Management Of Postpartum Hemorrhage Research Articles

After the Unexpected: Ontario Midwifery Clients’ Experiences of Postpartum Hemorrhage

Background: The incidence of postpartum hemorrhage (PPH) varies worldwide. While there is abundant research to guide midwifery practice regarding the acute clinical management of PPH, there is less known about the psychological needs of clients and families following significant blood loss during birth, and no relevant research conducted in a Canadian setting. Methods: Analysis of qualitative data was conducted based on data from two focus groups and two online surveys with participants who had received midwifery care during at least one pregnancy and had experienced at least one PPH. Objective: The goal of this research was to describe the experiences of midwifery clients in Ontario who had suffered a PPH and to compare those findings to what is documented in existing literature. Findings: This study found a range of physical and emotional responses to the experience of PPH, ranging from no effect to short- or longer-term psychological trauma, which is consistent with a small but growing body of international studies. While the risk of delayed lactogenesis increases with PPH, most participants in this study reported no breastfeeding concerns. This study is unique in reporting on creative strategies families developed to cope with PPH. This article has been peer reviewed.

Evaluating the Quality of Postpartum Hemorrhage Nursing Care Plans Generated by Artificial Intelligence Models.

With the rapidly advancing technological landscape of health care, evaluating the potential use of artificial intelligence (AI) models to prepare nursing care plans is of great importance. The purpose of this study was to evaluate the quality of nursing care plans created by AI for the management of postpartum hemorrhage (PPH). This cross-sectional exploratory study involved creating a scenario for an imaginary patient with PPH. Information was put into 3 AI platforms (GPT-4, LaMDA, Med-PaLM) on consecutive days without prior conversation. Care plans were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. Med-PaLM exhibited superior quality in developing the care plan compared with LaMDA ( Z = 4.354; P = .000) and GPT-4 ( Z = 3.126; P = .029). Our findings suggest that despite the strong performance of Med-PaLM, AI, in its current state, is unsuitable for use with real patients.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

ObjectiveThere are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international...

Postpartum hemorrhage prevention and management in women in an inpatient postpartum unit: a best practice implementation project.

Ninety percent of maternal deaths are attributed to postpartum hemorrhage, with 50% being preventable. Annually, University of Mississippi Medical Center staff have more than 20,000 obstetrical encounters and deliver thousands of infants, with ∼75% being high-risk. The mother/baby unit, 3 Wiser, experienced two postpartum hemorrhages in August 2022. Post-event debriefings revealed opportunities for improvement. This project aimed to promote evidence-based practices regarding the prevention and management of postpartum hemorrhage in 3 Wiser. The project was guided by the JBI Model of Evidence-Based Healthcare and used the JBI Practical Application of Clinical Evidence System together with the Getting Research into Practice audit and feedback strategy. Four evidence-based practices were selected as audit criteria. After baseline audits were conducted, strategies to improve compliance with evidence-based practices were implemented. Finally, a follow-up audit was conducted, and the results of both audits were compared. The baseline audits revealed 84% average compliance with the four evidence-based practices. Strategies to improve compliance included a simulation for nursing staff with a review of postpartum hemorrhage policies and skills. The post-implementation audit revealed 98% average compliance with the four evidence-based practices, a 14% increase from the baseline audit. This evidence implementation project utilized a clinical audit process, which led to improvements in practice related to the prevention and management of postpartum hemorrhage in the inpatient postpartum unit.

Rotational thromboelastometry for the transfusion management of postpartum hemorrhage

Rotational thromboelastometry for the transfusion management of postpartum hemorrhage

Uterine balloon volume shifts using a free-flow uterine balloon in the management of refractory postpartum haemorrhage.

Background. Uterine balloon tamponade (UBT) is used as part of the post partum haemorrhage (PPH) algorithm for the treatment of PPH. Objectives. The free-flow Ellavi uterine balloon controls the pressure in the uterine balloon by adjusting the height of the supply bag above the patient and allows for expulsion of water from the balloon. The study quantified the volume shifts in the supply bag and assessed the optimal use of the Ellavi UBT by reducing the intrauterine pressure at regular intervals. Methods. A prospective descriptive study of consecutive patients with refractory PPH was conducted. For group A, the supply bag was weighed every 30 minutes with a sensitive digital scale. Additionally, for group B the supply bag was lowered by 50% and the uterus gently massaged for 30 seconds.Results. Thirteen patients were included in the study. The mean volume was 23.5 mL for Group A and 132.7 mL for Group B. The difference in the means of groups A and B was borderline significant (p=0.06). Conclusion. The study did find volume shifts in the free-flow system, which may be enhanced by lowering the supply bag halfway at regular intervals.

Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage – A single-center retrospective cohort study

IntroductionRed blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved. ObjectiveTo determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries. Study designMonocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL). ResultsOver the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion”. After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27–9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69–24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80–9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57–15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05–12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions. ConclusionsIn a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.

Use of Fibrinogen in Prevention and Management of Postpartum Haemorrhage in High Risk Patient

Use of Fibrinogen in Prevention and Management of Postpartum Haemorrhage in High Risk Patient

How to choose and apply a uterine compression suture for the management of postpartum hemorrhage?

SynopsisB‐Lynch 1 uterine compression suture is useful for bleeding from the uterine body and “B‐Lynch 2” (transverse B‐Lynch) for bleeding from the lower uterine segment.

Maternal mortality review in a major tertiary referral hospital in Liberia, 2018–2021

ObjectivesAnecdotal evidence showed increased maternal deaths at the major tertiary hospital over the past two years (2020–2021). We reviewed the maternal death audit data, identified the main causes of maternal death, and associated risk factors. Findings were shared with policymakers to help reduce maternal mortality. Study designWe conducted a secondary data review and descriptive analysis of maternal death at the tertiary hospital located in Monrovia. MethodThe maternal death data were extracted from patient medical records, including death certificates and maternal audit records. The record of live births was obtained from the delivery register. Data were analyzed using Epi Info version 7.2 Maternal mortality ratio (MMR) was estimated, the leading direct and indirect causes of maternal death were identified, and the factors associated with maternal death were explored using logistic regression at a 5% level of significance. ResultsThere are a total of 233 maternal deaths and 14, 879 live births giving a maternal mortality ratio (MMR) of 1565 per 100,000 live births during the period under review. The median age of the mothers at death was 29 (14–45) years. About 40.3% (94/233) of cases died within <1 day of admission, referrals accounted for 59% (137/233) of the cases. Direct causes of death accounted for 66% (147/223). Hemorrhage [30.6% (45/147)], Eclampsia [(30/147) 20.6%] and Sepsis [(30/147) 20.6%] were the main direct causes of death while cardiovascular-related [18.4% (14/76)] and HIV/AIDS [16% (12/76)] were the leading indirect cause of death. Patients from referred other facilities were 7.9 times more likely to die as compared to non-referral (pOR:7.9, 95%CI: 5.9–10.6, p < 0.001). ConclusionThe maternal mortality ratio remained high. Referrals were done late. The Liberia Ministry of Health should equip more secondary-level health facilities and tertiary hospitals to handle maternal emergencies and sensitize the populace and healthcare workers on prompt identification and referral of obstetric emergencies. The MoH also needs to improve the blood transfusion services to help in the management of postpartum hemorrhage.

Reducing trainee mistakes. Better performance with changing to a high-fidelity simulation system?

Postpartum hemorrhage is a significant cause of both maternal morbidity and mortality worldwide and is increasing in incidence. This study aimed to assess improvement and identify shortcomings in trainee performance in different simulation systems in the management of postpartum hemorrhage. To perform a pilot study evaluating and comparing high- and low-fidelity simulation models, assessing improvement in repeated performance with high-fidelity mode and identifying mistakes made assessed using Objective Structured Assessment of Technical Skills and thereby exploring what aspects of emergency management of postpartum hemorrhage should be prioritized in teaching settings and assessing what simulation setup is most effective in achieving competence. This was a prospective randomized, single-blinded, single-institution trial in a population of 17 junior obstetrical trainees at the Charité University Hospital Obstetric Simulation Center in Berlin. Trainees were randomized into 2 groups, with either initial low-fidelity simulation or high-fidelity simulation, followed by repeated assessment of performance, using the high-fidelity model simulation system. Individual simulation sessions were video-recorded and transcribed, and the timing of interventions was documented. Strandardized Objective Structured Assessment of Technical Skills forms were used as a checklist for performance. There was a statistically significant general improvement in performance (P=.02; 24.7-27.2 of 31.0 points; average of 8.7%) in the second cycle of simulation assessment and a statistically significant training effect (P=.043; 24.4-28.4 of 31.0 points; average of 12.9%) in the group that underwent repeat simulation assessment from the initial low-fidelity system to the high-fidelity system compared with the group using the same high-fidelity setup (P=.276; 25.0-25.8 of 31.0; average of 2.4%). There was an improvement in the performance when trainees underwent a repeated cycle of simulation assessment changing from a low-fidelity system to a high-fidelity system. Simulation assessment can identify mistakes and learning gaps that are important for obstetrical trainees. This study found that trainees make the same mistakes, regardless of which simulation model was initially used.

