Saving women’s lives: evidence-based recommendations for the prevention of postpartum haemorrhage

摘要: Failure of the uterus to contract adequately after childbirth (atonicity) is most common cause postpartum haemorrhage (PPH), leading maternal death in Africa and Asia.1 Attempts identify women at risk atonic PPH have been unsuccessful. Numerically, more without factors compared those with factors. To prevent PPH, interventions should therefore be targeted all during childbirth. Active management third stage labour has described as a package comprising following interlocking interventions: administration prophylactic uterotonic birth baby, usually also early cord clamping cutting, controlled traction.2 Other definitions this include uterine massage, but reference timing clamping.3 In contrast, expectant (also called physiological or conservative) involves waiting for signs separation allowing placenta deliver spontaneously, aided by gravity nipple stimulation.2 While there agreement on beneficial effects active prevention less consensus issues such importance intervention’s individual components, best methods requirements safe intervention under conditions limited resources. particular, choice uterotonics subject discussion debate. Injectable oxytocin recommended routine use labour;3 however, injection requires skills sterile equipment. Oxytocin may inactivated if exposed high ambient temperatures.4 misoprostol, prostaglandin analogue effects, reportedly stable than administered oral, sublingual rectal routes several studies.5 Misoprostol approved6 included national guidelines7 some countries. Suggestions made provide misoprostol tablets where not available8 non-skilled providers9 themselves PPH.10 The WHO Technical Consultation Prevention Postpartum Haemorrhage Geneva 18–20 October 2006 reviewed evidence provided answers these questions widely-accepted methodology guideline development.11 head-to-head comparisons context labour, injectable ergometrine are equally effective preventing PPH. Injectable side-effects heat light oxytocin. Oral thought ineffective.4,12 Compared oxytocin, severe additional occur significantly often oral misoprostol. This higher acquisition costs There insufficient support other routes, prostaglandins instead Therefore, drug (The complete set recommendations13 from consultation its supporting available www.who.int/making_pregnancy_safer/en) What health programme managers do recommendations? When guidelines updated informed decisions major deaths, recommendations can form basis local judgements. Additional consider cost: level, disposable syringes needles currently expensive procure dose used prevention. The increased incidence need among receiving significant programmatic implications, especially settings anaemia access emergency obstetric care limited. Concerns about oxytocin’s stability tropical environments refrigeration possibly overstate problem. relatively temperatures below 30 °C.4 Moreover, when routinely (for every parturient), rapid turnover stock will result shorter environmental exposures. Surveys show that accessible facilities lack due system failures affect any commodity.14,15 Maternal experience cold chain immunization programmes ensure environment If private enterprises keep cola drinks beer cold, even remote areas countries power supplies, same possible oxytocin. Training skilled providers competency infection-prevention practices, well childbirths. Making single-dose pack further help reduce concerns related safety. In addition, activities seek expand community awareness, response demand quality services, within review deaths morbidity act lessons learned. While alone absence components likely PPH,16 lay non-facility settings. Inappropriate powerful drugs, before childbirth, associated perinatal death. ■