Management Of Postpartum Hemorrhage Research Articles

Low-Cost, Durable Sheepskin Uterine Model for Obstetric Hemorrhage Emergency Simulation.

Postpartum hemorrhage is a common obstetrical emergency. Because the majority of cases respond to conservative medical therapies, trainees have limited clinical experience with hemostatic sutures or placement of a Bakri intrauterine balloon for refractory postpartum hemorrhage. Simulations provide an invaluable adjunct to resident education to learn and practice these hemostatic techniques. We aimed to create a low-cost, reproducible simulation model to prepare residents for uterine atony interventions such as B-Lynch, Bakri balloon placement, and uterine artery ligation. Using low-cost supplies, a reusable, life-sized recent postpartum uterus was constructed from pieces of sheepskin and sewn together with various expired suture. The sheepskin material allowed for repeated, secure placement of B-Lynch and O'Leary sutures and Bakri balloons, as well as offering the required compressibility to simulate a boggy uterus. Finally, sections of a red robin catheter were incorporated along the lateral lower borders of the model to simulate blood vessels for practicing uterine artery ligations. The model was used about 50 times over the span of 3 years to practice uterine hemostatic suturing. Residents found this model lifelike, accurate in size, and multifunctional for practicing these various techniques. The sheepskin material proved to be very resistant to repeated suturing, and also provided strong suture pull through strength. The durability of the sheepskin material demonstrates that this model can be used for repeated simulations or individual practice. The sheepskin uterus model provides trainees a realistic, low-cost, reproducible, simulation of a hypotonic uterus and allows for multiple modalities for managing postpartum hemorrhage. · We provide instructions for the creation of a sheepskin model for obstetric hemorrhage simulation.. · We demonstrate use of the sheepskin model in various obstetric hemorrhage management techniques.. · We demonstrate that the model is durable and lifelike based off of resident feedback..

Carbetocin vs oxytocin in third stage labour: a quantitative review of low- and middle-income countries

Background/Aims Postpartum haemorrhage is a global concern and is a leading cause of maternal mortality in low- and middle-income countries. Oxytocin is the preferred prophylactic uterotonic; however, it is heat sensitive and therefore may not be suitable in low- and middle-income countries, which are often warm climates. An alternative is carbetocin, which is heat stable and longer acting. Methods Literature was sourced from the EBSCO, CINAHL, Medline and Global Health databases. Studies written in English in the last 10 years, that compared carbetocin to oxytocin in management of postpartum haemorrhage were selected. An ABCDFIX mnemonic tool was used to individually critique each study. Results The key themes were postpartum haemorrhage over 500ml, postpartum haemorrhage over 1000ml, need for blood transfusion, retained placenta, haemoglobin levels and need for additional uterotonics. The use of carbetocin may reduce the risk of postpartum haemorrhage and the need for additional uterotonics in low- and middle-income countries. Conclusions The use of carbetocin, instead of oxytocin, in low- and middle-income countries may reduce the risk of postpartum haemorrhage after vaginal birth and the need for more uterotonics. However, more research is needed in these settings.

