Table 5 ‘Key discussion points’ and the consensus reached during the PPH guideline development process

1

Should the threshold for PPH be blood loss of 500mL (WHO) or 1000mL (Netherlands)?

Blood loss after vaginal delivery is often underestimated. Therefore, blood loss of 500mL will be considered PPH.

2

How should the blood loss be measured, by a measuring cup, by weight or estimation)

Blood loss needs to be measured by measuring cup or by weight (minus the pad). To be precise, it is advised to exchange the pads just after childbirth to subtract the amniotic fluid loss.

3

Should oxytocin prevention after childbirth always be available and given, including in rural areas?

The cost-efficacy was discussed and health care workers of the interior (n=12) and the different stake holders agreed that oxytocin should be made available in the interior. Misoprostol use in the interior is avoided as much as possible to avoid unsafe abortion.

4

Can the oxytocin-infusion used for uterine stimulation be used as preventive measure for PPH or is an extra bolus of oxytocin needed?

A calculation of the blood oxytocin concentration after bolus or infusion revealed that an extra (intravenous or intramuscular) 5-10 units of oxytocin bolus is necessary for adequate prevention op PPH based on international recommendation [31, 32, 33].

5

Which health care providers should be permitted to perform controlled cord traction?

Midwives should all be competent in performing controlled cord traction. If they do not feel competent to do so, they should be trained by more experienced personnel.

6

Misoprostol is frequently used in PPH in Suriname, what is the additional value on top of adequate oxytocin infusion?

If oxytocin is adequately administered (an extra shot of 5 units plus continuous infusion of 10 units in maximum four hours), misoprostol has no additional value [32]. If oxytocin is not available, or the uterus does not contract sufficiently, misoprostol can be given.

7

What should the oxytocin regimen be in caesarean section?

Oxytocin 5 units slowly intravenously, followed by an infusion (10 units in four hours) is advised in all caesarean sections [33].

8

In severe PPH should crystalloids or colloids be used?

International recommendations show no better outcome when using colloids [34]. Colloids are more expensive, adverse effects have been reported and there is no decrease in the risk of respiratory problems due to pulmonary oedema [35]. The preference is to use crystalloids.

9

What is the ideal ratio for the transfusion of packed cells, fresh frozen plasma and platelets?

Ratio 1 : 1 : 0. For every packed cell also fresh frozen plasma. In acute severe blood loss it is advised to initiate the fresh frozen plasma transfusion, as it is generally available more rapidly than packed cells. Platelet transfusion is given on indication (coagulopathy).

10

Should a parthograph always be used?

The partograph is an important tool to assess the progress of labour. Induction or slow progress of labour and oxytocin-stimulation are merely a few examples of PPH risk factors.

11

When is tranexamic acid recommended and what is the risk for a subsequent thrombo-embolism?

Tranexamic acid (1 gram in 10 minutes) is recommended in cases of > 1000 mL blood loss. In on going blood loss, it is advised to repeat this after 30 minutes [36]. It should not be administered to women with a contra-indication for antifibrinolytic therapy (e.g. thrombosis in pregnancy). The results of the WOMAN trial are to be published.

12

What are more affordable options for an intra-uterine tamponade balloon such as the Rush or Bakri?

Intra-uterine balloon can be made with condoms and a urinary catheter. Recommendations were to insert a large vaginal tampon after the balloon insertion to prevent displacement.

13

How often should vital signs be monitored after severe PPH?

Every 5 to 10 minutes during blood loss. After PPH vitals should be recorded after 30 minutes, one hour, 2 hours, 4 hours and 8 hours.