Introduction

Efforts such as the Safe Motherhood Initiative and the World Health Organization (WHO) Making Pregnancy Safer Division and strategies to meet the United Nations Millennium Development Goals are supporting worldwide activities to reduce maternal and newborn mortality. Despite these efforts, hundreds of thousands of women and babies die or become disabled due to complications of pregnancy and childbirth every year; half of these maternal deaths occur within 24 hours of childbirth (1).

Postpartum hemorrhage (PPH) is the leading direct cause of maternal death in developing countries and results from problems during and immediately after the third stage of labor (2). PPH is an unpredictable and rapid cause of maternal death worldwide, with two-thirds of women with PPH having no identifiable risk factors. Seventy to ninety percent of immediate PPH is attributed to uterine atony (failure of the uterus to properly contract after birth) (3, 4).

Fortunately, research shows that using simple, low-cost interventions can help avoid most of these tragic outcomes. Current evidence indicates active management of the third stage of labor (administration of uterotonic drugs, controlled cord traction, and fundal massage after delivery of the placenta) can prevent up to 60 percent of uterine atony (5) in situations where:

• National guidelines support the use of active management of the third stage of labor (AMTSL).
• Health workers receive training in using AMTSL and administering uterotonic drugs.
• Injection safety is ensured.
• Necessary resources (uterotonic drugs and cold chain for storage of uterotonic drugs; equipment, supplies, and consumables for infection prevention and injection safety) are available

Ongoing research in various settings continues to identify the best approaches for preventing and managing postpartum bleeding and its complications. By developing national guidelines, training skilled birth attendants, improving work environments of skilled providers, and supporting the development of improved access to care, more women will have access to this life-saving intervention.

About the learning materials

POPPHI developed a learning package on the prevention of postpartum hemorrhage consisting of a reference manual, participant’s notebook, and facilitator’s guide. This learning package was developed for use by nurses, midwives, and doctors providing childbirth and immediate postpartum care.  

Information about implementing AMTSL is featured in this reference manual as well as the corresponding participant’s notebook and facilitator’s guide. These documents comprise a set and should be used together. These resources are distinguished within the series by a corresponding icon located at the top of the right hand page:

Training objectives

This course is designed to be utilized for in-service training, with the overall objective of providing updates about AMTSL use to equip nurses, midwives, and clinical and health workers to carry out the following:

• Provide safe, respectful, and friendly care to women, newborns, and their families. Women and families will then be more likely to utilize the health care system with confidence because they know they will receive competent, compassionate care.  
• Follow an evidence-based protocol for safe care during active management of the third stage of labor and in the immediate postpartum, including clear guidelines on when to refer mothers with complications, ensuring timely action is taken.
• Provide greater protection from infection for their clients and themselves.
• Store uterotonics correctly to maintain their potency.

This three-day core clinical training will provide the information needed to perform AMTSL and help prevent PPH and will focus on the following core topics:

• Review of the third stage of labor and evidence for use of AMTSL.
• Causes and prevention of PPH.
• Uterotonic drugs.
• Steps in AMTSL.

Some country programs may decide to include some of the “additional topics” in their PPH prevention training course. Additional topics that may be included in country programs include:

• Infection prevention.
• Birth preparedness and complication readiness.
• Managing complications during the third stage of labor.

Participants are encouraged to apply their knowledge and skills to improving clinical services and training other providers. Ultimately, this training will help improve the quality of care for women—mothers, wives, and vital members of the community—and help them stay healthy.

How to use the learning materials

Reference Manual, Participant’s Notebook,

Facilitator’s Guide, and Slides