Effiacy of nausicaa compression sutures in terms of PPH management

ABSTRACT;
 BACKGROUND:Postpartum haemorrhage(PPH) is the most importantr cause of maternal death in Pakistan.Over 125,000 maternal deaths have been reported each year due to PPH. Major causes of PPH include uterine atony and haemorrhage from the placental bed. There is a recent increase in the rate of cesarean section which has increased the incidence of Placenta previa as well as placenta accreta spectrum. Apart from medical management, there are various conservative surgical interventions before imparting to hysterectomy such as uterine compression sutures which effectively secure hemostasis. The Nausicaa compression suture has been a new technique which effectively controls PPH in patients with uterine atony, placenta previa and accrete spectrum.
 OBJECTIVE: The objective of this study is to determine the efficacy of Nausicaa compression sutures in patientswith PPH undergoing cesarean section.
 PATIENTS AND METHOD: This study was conducted in the Obstetrics and Gynaecology department of Sir Ganga Ram Hospital,Lahore from 1st September2020 to 30th June,2022. Total of 80 patients who had PPH during cesarean section due to uterine atony or placenta previa spectrum were enrolled after informed consent. Nausicaa compression suture was applied to the anterior, posterior and both uterine walls where required.Successful procedure was those where only Nausicaa compression suture was sufficient to control PPH.
 RESULTS:The average age of patients was 30.3±4.2 years. There were 24(30%) primigravidas, 28(35%) were G2P1+0 and 28(35%) were multigravidas. The mean gestational age of patients was 37.58 weeks. 46 patients were operated on for indication of placenta previa. 6 patients had placenta accrete. 28 patients had other indications of LSCS. In 9 patients Nausicaa sutures were applied to the anterior uterine wall while in 71 patients to anterior and posterior uterine walls. In 62 patients Nausicaa suture was sufficient to control PPH. 10 patients required other interventions, while 8 patients required emergency hysterectomy due to intractable hemorrhage.
 CONCLUSION: The Nausicaa compression suture is an effective suture to control postpartum hemorrhage in patients with placenta previa and atonic uterus. It is most effective when applied to anterior and posterior both uterine walls separately.
 KEY WORDS: Post partum hemorrhage(PPH), Nausicaa Compression suture, Cesarean section.

Usefulness of a low-cost simulation model for teaching internal manual aortic compression. A survey-based mannequin evaluation.

To evaluate the users' opinion on internal manual aortic compression (IMAC) training, using a low-cost simulation model. An educational strategy was designed to teach IMAC, which included: (1) guided reading of educational material and viewing an explanatory video of IMAC; (2) an introductory lecture with the anatomical considerations, documentation of the cessation of femoral arterial flow during IMAC, and real clinical cases in which this procedure was used; and (3) simulated practice of IMAC with a new low-cost manikin. The educational strategy was applied during three postpartum hemorrhage workshops in three Latin American countries and the opinions of the participants were measured with a survey. Almost all of the participants in the IMAC workshop, including the simulation with the low-cost mannikin, highlighted the usefulness of the strategy (scores of 4/5 and 5/5 on the Likert scale) and would recommend it to colleagues. We present a low-cost simulation model for IMAC as the basis of an educational strategy perceived as very useful by most participants. The execution of this strategy in other populations and its impact on postpartum hemorrhage management should be evaluated in further studies.

Early treatment with Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes) ameliorates post-partum hemorrhage with coagulopathy caused by amniotic fluid embolism in rabbits

Amniotic fluid embolism is an unpredictable and sometimes lethal complication of childbirth. Fibrinogen γ-chain peptide-coated, ADP-encapsulated Liposomes (H12-(ADP)-liposomes), which were developed as a platelet substitute, may be useful to control postpartum hemorrhage with consumptive coagulopathy. This study aimed to establish a hemodynamically stable amniotic fluid embolism animal model and evaluate the efficacy of H12-ADP-liposome infusion in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism-involved coagulopathy. Pregnant New Zealand white rabbits (28th day of pregnancy or normal gestation period of 29-35 days) underwent cesarean delivery, followed by intravenous administration of amniotic fluid (a total of 3.0 mL administered in 4 doses over 9 minutes). Thereafter, uncontrolled postpartum hemorrhage was induced by transecting the right midartery and concomitant vein in the myometrium. After initial bleeding for 5 minutes, rabbits received isovolemic fluid resuscitation through the femoral vein with an equivalent volume of blood loss every 5 minutes for 60 minutes. The transfusion regimens included platelet-rich plasma, platelet-poor plasma, and a bolus administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion (8 rabbits per group). Moreover, 60 minutes after initiation of bleeding, rabbits received surgical hemostasis by ligation of bleeding vessels, except in cases with spontaneous hemostasis. The administration of amniotic fluid caused thrombocytopenia (56±3 × 103/μL) and prolonged both clotting time (before administration: 130.0±3.0 to 171.0±5.0 seconds) and prothrombin time (4.5±0.1 to 4.7±0.1 seconds). After the initial 5-minute bleeding in the rabbits, the mean arterial pressure fell to 43±2 mm Hg. Platelet-poor plasma transfusion alone further prolonged clotting time and prothrombin time at 60 minutes (192.0±10.0 and 5.2±0.1 seconds, respectively) with decreasing mean arterial pressure to <40 mm Hg. By contrast, the administration of H12-ADP-liposomes followed by platelet-poor plasma transfusion reduced the prolonged clotting time (153.0±5.0 seconds) and prothrombin time (4.9±0.1 seconds) similar to platelet-rich plasma transfusion (154.0±11.0 and 4.9±0.1 seconds, respectively) at 60 minutes. These rabbits maintained a mean arterial pressure of >45 mm Hg throughout the experiment. H12-ADP-liposome infusion and platelet-poor plasma transfusion and platelet-rich plasma transfusion yielded spontaneous hemostasis in 4 of 8 rabbits, whereas platelet-poor plasma transfusion did not stop bleeding in any of the rabbits. The total blood loss was 59±17 mL in the H12-ADP-liposomes and platelet-poor plasma group, which was half of that in the platelet-poor plasma group (124±10 mL). H12-ADP-liposome infusion may be effective in the initial management of postpartum hemorrhage complicated with amniotic fluid embolism, resulting in mitigation of consumptive coagulopathy.

