6.3  Intervention in complications after applying AMTSL

6.3.1  Excessive bleeding (postpartum haemorrhage or PPH)

You will learn the definition of excessive bleeding and the actions to take if the woman has postpartum haemorrhage (PPH) in Study Session 11 of this Module; it also describes the interventions you can take during and after the third stage of labour to reduce the risk of PPH. The main points are summarised briefly here.

• Rubbing the uterus and (if you have been trained to do it) using the two-handed pressure method (Study Session 11).
• Giving a second dose of oxytocin 10 IU by intramuscular injection, or a second dose of misoprostol 400 µg rectally (by pushing the tablets gently into the rectum through the woman's anus), or by putting the tablets under her tongue where they can slowly dissolve.
• Initiating breastfeeding immediately after delivery: the contractions that expel the milk will also make the uterus contract.

Remember not to exceed 1,000 µg of misoprostol (5 tablets). If the woman has already taken 600 µg (3 tablets) after the birth of the baby, and she needs a second dose because of excessive bleeding, it should be no more than 400 µg (2 tablets) via the rectum. This way, the woman will have fewer side-effects. If she did not take 600 µg of oral misoprostol after the birth of the baby and has signs of excessive bleeding, give her 1,000 µg of misoprostol via the rectum in one dose.

If the bleeding does not stop quickly after the second dose of misoprostol, then refer the woman to the nearest health facility urgently. Sometimes, bleeding comes from a torn vagina, a torn cervix, or a torn uterus. Usually this bleeding comes in a constant, slow trickle. The blood is usually bright red and thin. Actions to take while waiting for transport:

• Lie the mother down with her feet higher than her head and her head turned sideways; keep her warm with blankets.
• Secure an intravenous (IV) line and begin fluid infusion with Normal Saline or Ringer’s Lactate solution. (You learned how to do this in Study Session 22 of the Antenatal Care Module and your practical skills training.) You may be trained to add a further dose of oxytocin to the fluids in the IV bag, but this is only possible if you can keep the drug refrigerated until needed.
• Keep the area of the vulva and perineum clean.
• Arrange to accompany the mother to the hospital if at all possible.
• Also ask family members or friends to go with the mother and look after the baby (and to be possible blood donors).