ACOG Expands Recommendations to Treat Postpartum Hemorrhage

The American College of Obstetricians and Gynecologists (ACOG) today released expanded guidance on postpartum hemorrhage—the leading cause of maternal mortality worldwide—to include recommendations for standard, hospital-wide protocols, as well as potential treatments.

While maternal mortality rates due to postpartum hemorrhage have decreased in the last four decades it still accounts for more than 10 percent of pregnancy-related deaths. Postpartum hemorrhage is excessive bleeding (1,000 mL or greater) within the first 24 hours after birth but can occur up to 12 weeks postpartum. While there can be several causes, uterine atony, or when the uterus fails to contract after delivery, accounts for 70-80 percent of cases and should usually be considered first.

ACOG recommends that all hospitals put organized, systematic processes in place to help coordinate the response and management of postpartum hemorrhage. In an effort to reduce rates of maternal mortality and morbidity nationwide, ACOG partners with 24 organizations to implement the Alliance for Innovation on Maternal Health (AIM), which includes the implementation of consistent maternity care practices for several conditions including obstetric hemorrhage. Today, 13 states and three health networks, representing 1.5 million births, are active participants.

"The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail," said Aaron Caughey, M.D., Ph.D., one of the authors of the updated Practice Bulletin and professor and chair of Obstetrics and Gynecology at Oregon Health & Science University.

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.

"By implementing standard protocols, we can improve outcomes," Caughey said. "And this is even more critical for rural hospitals that often do not have the ability to treat a woman who may need a massive blood transfusion. They need to have a response plan in place for these obstetric emergencies, which includes triage and transferring patients to higher-level facilities, if necessary."

Risk assessment tools can help identify whether a woman is likely to experience excessive bleeding, and includes factors such as lacerations, retained placenta and abnormally adherent placenta, known as placenta accreta. With regard to the latter, an ob-gyn should have high suspicion for this condition, particularly in the presence of placenta previa and a prior cesarean delivery.

In an effort to reduce the incidence of postpartum hemorrhage, there are three components for active management of the third stage of labor: oxytocin administration, uterine massage and umbilical cord traction. Uterotonics, agents used to contract the uterus, should be the first-line treatment for postpartum hemorrhage caused by uterine atony, although the specific agent is up to the provider's discretion.

Other medical and surgical approaches to treat postpartum hemorrhage include intrauterine balloons and tranexamic acid. Tranexamic acid, which prevents blood clots from breaking down, can be administered when initial therapies fail and has been shown to reduce mortality when given within three hours of birth.

"Less invasive methods should always be used first," said Caughey. "If those methods fail, then more aggressive interventions must be considered to preserve the life of the mother."