quality evidence)

Organisation of care

*This recommendation has been updated in the WHO 2018 updated recommendation on tranexamic acid for
the treatment of postpartum haemorrhage. 4

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 25

 a. The use of formal protocols by health facilities for the prevention and treatment of PPH
is recommended. (Weak recommendation, moderate-quality evidence)
b. The use of formal protocols for referral of women to a higher level of care is
recommended for health facilities. (Weak recommendation, very-low-quality evidence)
c. The use of simulations of PPH treatment is recommended for pre-service and in-service
training programmes. (Weak recommendation, very-low-quality evidence)
d. Monitoring the use of uterotonics after birth for the prevention of PPH is recommended
as a process indicator for programmatic evaluation. (Weak recommendation, very-low-
quality evidence)

Annex 3: SBAR communication and referral tool*

S Situation: a concise statement of the problem

State clearly:

 What is your grade

 Where you are calling from
 Which patient you are calling about: name and age

Why are you calling?

B Background (pertinent and brief information related to the situation)

 State the admission diagnosis and date of admission

 State any important history

Give a brief summary of the treatment to date

A Assessment (analysis and considerations of options — what you

found/think)

 State the findings of the initial assessment

 State the most recent vital signs: respiratory rate, heart/pulse
rate, B/P, temperature, oxygen saturations, AVPU (Alert,
Voice/or new confusion, Pain or Unresponsive), Blood sugar
 What is the state of the uterus?
 What is the state of the placenta?
 What is your assessment of lacerations?

R Recommendation (action requested/recommended — what you want)

State clearly what your recommendation is or what do you want?

*If referral communication is via telephone, ask the receiver to repeat key information to ensure
understanding

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 26

Annex 4: B-Lynch surgical technique for control of massive
postpartum haemorrhage

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 27

Annex 5: Modified Early Obstetric Warning score chart

FIGO Postpartum Haemorrhage Clinical Protocol and Care Pathways 28

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