Practical approaches to managing postpartum haemorrhage with limited resources

Detection and management of postpartum haemorrhage: Qualitative evidence on healthcare providers' knowledge and practices in Kenya, Nigeria, and South Africa

Background

Postpartum haemorrhage (PPH) is the leading cause of maternal death globally. Most PPH deaths can be avoided with timely detection and management; however, critical challenges persist. A multi-country cluster-randomised trial (E-MOTIVE) will introduce a clinical care bundle for early detection and first-response PPH management in hospital settings. This formative qualitative study aimed to explore healthcare providers' knowledge and practices of PPH detection and management after vaginal birth, to inform design and implementation of E-MOTIVE.

Methods

Between July 2020-June 2021, semi-structured qualitative interviews were conducted with 45 maternity healthcare providers (midwives, nurses, doctors, managers) of nine hospitals in Kenya, Nigeria, and South Africa. A thematic analysis approach was used.

Results

Four key themes were identified, which varied across contexts: in-service training on emergency obstetric care; limited knowledge about PPH; current approaches to PPH detection; and current PPH management and associated challenges. PPH was recognised as an emergency but understanding of PPH varied. Early PPH detection was limited by the subjective nature of visual estimation of blood loss. Lack of expertise on PPH detection and using visual estimation can result in delays in initiation of PPH management. Shortages of trained staff and essential resources, and late inter-hospital referrals were common barriers to PPH management.

Conclusion

There are critical needs to address context-specific barriers to early and timely detection and management of PPH in hospital settings. These findings will be used to develop evidence-informed implementation strategies, such as improved in-service training, and objective measurement of blood loss, which are key components of the E-MOTIVE trial (Trial registration: ClinicalTrials.gov: NCT04341662).

Midwives' experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria

Background

Postpartum haemorrhage (PPH) is one of the major complications of childbirth which may result in maternal morbidity and mortality, especially in low and middle-income countries like Nigeria. Midwives play a vital role in preventing and managing PPH in Nigerian rural communities. The aim of this study is to understand the experiences of midwives in rural maternity care settings in order to provide appropriate support and improve practice.

Methods

An exploratory, qualitative study of a purposive sample of 15 practicing midwives was carried out using semi-structured interviews from November 2018 to February 2019. Data were transcribed verbatim and analyzed using content analysis.

Results

Four themes were identified: 1. interventions for preventing PPH; 2. approaches to managing PPH; 3. challenges of preventing and managing PPH and 4. ways of supporting midwives to overcome these challenges in rural health care settings. Midwives employed various strategies, such as antenatal education, diagnosis and treatment of anaemia to counteract complications from possible PPH. Understanding PPH as a life-threatening condition enabled the midwives to provide holistic and effective management that sometimes involved a multidisciplinary team approach. Inadequate resources and delay in seeking health care, however, militate against their efforts. The midwives also identified the need for continuing education and training to enhance their standards of care.

Conclusion

These midwives in Nigerian rural health care settings engage in preventive practices and active management of PPH though not without barriers, such as inadequate resources. There is a need for midwives in rural areas to have cultural competence, be provided with adequate resources and participate in ongoing education in order to be more effective.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04804-x.

Autotransfusion in low-resource settings: a scoping review

INTRODUCTION

Globally, haemorrhage is the leading cause of both maternal mortality and preventable trauma death. For patients suffering from haemorrhage, prompt blood transfusion can be life-saving; however, safe and sufficient blood is often lacking in low-resource settings (LRS). Autotransfusion (AT), in which the patient's own blood is collected and transfused back, is an established alternative to donor blood transfusions, although one that is primarily performed with advanced AT systems. Research on basic AT in LRS is scarce. Therefore, we aimed to consolidate all available information on the current use of basic AT in LRS and to identify AT techniques and devices described for use in such settings.

DESIGN

Scoping review.

METHODS

We systematically searched four key databases: PubMed, Web of Science, Global Health and Cochrane Library as well as several grey literature databases and databases of relevant organisations. The final search was conducted on 22 April 2019. We included all types of studies referring to any information on basic AT used or sought to be used in LRS, published in English and dated after 31 December 2008. We synthesised the data from the included studies, results were charted or summarised narratively.

RESULTS

Some 370 records were reviewed, yielding 38 included documents. We found a paucity of scientific evidence as well as contradictory information on the extent of AT use and that AT use is largely undocumented. The most commonly described indications were haemoperitoneum (primarily among obstetric patients) and haemothorax. We identified three AT techniques used in LRS. Additionally, two new devices and one filter are described for potential use in LRS.

CONCLUSIONS

Basic AT is practiced for certain obstetric and trauma indications. However, context-specific studies are needed to determine the technique's safety and effectiveness. Extent of use is difficult to assess, but our results indicate that basic AT is not a widely established practice in LRS. Future research should address the bottlenecks hampering basic AT availability. New AT devices for use in LRS are described, but their utility and cost-effectiveness remain to be assessed.

Clinical algorithms for management of third stage abnormalities

AIMS

To develop algorithms for identifying, managing and monitoring postpartum haemorrhage (PPH) and other third stage of labour abnormalities after vaginal delivery.

POPULATION

Women with low-risk singleton term pregnancies who have had a vaginal delivery.

SETTING

Hospital settings with a particular focus on healthcare facilities in low- and middle-income countries (LMICs).

