INSIGHT: Critical Issues in Global Nursing Part II

Maternal Mortality Part II: Innovative advances for management of postpartum hemorrhage

This is Part two of the series to create greater awareness around the problem of postpartum hemorrhage (PPH). Last week, the causes, risk factors and preventions for PPH were reviewed. This week, treatments will be examined including a breakthrough innovation designed to slow bleeding and give women additional time to reach and receive care.

In cases of PPH, it is imperative to establish its cause, stop it immediately, prevent acute blood loss, restore the volume of circulating blood and stabilize blood pressure. Detailed in Helping Mothers Survive Bleeding After Birth Provider Guide by Jhpiego, treatment for postpartum hemorrhage may include:

  • Medication (to stimulate uterine contractions)
  • Uterine massage (to stimulate contractions)
  • Removal of placental pieces that remain in the uterus
  • Bakri balloon or a Foley catheter
  • Blood transfusion
  • Surgery

It is important for nurses to be able to recognize the signs and symptoms of PPH earlier. The estimated time to death from the start of a bleeding complication is often very short – sometimes just two hours. Delays in identifying hemorrhage, reaching and receiving care can increase dangers due to bleeding.

Emerging technologies are currently being researched and implemented to prevent these unnecessary deaths. One such initiative is being led by Lwala Community Alliance (Lwala). Lwala is working with government health facilities in Kenya to improve identification of obstetric complications and has partnered with the University of California – San Francisco (UCSF) to implement a device called the nonpneumatic anti-shock garment (NASG).

The NASG is a low-cost proven device used to stabilize women suffering from severe bleeding and shock. It is a compression garment that reduces blood flow to the lower extremities while preserving blood flow to the vital organs, providing the patient up to 72 hours to be transferred to a tertiary facility where she can receive advanced care.

NASG in actionThe NASG can be used in combination with other hemorrhage treatments including: uterotonics, massage, uterine tamponade balloon (UBT), and surgeries. However, it cannot be used alone: the main value that the NASG brings to the reduction of maternal mortality is providing clinicians more time to transfer a patient to advanced care.

The NASG device has undergone clinical trials in four countries and it has been recommended to be integrated into the management of PPH by the World Health Organization (WHO) and the Kenyan Ministry of Health. Recognizing the potential of this intervention to reduce maternal mortality, the Kenyan Ministry of Health has called upon Lwala to lead the first county-wide scale-up of the NASG device. In March of 2018, Lwala piloted this intervention within fifteen facilities and has since trained more than 90 medical staff, across 15 facilities, on this low-cost intervention. They have distributed 40 NASG garments and trained 34 trainers-of-trainers (TOTs) on its application and instruction. The garment has been utilized in an average of 10 cases per month.

Evidence to date shows NASG to be an effective tool in stabilizing hemorrhaging women during delays in reaching advanced care. It is increasingly being recognized and included as a component of comprehensive programs to manage obstetric hemorrhage in a growing number of resource-challenged countries.

We welcome your feedback and encourage you to share what’s working in your setting to manage or prevent PPH. Please email us at  [email protected] to share your information. Thank you for being a part of global nursing development!

Yours in Nursing,


Lisa D. Cole, MA, RN

Director, Mary K Center for Global Nursing Development