Awareness and use of tranexamic acid in the management of postpartum hemorrhage among health care professionals in Enugu, Nigeria.

This study was conducted to determine the knowledge, practice, and barriers regarding the use of tranexamic acid (TXA) for the prevention and treatment of postpartum hemorrhage (PPH) among health care providers in Enugu, Nigeria. A cross-sectional study was conducted among health professionals (doctors, pharmacists, and nurses) in two Nigerian tertiary teaching hospitals (one federal and one state). A total of 220 questionnaires were distributed and 207 were returned (response rate: 94%) and analyzed using SPSS for inferential statistics with a level of significance of P < 0.05. Only 23.7% of the respondents had good knowledge of TXA use in PPH (P < 0.001), and awareness of the recent World Health Organization (WHO) recommendation on the use of TXA for PPH was low (19.8%, P < 0.001). The majority of the respondents had neither prescribed nor dispensed TXA (30%, P < 0.001). Very few respondents used TXA for all cases of PPH (16.4%, P < 0.001). Barriers against its use include nonawareness of the latest WHO recommendation, preference for other uterotonics, and cost of the drug. There was poor knowledge of TXA, poor awareness of its recommendation, and low use for PPH among different cadres of health care providers.

Postpartum haemorrhage occurring in UK midwifery units: A national population-based case-control study to investigate incidence, risk factors and outcomes.

To estimate the incidence of, and investigate risk factors for, postpartum haemorrhage (PPH) requiring transfer to obstetric care following birth in midwifery units (MU) in the UK; to describe outcomes for women who experience PPH requiring transfer to obstetric care. We conducted a national population-based case-control study in all MUs in the UK using the UK Midwifery Study System (UKMidSS). Between September 2019 and February 2020, 1501 women with PPH requiring transfer to obstetric care following birth in an MU, and 1475 control women were identified. We used multivariable logistic regression, generating adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to investigate risk factors for PPH requiring transfer to obstetric care. The incidence of PPH requiring transfer to obstetric care following birth in an MU was 3.7% (95% CI 3.6%-3.9%). Factors independently associated with PPH requiring transfer to obstetric care were smoking during pregnancy (aOR = 0.73; 95% CI 0.56-0.94), nulliparity (aOR = 1.96; 95% CI 1.66-2.30), previous PPH (aOR = 2.67; 95% CI 1.67-4.25), complications in a previous pregnancy other than PPH (aOR = 2.40; 95% CI 1.25-4.60), gestational age ≥41 weeks (aOR = 1.36; 95% CI 1.10-1.69), instrumental birth (aOR = 2.69; 95% CI 1.53-4.72), third stage of labour ≥60 minutes (aOR = 5.56; 95% CI 3.93-7.88), perineal trauma (aOR = 4.67; 95% CI 3.16-6.90), and birthweight 3500-3999g (aOR = 1.71; 95% CI 1.42-2.07) or ≥4000g (aOR = 2.31; 95% CI 1.78-3.00). One in ten (10.6%) cases received a blood transfusion and one in five (21.0%) were admitted to higher level care. The risk factors identified in this study align with those identified in previous research and with current guidelines for women planning birth in an MU in the UK. Maternal outcomes after PPH were broadly reassuring and indicative of appropriate management. NHS organisations should ensure that robust guidelines are in place to support management of PPH in MUs.