SEARCH STRATEGY

Searches for international and national guidance documents, research databases (Cochrane, Medline and CINAHL) and published systematic reviews. Searches were limited to work published in English between 1 January 2008 and 31 December 2018.

CASE SCENARIOS

Four interlinked case scenarios were identified for algorithm development: (1) an approach to PPH after vaginal delivery, (2) uterine atony, (3) genital tract trauma and (4) retained placenta/placental products.

CONCLUSIONS

The development of clear approaches to the assessment, resuscitation, treatment and monitoring of the four case scenarios are presented as algorithms, based on available evidence. They need to be field tested and evaluated for effectiveness, and may be adapted for electronic decision support tools using artificial intelligence in different settings. Further research is needed around multimodal sequential packages of care for PPH, conservative surgical measures, resuscitation in LMICs, and how a respectful maternity care focus can be incorporated into the algorithms.

TWEETABLE ABSTRACT

Algorithm development for standardised approaches to managing PPH in low-resource settings.

Risk factors for postpartum haemorrhage in the Northern Province of Rwanda: A case control study

Background

Postpartum haemorrhage (PPH) remains a major global burden contributing to high maternal mortality and morbidity rates. Assessment of PPH risk factors should be undertaken during antenatal, intrapartum and postpartum periods for timely prevention of maternal morbidity and mortality associated with PPH. The aim of this study is to investigate and model risk factors for primary PPH in Rwanda.

Methods

We conducted an observational case-control study of 430 (108 cases: 322 controls) pregnant women with gestational age of 32 weeks and above who gave birth in five selected health facilities of Rwanda between January and June 2020. By visual estimation of blood loss, cases of Primary PPH were women who changed the blood-soaked vaginal pads 2 times or more within the first hour after birth, or women requiring a blood transfusion for excessive bleeding after birth. Controls were randomly selected from all deliveries without primary PPH from the same source population. Poisson regression, a generalized linear model with a log link and a Poisson distribution was used to estimate the risk ratio of factors associated with PPH.

Results

The overall prevalence of primary PPH was 25.2%. Our findings for the following risk factors were: antepartum haemorrhage (RR 3.36, 95% CI 1.80–6.26, P<0.001); multiple pregnancy (RR 1.83; 95% CI 1.11–3.01, P = 0.02) and haemoglobin level <11 gr/dL (RR 1.51, 95% CI 1.00–2.30, P = 0.05). During the intrapartum and immediate postpartum period, the main causes of primary PPH were: uterine atony (RR 6.70, 95% CI 4.78–9.38, P<0.001), retained tissues (RR 4.32, 95% CI 2.87–6.51, P<0.001); and lacerations of genital organs after birth (RR 2.14, 95% CI 1.49–3.09, P<0.001). Coagulopathy was not prevalent in primary PPH.

Conclusion

Based on our findings, uterine atony remains the foremost cause of primary PPH. As well as other established risk factors for PPH, antepartum haemorrhage and intra uterine fetal death should be included as risk factors in the development and validation of prediction models for PPH. Large scale studies are needed to investigate further potential PPH risk factors.

The WOMAN trial: clinical and contextual factors surrounding the deaths of 483 women following post-partum haemorrhage in developing countries

BACKGROUND

Post-partum haemorrhage (PPH) is a leading cause of maternal death worldwide. The WOMAN trial assessed the effects of tranexamic acid (TXA) on death and surgical morbidity in women with PPH. The trial recorded 483 maternal deaths. We report the circumstances of the women who died.

METHODS

The WOMAN trial recruited 20,060 women with a clinical diagnosis of PPH after a vaginal birth or caesarean section. We randomly allocated women to receive TXA or placebo. When a woman died, we asked participating clinicians to report the cause of death and to provide a short narrative of the events surrounding the death. We collated and edited for clarity the narrative data.

RESULTS

Case fatality rates were 3.0% in Africa and 1.7% in Asia. Nearly three quarters of deaths were within 3 h of delivery and 91% of these deaths were from bleeding. Women who delivered outside a participating hospital (12%) were three times more likely to die (OR = 3.12, 95%CI 2.55-3.81) than those who delivered in hospital. Blood was often unavailable due to shortages or because relatives could not afford to buy it. Clinicians highlighted late presentation, maternal anaemia and poor infrastructure as key contributory factors.

CONCLUSIONS

Although TXA use reduces bleeding deaths by almost one third, mortality rates similar to those in high income countries will not be achieved without tackling late presentation, maternal anaemia, availability of blood for transfusion and poor infrastructure.

Management of the third stage of labour: (for the Optimal Intrapartum Care series edited by Mercedes Bonet, Femi Oladapo and Metin Gülmezoglu)

The physiology of the third stage of labour is described. Active management reduces the risk of postpartum haemorrhage (PPH), due to the use of a uterotonic agent. Intramuscular Oxytocin 10 IU has the highest efficacy and lowest side effect profile, although ergometrine, carbetocin and misoprostol are also effective. The appropriate uterotonic in different settings such as home birth by unskilled attendants and at caesarean section is discussed. For the latter, there is less consensus on the optimal dose/route of oxytocin, this topic remaining on the research agenda. Delayed cord clamping enables transfusion of blood to the neonate and is recommended rather than early clamping. Controlled cord traction should only be performed by skilled birth attendants and confers minimal advantage in preventing retained placenta. The importance of early recognition of PPH, and preparedness, is emphasised. An approach to medical and surgical management of PPH is presented.