Role of intensive care in management of post-partum hemorrhage (PPH)

The management of obstetric emergencies is a challenge and in most hospital setting the management in intensive care is ill-defined. A multidisciplinary approach to the management of obstetric emergency helps to give favorable outcome. In low resource setting, maternal care can be challenging as it faces lack of infrastructure facilities, specialist trained in intensive care, availability of drugs and equipment. Though early intervention is the need of hour there are delays in seeking healthcare due to lack of awareness, financial constraints, culture and beliefs. This article describes the approach to management of PPH in intensive care, defining clear transition from labor care to intensive care should occur.

Perception of health care providers on the quality of oxytocin across six E-MOTIVE Trial sites in Kenya

Background: According to the WHO, in 2020, almost 800 women died daily from preventable causes related to pregnancy and childbirth. An estimated 95% of these deaths were in low- and middle-income countries (LMICs). Postpartum hemorrhage (PPH), excessive bleeding after childbirth, is a leading cause of maternal death globally. Of the estimated 95% of maternal deaths in LMIC, an unacceptable 95% were due to PPH. A significant barrier to women receiving PPH treatment is access to quality PPH medicines, which is the basis for reducing maternal mortality. The E-MOTIVE Trial Kenyan hub conducted an online survey on September after the E-MOTIVE trial findings were released. This survey assessed the perception of health care providers’ (HCPs) of the quality of oxytocin in Augmentation of Labour, Active Management of third Third Stage of Labor (AMSTL), including PPH management. Methods: An online survey was conducted using the Survey Monkey platform in Gatundu level 4 hospital, Makindu subcounty hospital, and Vihiga, Embu, Nyeri, and Kakamega county referral hospitals. The survey targeted HCPs working within the respective maternity units. The results were analyzed in Excel. Results: 56 HCPs across the 6 health facilities participated in the survey. On augmentation of labor, Oxymed Medisel and Oxytocin Umedical were perceived to be more effective, while a score of 100% with Curtocin and Oxyt Kilitch were perceived to be very ineffective. On AMSTL, Oxymed Medisel, Syntocinin Norvatis, and Oxytocin Laborate were perceived to be very effective, whereas Curtocin and Oxyt Kilitch were perceived to be very ineffective. On PPH management, Oxytocin Umedical, Syntocinon Norvatis, and Oxytocin Laborate were perceived to be very effective, whereas Curtocin and Oxyt Kilitch were perceived to be very ineffective. Oxytocin Laborate was available across the health facilities, with other brands lacking in some facilities. Conclusion: Access to and availability of quality PPH medicines are key to effectively managing PPH and reducing maternal mortality.

HAYMAN COMPRESSION SUTURES : AN UNDERUTILIZED TOOL FOR MANAGEMENT OF UTERINE ATONY AND POSTPARTUM HAEMORRHAGE.

Background: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in low- andmiddle-income countries. Uterine atony accounts for 70–80% of PPH cases. Management of PPH isusually based on a cascade beginning with the use of uterotonics and eventually hysterectomy in casesof refractory PPH. Different compression suture techniques have been described and used for themanagement of uterine atony where medical management is insufficient and preservation of fertility isdesired.Case presentation: This is a series of four patients who presented to our facility and consequentlydeveloped uterine atony that was unresponsive to medical management during cesarean delivery despitethe use of multiple uterotonics. All four patients had established risk factors for uterine atony, includinginduction of labor, augmentation of labor, chorioamnionitis, or fetal macrosomia. Hayman compressionsutures were performed in all four patients with success. Estimated blood loss in the series ranged from400 to 1200 mls. All patients recovered well with no complications reported during the postpartum period.Conclusion: Hayman compression sutures offer an alternative to the more ubiquitous B-Lynch suturewith several advantages, including ease of placement and no need for a hysterotomy in PPH post vaginalbirth or placement post repair of hysterotomy in cesarean cases. Thus, the may be easier to perform forjunior health care professionals as well as in stressful situations.

Clinical Prediction of Retained Products of Conception: Combining Obstetric History and Ultrasound for Improved Accuracy in Severe Postpartum Hemorrhage.

