“AFP Vision 2028: A World-Class Armed Forces, Source of national Pride”

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Camp Colonel Victoriano K. Luna, V. Luna Avenue, Quezon City

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE

A local protocol for preventing and managing PPH is available

Adequate equipment, drugs and personnel are readily available in case
of PPH
Early recognition and initiation of measures to reduce bleeding
Active management of the 3rd stage of labour is always offered
Active management of 3rd stage is appropriately performed:
• abdomen palpated to rule out the presence of another baby within 1 minute
of birth
• oxytocin 10 U IM is given within 1 minute after birth (if not available use:
ergometrine 0.2 mg IM; Carbetocin 100 mcg IV or IM)
• controlled cord traction is performed
• cord is never pulled without pushing the uterus up with the other hand
• fundus of the uterus is checked after placenta (massaged if necessary)

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE:

EARLY RECOGNITION

H - HALT the bleeding, call for HELP, designate the HEAD of the team, HOLD
the baby

Uterine tonus is controlled after delivery (every 15 min in the first hour; at the end
of the 2nd, 3rd, 4th hour, then every 4 hours) and uterus massaged if necessary

In the delivery room and during early puerperium there are special pads or bags
to measure the blood loss

Team approach is initiated by calling for HELP - inform senior obstetrician,

midwife, anesthesiologist, and assigning a HEAD of the team.

HOLD the baby away from the mother for safety

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE:

INITIAL ASSESSMENT AND TREATMENT
A - ASSESS ABCs, ASK for the PPH Kit, ALERT the blood bank
A written procedure is in place to alert the senior obstetrician senior/ midwife/ anaesthesiologist on call
The blood bank is 24 hours available, and blood can be obtained without delay
A postpartum hemorrhage kit is organized and includes the following:
• Oxytocin (refrigerated)
• Tranexamic acid
• Carboprost
• Carbetocin
• Methergine
• Large Bore needles (gauge 16 or 18)
• Crystalloids and Colloids
• Blood sample vials
• Foley catheter
• Urine bag
• 30cc or 50cc syringe
• Sterile gloves
• Monocryl 0 or 1-0 round needle
A written protocol is readily available for initial assessment and treatment. Key elements should include:
a) insertion of one or two large bore (16 Gauge) IV line
b) crystalloid infusion started immediately (1L in 15 minutes ~3ml fluids per 1 ml blood loss)
c) oxygen administration by face mask (6-8 LPM)
d) blood pressure, pulse, oxygen saturation, and urine output checked
E - Establish the ETIOLOGY and EVALUATE amount of bleeding and need for blood

AFP Core Values: Honor, Service, Patriotism

 “AFP Vision 2028: A World-Class Armed Forces, Source of national Pride”

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER
DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
Camp Colonel Victoriano K. Luna, V. Luna Avenue, Quezon City

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE:

M - MAXIMIZE MEDICAL OPTIONS, AND O – OBSERVE RESPONSE

a. Oxytocin IV 20-40 IU in 1L normal saline, infuse 500ml over 10

minutes then 250ml per hour
b. Tranexamic acid 500-1000 mg q6 hours (1 g in 10 mL (100 mg/mL)
at 1 mL per minute (i.e., administered over 10 minutes), second dose
of 1 g IV if bleeding continues after 30 minutes)
c. Methylergonometrine 0.2 mg IM every 2-4 hours (except in patients
with hypertension and cardiac disease)
d. Carboprost 250 mcg IM q 15-20 mins, max of 8 doses (except in
patients with asthma or pulmonary disorders

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE:

REFRACTORY HEMORRHAGES AFTER MEDICAL TREATMENT

S – SHIFT to the operating theater

- Patient and/or family is counseled
- Consent must be obtained
- Anesthesiologist/Senior Obstetricians/Nurses must be informed
Source of bleeding must be addressed: Vaginal/cervical lacerations should be
repaired, retained products of conception must be evacuated, flaccid uterus
T – TRANSFUSION and TAMPONADE
- Blood transfusion should be initiated if with continued blood loss or clinical
signs of anemia/hypoxia (tachycardia, dyspnea, reduced oxygen saturation,
oliguria)
- Blood products should be counterchecked prior to transfusion
- Balloon tamponade (Bakri or modified balloon tamponade) may be done while
waiting for blood products or for the surgical team to be complete, or if patient is
for transport

PREVENTION AND MANAGEMENT OF POSTPARTUM HEMORRHAGE:

REFRACTORY HEMORRHAGES AFTER MEDICAL TREATMENT

A – Abdominal APPROACH, S – compression SUTURES, SYSTEMATIC

devascularization
- Recognition for the need for abdominal exploration and intervention is timely
- A printed diagram of B-Lynch or Hayman compression suture technique and
landmarks for systematic devascularization is easily available
- Monocryl 0 or 1-0 is kept in the PPH kit if not available in the hospital pharmacy
I – INTERVENTIONAL embolization
- Embolization of the uterine arteries can be offered and rapidly performed
S – SURGERY, SCRIBE
- Total hysterectomy is preferred to subtotal hysterectomy, although the latter
may be performed faster and be effective for bleeding due to uterine atony.
Subtotal hysterectomy may not be effective for controlling bleeding from the
lower segment, cervix, or vaginal fornices.
- All the findings and interventions are properly documented in the patient’s
records

AFP Core Values: Honor, Service, Patriotism