The uterine tourniquet, a simple maneuver that may facilitate surgical management of postpartum hemorrhage.

SynopsisThe uterine tourniquet is a temporary intervention that facilitates the application of other procedures for definitive control of postpartum hemorrhage.

Doğum Sonu Kanama Yönetiminde Ebelerin Bilgi ve Becerilerini Geliştirmek İçin Yerinde Simülasyon Kullanimi: Amasya- Şanlıurfa Örneği

Postpartum hemorrhage has a primary and important place in the pre- and post-graduate education of midwives, who are primarily responsible for maternal health. This research aims to develop the knowledge and skills of midwifes in obstetrics units through simulation method in postpartum haemorrhage management. &#x0D; The research is in a quasi-experimental, single-group pre-test and post-test design. A training included 28 midwives who agreed to participate in the research between June 1st and July 14th. This educational intervention lasted for 24 hours and included theoretical, skills training and skills training accompanied by scenarios, and it was designed to be given in the hospital. Gathered data were evaluated through SPSS package software. &#x0D; Knowledge and skills before and after the educational intervention, and Self-Confidence/Efficiency Scale scores in Patient Intervention were found to be statistically significant. An increase in all scores before and after the educational intervention was observed. When these two hospitals were compared, some differences emerged.&#x0D; Simulation improves both knowledge and skills even for a difficult subject such as postpartum hemorrhage, but there are differences between hospitals due to differences in practice. This may mean that we need to share our experiences more with each other.

Real-World Utilization of an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device.

To assess the real-world effectiveness and safety of a U.S. Food and Drug Administration (FDA)-cleared intrauterine vacuum-induced-hemorrhage control device for postpartum hemorrhage (PPH) management. Sixteen centers in the United States participated in this observational, postmarket registry medical record review (October 2020 through March 2022). The primary effectiveness outcome was treatment success , defined as bleeding control after insertion with no treatment escalation or bleeding recurrence. Additional outcomes included blood loss, time to device insertion, indwelling time, bleeding recurrence, and time to bleeding control. Treatment success and severe maternal morbidity measures (transfusion of 4 or more units of red blood cell, intensive care unit admission, and hysterectomy) were evaluated by blood loss before insertion. To assess safety, serious adverse events (SAEs) and adverse device effects were collected. All outcomes were summarized by mode of delivery; treatment success was summarized by bleeding cause (all causes, any atony, isolated atony, nonatony). In total, 800 individuals (530 vaginal births, 270 cesarean births) were treated with the device; 94.3% had uterine atony (alone or in combination with other causes). Median total blood loss at device insertion was 1,050 mL in vaginal births and 1,600 mL in cesarean births. Across all bleeding causes, the treatment success rate was 92.5% for vaginal births and was 83.7% for cesarean births (95.8% [n=307] and 88.2% [n=220], respectively, in isolated atony). Median indwelling time was 3.1 hours and 4.6 hours, respectively. In vaginal births, 14 SAEs were reported among 13 individuals (2.5%). In cesarean births, 22 SAEs were reported among 21 individuals (7.8%). Three (0.4%) SAEs were deemed possibly related to the device or procedure. No uterine perforations or deaths were reported. For both vaginal and cesarean births in real-world settings, rapid and effective bleeding control was achieved with an FDA-cleared intrauterine vacuum-induced hemorrhage-control device. The safety profile was consistent with that observed in the registrational trial (NCT02883673), and SAEs or adverse device effects were of the nature and severity expected in the setting of PPH. This device is an important new tool for managing a life-threatening condition, and timely utilization may help to improve obstetric hemorrhage outcomes. ClinicalTrials.gov , NCT04995887.

Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is the primary cause of maternal mortality and morbidity worldwide: in fact, about a quarter of deaths that occur during pregnancy, childbirth or the puerperium are caused by postpartum hemorrhage. There are many causes of postpartum hemorrhage, the most important are: uterine atony, lacerations of the cervix and/or perineum, retention of placental material, coagulation problems, uterine inversion, uterine rupture. This causes of PPH are represented by the ‘4Ts’ formula: tone, tissue, trauma, thrombin. An important role is played by prevention: identification of risk factors, prophylaxis with oxytocin at the time of delivery, early treatment. The first important thing is the quantification of blood loss because the clinical signs are often blurred and due to frank anemia resulting in tachycardia, small and frequent pulse, hypotension, sweating, paleness. As previously mentioned, it is important to act early in the case of PPH through maintenance of velamina and targeted therapies that differ according to the cause of PPH (the 4T algorithm is useful). Early intervention reduces the need for blood transfusions and reduces the incidence of serious complications such as DIC. However, the management of postpartum hemorrhage is not limited to the postpartum phase, but the patient must be monitored in the puerperium, a phase in which the thromboembolic risk is increased. The couple must also be informed of the risk of PPH in future pregnancies. PPH represents a serious risk for the patient and requires multidisciplinary input and proper preparation of the team working in the delivery room.

Postpartum hemorrhage: clinical features and management in a tertiary care center of Nepal

Introduction: Obstetric haemorrhage continues to account for a substantial proportion of maternal deaths in Nepal, despite implementation of different strategies. The most common type of obstetric haemorrhage is postpartum hemorrhage (PPH), mainly primary. Understanding its burden in the health care setting was the objective of this study by assessing its prevalence, associated factors and management. Method: This was a retrospective study conducted at Patan Academy of Health Sciences from Mar 2019 to Mar 2022. Demographic, obstetrical, medical factors and management of primary PPH was collected from medical record. Statistical analysis was done using Statistical Packages for Social Sciences (SPSS-20). Results were expressed using frequencies, tables and figures. Result: From a total 17,770 deliveries, primary PPH was seen in 84(0.47%). Most of them 49(58.3%) were multipara. The frequency and impact of PPH can be effectively reduced by reducing avoidable risk factors, especially those related to obstetric interventions as increased caesarean section rate which was 48(57.1%) among primary PPH. Other associated risk factors were induction of labor 32(38.1%), pre-existing medical diseases 32(38.1%), history of antepartum hemorrhage 15(17.9%), previous caesarean section 19(22.6%). Uterine atony 43(51.2%), abnormal placentation disorder 16(19%), genital trauma 9(10.71%), retained tissue 5(5.95%) were the leading causes of PPH. PPH in morbidly adherent placenta like placenta accreta spectrum was 8(9.5%) and placenta increta 1(1.2%). PPH was controlled by conservative management in 24(28.6%). Surgical intervention was required in 34(40.5%) including hysterectomy in 14(16.7%). Conclusion: PPH can be minimized by extra vigilance and planned conjoined management.

P₂A₀ 38-year-old Woman Postpartum Hemorrhage with Hemorrhagic Shock and Severe Anemia Caused by Uterine Atony: A Case Report from Southwest Sumba, East Nusa Tenggara

Postpartum hemorrhage is one of the most common obstetric emergencies and the largest contributor to maternal mortality in the world, with uterine atony being the most common cause. A 38-year-old woman came to Karitas Hospital complaining of vaginal bleeding after giving birth three hours ago. On examination, the patient was somnolent with signs of shock. Anemic conjunctiva, pale lips, weak contractions of the uterus, and active vaginal bleeding. The laboratory results show severe anemia and leukocytosis. The diagnosis was P2A0 38-year-old woman, postpartum spontaneously with hemorrhagic postpartum caused by uterine atony with hemorrhagic shock and severe anemia. The treatment was given according to the algorithm for managing postpartum hemorrhage. Uterine atony is caused by many factors, one of which is precipitous labor as experienced by the patient. Fluid rescucitation, uterotonics, uterine massage, bimanual compression, and the insertion of a condom catheter were given because there was still active bleeding after the 3rd stage of active management. Finally, surgical intervention should’ve been taken as the last step to stop the bleeding. Fast and precise handling can prevent complications of postpartum hemorrhage, namely shock and death.

