AFJOG

GUIDELINES Prevention (a) After vaginal delivery: • Carbetocin (PABAL ® ) 100µg IV bolus or 10 IU oxytocin IMI • Controlled cord traction • Massage uterus (b) At CS • Carbetocin (PABAL ® ) 100µg IV bolus or 5-10 IU oxytocin IMI (c) At risk of PPH (see list in guideline): • Consider carbetocin OR oxytocin/ ergometrine infusion inaddition to above Undelivered • Repeat cord traction • Manual removal of placenta Placenta MANAGEMENT OF PPH Diagnosis of PPH ≥500 mL in the calibrated drape or tray and/ or appears excessive by clinical judgement E-MOTIVE bundle • Call for assistance and PPH box • Massage the uterus and check if bladder empty • Insert IV cannula • Carbetocin 100µg IVI infusion or oxytocin 10 IU infusion/slow IV injection • Tranexamic acid 1 1gm infusion/slow IV injection and second dose after 30 minutes • Infusion Oxytocin 20 IU in 1L Ringer's lactate at 125mL/hr • Second IV line/administer IV fluids as required for resuscitation • Examine for cause of PPH and monitor vital signs Complete Uterus Incomplete • Evacuation of uterus • Digital exploration • Ovum forceps and largest curette Soft • Massage uterus and expel clots • Continue carbetocin/oxytocin infusion • Ergometrine 2 0.5mg or syntometrine 2 1 amp IMI and Misoprostol 400 µg sublingually • Balloon tamponade Not felt • Check vaginally for inverted uterus • Replace immediately • Hydrostatic reduction: - Saline infusion into vagina - Hold vulva around tube or use rubber vacuum cup in vagina for seal Firm • Suture lacerations of perineum, vagina or cervix If ongoing bleeding: ESCALATE CARE • Repeat tranexamic acid • Examine in theatre³ • Explore for retained products and deep lacerations • Balloon tamponade or Jada suction device (to be launched soon) • Laparotomy: 4 - aortic compression - uterine brace sutures - uterine artery ligation - hysterectomy 1 Avoid if BP or cardiac 2 Avoid if VTE or artificial heart valves ➔ ³ In facilities with no theatre facility, patient will need emergency referral. To optimise condition, consider: • Balloon catheter tamponade • Non-pneumatic anti-shock garment (if available) 4 At laparotomy, apply uterine tourniquet before transfer if unable to perform hysterectomy African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 35