ACOG updates guidance on postpartum hemorrhage- calls for standard, coordinated, protocol based intervention

The American College of Obstetricians and Gynecologists (ACOG) recently released expanded guidelines for management of postpartum hemorrhage (PPH)—the leading cause of maternal mortality worldwide.

PPH is defined as total blood loss of 1000 ml or more along with signs or symptoms of hypovolemia within 24 hours after the labor, but can occur up to 12 weeks postpartum. Although Maternal Mortality Rates(MMR) have decreased worldwide in last 4 decades, it still accounts for 10% of all pregnancy related mortality.

Incidence varies, but 1-5% is reasonable estimate, with uterine atony accounting for 70-80% of cases PPH.

This practice bulletin discusses the risk factors along with evaluation, prevention, and management of maternal hemorrhage.

It also calls upon all obstetricians and other obstetric care providers to formulate standard protocols for recognizing, evaluating and management of maternal hemorrhage by multidisciplinary approach and implement it in every center.

Multidisciplinary teams, including physicians, nurses and midwives, should be trained to implement key elements in four categories, including readiness to respond; recognition and prevention measures; multidisciplinary response; and data reporting and systematic learning, including drills like simulation-based training.

ACOG also has partnered with multiple organization to implement the care bundle suggested by  Alliance for Innovation on Maternal Health (AIM), which many states have are already adapted.

It also lays emphasis on identifying the patients at risk of developing PPH, prenatally, during admission and during labor. It includes patients with vaginal lacerations, retained placenta, abnormally adherent placenta with previous cesarean section. All Ob-gyn should be aware of high risk of PPH in placenta previa with previous uterine scar.

Uterotonic agents should be the first line of treatment in case of atonic PPH, choice of a specific agent is at the discretion of the provider as none is identified as superior over other. Active management of third stage of labor should be implemented.

All hospitals, especially those in rural areas should be able to escalate the efforts quickly, and have a specific plan to go to next level of treatment or quickly refer patient to a specialty hospital.

Tranexamic acid can be given when primary line of therapy fails, it is especially found effective if given within 3 hours of birth.

Surgical approach includes Intrauterine balloon tamponade, but less invasive methods should always be used first. 

All hospitals should have functioning massive transfusion protocols and ‘hemorrhage carts’, with all the necessary medication in place.

The Practice Bulletin #183, "Postpartum Hemorrhage" is published in October issue of Obstetrics and Gynecology.

ACOG press release

Patient Safety Bundles on obstetric hemorrhage.