Clinical and Community Action to Address Postpartum Hemorrhage

ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR (AMTSL)

STEP 2: CONTROLLED CORD TRACTION STEP 3: MASSAGE THE UTERUS

Remember to review all ANC records for number of babies and overall maternal health

STEP 1: ADMINISTER UTEROTONIC WITHIN 1 MINUTE OF DELIVERY OF THE BABY

Prepare Oxytocics (Oxytocin, Ergometine or Misoprostol) during second stage of labor Clamp and cut the cord

Wait until pulsation of cord stops

Immediately massage fundus of uterus until it contracts

Deliver baby Re-clamp cord close to the perineum

If membranes tear, gently examine cervix, remove any pieces of membrane missing

Rule out presence of additional babies

Confirm the uterus is contracted

Ensure none of the placenta is missing, if retained placental fragments are suspected, take appropriate action

Keep slight tension on cord close to the perineum Palpate for contracted uterus every 15 minutes, keep bladder empty, Repeat uterine massage if uterus is soft during first 2 hours With a contraction, stabilize uterus using counterpressure by pushing uterus upwards & backwards from just above the pubic symphysis (pubic bone), while gently pulling downwards on the cord; encourage mother to push

Give uterotonic Choice 1 -- Oxytocin (20IU) Choice 2 -- Ergometrine (0.2 mg) if no heart disease or elevated blood pressure Choice 3 Misoprostol (600g), if other uterotonics are contraindicated or unavailable

Teach mother and family to massage the uterus

Put baby to breast (if mother plans to breastfeed)

TAKE NOTE: If placenta does not descend during 30 40 seconds of controlled cord traction, STOP TRACTION

Gently hold cord and await next contraction. Repeat controlled cord traction

As placenta delivers, hold in two hands and gently turn so membranes are twisted on themselves until they slowly deliver