Background The current challenge is how to improve the management of postpartum hemorrhage (PPH) to reduce the maternal mortality rate further. This study aimed to investigate whether a combined specific obstetric history and ultrasonographic findings can improve the predictive accuracy of retained products of conception (RPOC) with severe PPH. Methods This retrospective study included 56 patients who were diagnosed with RPOC. We extracted the following clinical data: obstetric history of second-trimester miscarriage, the time at which there was clinical suspicion of RPOC after the previous pregnancy (TIME), grayscale ultrasonographic finding (RPOC long-axis length [SIZE]), and color Doppler ultrasonographic finding based on the Gutenberg classification (RPOC hypervascularity). In this study, we defined cases requiring blood transfusion therapy or transcatheter arterial embolization as severe PPH. The patients were divided into two groups according to the presence or absence of severe PPH. The predictors of severe PPH were evaluated using logistic regression models. Model A comprised a combination of second-trimester miscarriage and TIME, Model B comprised a combination of Model A and long-axis SIZE, and Model C comprised a combination of Model B and RPOC hypervascularity. Results The multivariable analysis showed that long-axis SIZE was the only significant predictor of severe PPH (odds ratio [OR], 10.38; 95% confidence interval [CI], 2.06-63.86) independent of second-trimester miscarriage, TIME, and RPOC hypervascularity. The c-statistic was higher in Model C (OR, 0.863; 95% CI, 0.731-0.936) than in Model A (OR, 0.723; 95% CI, 0.551-0.847) and Model B (OR, 0.834; 95% CI, 0.677-0.923). Conclusion Combining a specific obstetric history (second-trimester miscarriage and TIME) and ultrasonographic findings (long-axis SIZE and RPOC hypervascularity) improves the predictive accuracy of RPOC with severe PPH. This prediction model may be a useful clinical screening tool for RPOC with severe PPH.

Comparing visual estimation and hematocrit change in the assessment of blood loss among women undergoing cesarean delivery in a tertiary facility in northern Uganda.

Cesarean section poses a fourfold risk for postpartum hemorrhage (PPH), necessitating accurate blood loss estimation to enable timely interventions. However, the conventional visual estimation method often leads to underestimation, resulting in undiagnosed PPH even in our setting, Uganda. Yet, the quantitative standard techniques remain underutilized. We compared visual and calculated blood loss among women undergoing cesarean delivery at Gulu Regional Referral Hospital in northern Uganda. We employed a cross-sectional study design. We enrolled pregnant women scheduled for cesarean section and determined both calculated and visually estimated blood loss. Data analysis involved using Pearson's moment correlation coefficient to compare the two methods and logistic regression to determine the factors associated with PPH. We included 105 participants, most were primigravida (n = 100, 43%), aged 15-24 years (n = 100, 52%), with term gestation (n = 100, 75%). The mean visual estimated blood loss (vEBL) was 235.3 ± 123.7 ml (interquartile range (IQR) 50-600 ml), while the calculated estimated blood loss (cEBL) was 435.0 ± 1328.2 ml (IQR -11,182.1-2226.7 ml). Visual estimation underestimated blood loss in 90% of cases (n = 100), and 21% (n = 21) had undiagnosed PPH (>1000 ml blood loss). None of the respondents had PPH (>1000 ml blood loss) following vEBL. There was a small positive correlation between both methods (vEBL and cEBL; r = 0.1165; p = 0.2482). Women aged >35 years were 1.60 times more likely to experience PPH than their counterparts aged 25-34 years (adjusted odds ratio (AOR): 1.60; 95% CI: 1.11-2.30, p < 0.011). Chorioamnionitis increased the risk of PPH by 2.2 times (AOR: 2.20; 95% CI: 1.20-4.05, p < 0.012). The visual estimation technique significantly underestimated blood loss in up to 90% of cases, particularly during emergency cesarean sections. Among the 21% of cases diagnosed with PPH based on calculated blood loss, advanced maternal age and chorioamnionitis were notable contributing factors. Routine hemoglobin and hematocrit testing in obstetric care can be effectively utilized to objectively assess blood loss, aiding in the accurate diagnosis and management of PPH. Implementing these measures, even in resource-constrained settings, can significantly reduce the morbidity and mortality associated with PPH. Not applicable.