Intrauterine Tamponade Balloon for Management of Severe Postpartum Haemorrhage: Does Early Insertion Change the Outcome? A Retrospective Study on Blood Loss.

To evaluate the role of the timing of IUTB insertion and to assess the correlation between the time of insertion and outcome. A retrospective study in two tertiary care centres, including patients transferred for severe PPH management. A total of 81 patients were included: 52 patients with IUTB inserted before 15 min (group 1) and 29 patients with IUTB inserted after 15 min (group 2). The mean volume of blood loss in the group of patients with IUTB inserted before 15 min was significantly lower than in group of patients with IUTB set after 15 min. An IUTB could be inserted simultaneously with a uterotonic agent, within 15 min and not after 15 min as suggested by local guidelines, but further prospective studies are required to confirm this.

Implementing uterine balloon tamponade (UBT) device for immediate postpartum hemorrhage management: Leveraging resource allocation and highlighting noteworthy experiences

BackgroundThe use of uterine balloon tamponade (UBT) devices for intrauterine packing and management of vaginal bleeding by uterine atony has shown promising results in improving the quality of care and reducing maternal mortality. ObjectiveThis report aims to provide an overview of progress made in implementing UBT devices in northern Cote d'Ivoire. Material and methodsA four-year retrospective study was conducted in the North-East (163,645), North-Center (351,909), and North-West (57,983). In 2017, UBT was adopted by members of the healthcare system. Subsequently, 5 national and 32 regional trainers have been trained. The training session was a theoretical and practical program with a low simulator. UBT is a male condom tied to a urinary catheter, filled with liquid. Positive outcomes included stopping bleeding, avoiding the need for surgery, and preventing maternal deaths (MD). In 2018, 3,515 UBT devices were distributed. In 2019, monitoring tools and transmission circuits of the data were validated. In 2020, the collection of data and local manufacturing was launched. ResultsDuring the process, 978 health workers, mainly midwife (52.0%) and nurses (32.2%) out of the 1,295 assigned were trained. The number of trained individuals decreased from 209 in 2019 to 160 in 2020. A total of 1,715 UBT devices were locally manufactured, adding to the existing gift of 5,080 devices, with total availability of 6,795. The distribution of devices increased from 2017 to 2019 but decreased in 2020. Success rates increased from 87.3% in 2017 (365/418) to 95.0% in 2019 (556/585) and slightly decreased in 2020 to 98.0% (681/695). Adverse outcomes (144/2,193), included MD (35/2,193) and medical evacuation to the surgical center (109/2,193). ConclusionThe implementation of UBT in northern Cote d'Ivoire successfully reduced maternal death rates caused by immediate post-partum hemorrhage (IPPH). However, to ensure sustainability, further improvements are needed, including increased monitoring, ongoing training, and device availability.

Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity: a before-and-after study.

To determine the impact of the Obstetric Simulation Training and Teamwork (OB-STaT) curriculum on postpartum haemorrhage (PPH) rates and outcomes. Before-and-after study. Maternity care hospitals within the USA. Patients who delivered between February 2018 and November 2019. Interprofessional obstetric teamwork training (OB-STaT) conducted at each hospital. Electronic medical records for deliveries were reviewed for 6 months before and after conducting OB-STaT at participating hospitals. The PPH rate (blood loss of ≥1000 ml), uterotonic medications used, tranexamic acid use, blood product transfusion, hysterectomy, length of stay and composite maternal morbidity (postpartum haemorrhage, hysterectomy, transfusion of ≥4 units of blood products and intensive care unit admission for PPH). A total of 9980 deliveries were analysed: 5059 before and 4921 after OB-STaT. The PPH rates did not change significantly (5.48% before vs 5.14% after, p = 0.46). Composite maternal morbidity decreased significantly by 1.1% (6.35%-5.28%, p = 0.03), massive transfusions decreased by 57% (0.42%-0.18%, p = 0.04) and the mean postpartum length of stay decreased from 2.05 days (1.05 days SD) to 2.01 days (0.91 days SD) (p = 0.04). Following OB-STaT, haemorrhage medication use increased by 36% (14.8%-51.2%, p = 0.03), the use of tranexamic acid for PPH treatment almost doubled (2.7%-4.8%, p < 0.001) and the rate of hysterectomy significantly increased (0%-0.1%, p = 0.03). Although the PPH rates did not decrease, OB-STaT significantly improved maternal morbidity, decreased massive transfusions, and improved PPH management by increasing the utilization of uterotonic medications, tranexamic acid and hysterectomy.

