2.  To understand the importance of prompt and appropriate management in saving lives from PPH ◦ Define PPH ◦ List the causes and risk factors for PPH ◦ Discuss the steps taken in managing PPH

3.  Bleeding >500 ml after childbirth  Pad or cloth soaked in less than 5 minutes  Constant trickling of blood OR  Delivered outside health center and still bleeding

4.  Call for extra help  Massage uterus until it is hard and give OXYTOCIN 10 units IM

5.  Place cupped palm on uterine fundus and feel for state of contraction  Massage fundus in a circular motion with cupped palm until uterus is well contracted  When well contracted, place fingers behind fundus and push down in one swift action to expel clots  Measure/estimate blood loss and record

6.  Give IV fluids with 20 units oxytocin at 60 drops per minute  Empty the bladder: catheterize if necessary  Check and record BP and pulse every 15 minutes  Establish cause of bleeding

7.  Uterine atony  Tears of the cervix, vagina, or perineum  Retained placenta  Retained placental fragments  Inverted uterus  Ruptured uterus

8.  When uterus is hard, deliver placenta by controlled cord traction  If unsuccessful and bleeding continues – perform vaginal examination (check if placenta is in the cervix). Remove placenta carefully and check if complete.  Massage uterus

9.  If unable to remove placenta – REFER urgently to hospital  During transfer, continue IV fluids with 20 units oxytocin at 30 drops/minute

10.  Check placenta  If placenta complete ◦ Massage uterus to express any clot ◦ If uterus remains soft, give OXYTOCIN 10 units IM ◦ Continue IV fluids with 20 units Oxytocin at 30 drops/min ◦ Continue uterine massage until it is hard

11.  Placenta is not complete or not available for inspection ◦ Remove placental fragments by hand. ◦ If bleeding continues after fragments removed, refer woman urgently to hospital  Placenta is complete and vaginal bleeding continuous: ◦ Check for uterine atony ◦ Check for trauma

12.  Massage the uterus until it is well contracted  Give oxytocin ◦ Initial dose: 10 IU IM/IV or 20 IU IV infusion in 1 liter saline, 60 drops per minute  Continuing Dose ◦ IM/IV repeat 10 IU after 20 minutes if heavy bleeding persists OR ◦ 10 IU IV infusion in 1000 ml of saline, 30 drops per minute.

13.  ERGOMETRINE – 1 st line treatment of uterine atony not responsive to oxytocin  Rapid onset of action (2-5 min) after IM injection  Clinical effect persists for approximately 3 hours  Initial dose: 0.2 mg IM/IV slowly  Continuing dose: 0.2 mg IM after 15 minutes if bleeding persists (up to 5 doses=1.0 mg)

14.  DO NOT GIVE IF PATIENT IS HYPERTENSIVE, or has heart disease  Monitor BP and PR  Common side effects: nausea, vomiting, dizziness  Store at temperatures below 8°C and away from light

15. Bimanual compression of uterus AORTIC COMPRESSION Point of compression is just above the umbilicus and to the left

16. If uterus contracted and still bleeding:  Look for perineal, vaginal or cervical lacerations  Determine degree and extent of tear  If 3 rd degree tear – REFER to CEMONC facility

17.  For other tears – apply pressure over tear with sterile pad or gauze and put legs together. Do not cross the ankles.  Check after 5 minutes. If bleeding persists – repair the tear.

18. Giving birth should be about giving life not giving up a life.