Uterotonic Management of Postpartum Hemorrhage in Pregnancies Affected by Intra-amniotic Infection

Uterotonic Management of Postpartum Hemorrhage in Pregnancies Affected by Intra-amniotic Infection

A Multilobulated Intramural Fibroid in Pregnancy: A Clinical Case Report

Leiomyoma is the most common benign tumor of the female reproductive tract. It is prevalent among women in the age group 30 to 50 years. Other than placental estrogens and progesterone, a range of endocrine and paracrine factors have their impact on fibroid blood supply, growth rate, and risk of degeneration during the gestational and puerperal periods. The current case report is about a 30-year-old primigravida with pregnancy and a large fibroid presenting with complications such as malpresentation and pressure symptoms, ending up in a cesarean section at 36 weeks delivering a live baby with a birth weight of 2.5 kgs and a large fibroid weighing 6.4 kg. During the pregnancy, there was adequate fetal development, without major maternal complications. There were four crucial issues: tailored pregnancy surveillance, the decision of time and route of delivery, postpartum hemorrhage management, the decision to perform an interval myomectomy, and the management of decreasing blood loss perioperatively.

Uterine Balloon Tamponade: An Effective Tool for Managing Postpartum Haemorrhage

This article explores the crucial subject of Uterine Balloon Tamponade (UBT) as a very efficient method for controlling postpartum haemorrhage (PPH). Maternal mortality continues to be a pressing issue in global health, with postpartum haemorrhage playing a prominent role in this troubling pattern. This study investigates the versatile operational processes of UBT devices, with a particular focus on their capacity to stimulate uterine receptors, initiate contractions, and exert hydrostatic pressure to halt bleeding sinuses. The research highlights the crucial importance of healthcare workers, namely nurses, in promptly identifying and skillfully implementing UBT to achieve hemostasis. This resource offers a comprehensive examination of the many factors that contribute to postpartum haemorrhage (PPH), including uterine atony and retained placental fragments. It emphasises the need of implementing focused therapies to address these causes. The article highlights the worldwide inequalities in maternal healthcare and proposes comprehensive measures to tackle shortcomings in healthcare facilities, improve accessibility, and invest in highly qualified healthcare professionals. Evidence-based procedures, including UBT, are promoted for wider application, needing intensive instructional programs for healthcare practitioners. It is recommended that policymakers give high importance to maternal health on the international agenda, promoting cooperation across different fields of study and involving the community. In conclusion, the abstract highlights the need of taking proactive steps and working together to include UBT as a primary intervention in the management of PPH, with the main objective of decreasing global maternal death rates.

Efficacy of Bakri Intrauterine Balloon in Managing Postpartum Hemorrhage: A Comparative Analysis of Vaginal and Cesarean Deliveries with Placenta Accreta Spectrum Disorders.

BACKGROUND The incidence of placenta accreta spectrum disorder (PAS) has been increasing in past decades, and women with PAS are a high-risk maternal population. This study aimed to explore the performance of Bakri intrauterine balloon tamponade (IUBT) in the treatment of postpartum hemorrhage (PPH), among those with and without PAS. MATERIAL AND METHODS The outcomes of 198 women who underwent treatment for PPH using IUBT were retrospectively analyzed. The demographics and maternal outcomes were analyzed for vaginal and cesarean births, with PAS and without PAS. RESULTS Compared to women with vaginal births (n=130), women who underwent cesarean births (n=68) showed a higher proportion of age ≥35 years (χ²=6.85, P=0.013), multiple births (χ²=13.60, P<0.001), preeclampsia (χ²=9.81, P=0.002), use of transabdominal IUBT (χ²=84.12, P<0.001) and pre-IUBT interventions (χ²=41.61, P<0.001), but had less infused volume of physiological saline (t=6.41, P<0.001). Women with PAS (n=105) showed a higher rate of pre-IUBT intervention (χ²=4.96, P=0.029) and transabdominal IUBT placement (χ²=9.37, P=0.002) than non-PAS women (n=93). The 36 women with PAS (n=36) showed a higher rate of preeclampsia (χ²=4.80, P=0.029), pre-IUBT intervention (χ²=5.90, P=0.015), and transabdominal IUBT placement (χ²=14.94, P<0.001) and a shorter duration from delivery to Bakri insertion (χ²=3.31, P=0.002), than non-PAS women (n=32). CONCLUSIONS PAS was a major cause of PPH at 198 vaginal and cesarean births. An accurate and timely pre-IUBT intervention and Bakri IUBT placement was critical for controlling PPH in cesarean births, especially in women with PAS.