Knowledge, Attitude and Practices on the Use of Uterine Tamponade in the Management of Severe Postpartum Hemorrhage in Public Health Facilities of Niger State

Background: Obstetric hemorrhage is a contributor to worldwide maternal morbidity and mortality in low-resource countries. The aim of this study was to assess knowledge, attitude and practices on the use of uterine tamponade in managing severe postpartum hemorrhage (PPH) by healthcare personnel.&#x0D; Method: The study was descriptive and cross-sectional. A self-administered, structured questionnaire was used to collect data on uterine tamponade from untrained and trained health workers who take deliveries in labour wards of selected health facilities. Respondents were selected by cluster sampling technique. Data was analyzed using SPSS version 20. Frequencies were determined and chi-square was used to test the hypothesis. A p-value of &lt;0.05 was considered statistically significant.&#x0D; Results: The mean age of the respondents was 35 years ± 11.7. Slightly less than half of the respondents 62 (42.5%) had poor knowledge of uterine tamponade. The majority of respondents 120 (82.2%) had positive attitudes about uterine tamponade. This was associated with point of service, professional group, and previous training on uterine tamponade insertion (p&lt;0.05). About 70% (46; 69.7%) of respondents who had managed cases of refractory postpartum hemorrhage, had never conducted uterine tamponade. Reasons include inadequate knowledge (29; 63.0%) and unavailability of the commodities (9; 19.6%)&#x0D; Conclusion: Though knowledge about uterine tamponade was poor, attitude towards uterine tamponade in managing severe post- partum hemorrhage was good. However, this did not translate to good practices on the use of uterine tamponade in managing severe PPH. Training and re-training on the application of uterine tamponade should be conducted and commodities made available in every health facility.

Association of adverse outcomes with three-tiered risk assessment tool for obstetrical hemorrhage

Guidelines promote stratification for the risk for postpartum hemorrhage among parturients, although the evidence for the associated differential morbidity among the groups remains inconsistent among published reports. Using the California Maternal Quality Care Collaborative schema modified by the American College of Obstetrics and Gynecology, we compared the composite maternal hemorrhagic outcome and the composite neonatal adverse outcome among singletons who were categorized after delivery by the researchers as low-, medium-, or high-risk for postpartum hemorrhage. We hypothesized that the composite outcomes would be significantly different among the individuals in the different 3-tiered categories. This was a retrospective cohort study of all singleton parturients with a gestational age of at least 14 weeks who delivered at a single site within 1 year. The composite maternal hemorrhagic outcome included any of the following: estimated blood loss ≥1000 mL, use of uterotonics (excluding prophylactic oxytocin) or Bakri balloon, surgical management of postpartum hemorrhage, blood transfusion, hysterectomy, thromboembolism, admission to the intensive care unit, or maternal death. The composite neonatal adverse outcome included Apgar score <7 at 5 minutes, birth injury, bronchopulmonary dysplasia, intraventricular hemorrhage, neonatal seizure, sepsis, ventilation > 6 hrs., brachial plexus palsy, hypoxic-ischemic encephalopathy, or neonatal death. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted relative risks with 95% confidence intervals. Of the 4544 deliveries in the study period, 4404 (96.7%) met the inclusion criteria, and among them, 1745 (39.6%) were categorized as low, 1376 (31.2%) as medium, and 1283 (29.1%) as high risk. Overall, 941 (21.4%) participants experienced the composite maternal hemorrhagic outcome with 285 (16.4%) of those being in the low-risk group, 319 (23.2%) in the medium-risk group, and 337 (26.3%) in the high-risk group. Among all parturients, 95.7% in the low-, 89.4% in the medium-, and 85.3% in the high-risk group neither had an estimated blood loss or a quantified blood loss ≥1000 mL nor were transfused. After multivariable adjustment and when compared with the low-risk group, there was a significantly higher risk for the composite maternal hemorrhagic outcome in the medium-risk group (adjusted relative risk, 1.23; 95% confidence interval, 1.05-1.43) and in the high-risk group (adjusted relative risk, 1.51; 95% confidence interval, 1.31-1.75). Overall, 366 newborns (8.4%) developed the composite neonatal adverse outcome with 76 (4.2%) in of those being in the low-risk group, 153 (11.3%) in the medium-risk group, and 140 (11.1%) in the high-risk group. After multivariable adjustment and when compared with the low-risk group, there were no significant differences in the composite neonatal adverse outcome in the medium- (adjusted relative risk, 1.27; 95% confidence interval, 0.97-1.68) or the high-risk group (adjusted relative risk, 1.29; 95% confidence interval, 0.98-1.68). Although 8 of 10 parturients categorized as high risk neither had blood loss ≥1000 mL nor underwent transfusion, the risk stratification provides information regarding the composite maternal hemorrhagic outcome.

Harnessing the Power of Behavioral Science: An Implementation Pilot to Improve the Quality of Maternity Care in Rural Madagascar.

Postpartum hemorrhage (PPH) is the leading direct cause of maternal deaths worldwide, and women in low-income countries are at particularly high risk of dying from PPH-related consequences. Most deaths can be avoided through consistent provider adherence to prevention protocols and timely, appropriate management, yet providers do not consistently adhere to these best practices. USING BEHAVIORAL DESIGN TO DEVELOP SOLUTIONS TO IMPROVE PROVIDER CARE: We applied the behavioral design methodology to identify behavioral drivers, develop solutions, and build a program theory of change. Implementation research was conducted to understand the adoption, desirability, feasibility, and appropriateness of the solutions and explore suggestive findings related to impact. Data were collected through observation and in-depth interviews. Solutions developed included: (1) a timer to remind providers of the 1-minute window to administer oxytocin; (2) a glow-in-the-dark poster illustrating a simplified algorithm for PPH management; (3) badges to assign family members tasks to support providers during labor and delivery; and (4) a risk visualization exercise. Clinical mentors introduced the solutions during facility visits, and providers received orientation using videos. Solutions were piloted in 10 rural facilities in southeastern Madagascar during November-December 2020. Providers reported high adoption of the timers and task badges during routine deliveries. They remarked on the desirability and appropriateness of the timer, task badges, and algorithm poster, as well as the value of the cocreation process. Adoption of the timer solution shows promise in having a potential positive impact on increasing the awareness of and adherence to timely oxytocin administration. This work highlights the promise of applying behavioral science to identify underlying drivers of gaps in clinical practice and to develop innovative and desirable solutions to address them.

Risk factors for postpartum haemorrhage in twin pregnancies and haemorrhage severity.

This study evaluated risk factors for postpartum haemorrhage (PPH) in twin pregnancies, particularly factors associated with major PPH (blood loss of >1000 mL), to facilitate identification of high-risk twin pregnancies. This retrospective cohort study included all women with twin pregnancies who delivered at a tertiary obstetric unit in Hong Kong from 2009 to 2018 and experienced PPH (blood loss of ≥500 mL). Postpartum haemorrhage was classified using three thresholds for blood loss volume: ≥500 mL (all PPH), >1000 mL (major PPH), and >1500 mL (severe PPH). Risk factors for each threshold of PPH were analysed. In total, there were 680 twin pregnancies. The overall incidence of all PPH (≥500 mL) in this cohort was 27.8%, including minor PPH (500-1000 mL, 20.1%), major but not severe PPH (1001-1500 mL, 4.4%), and severe PPH (>1500 mL, 3.2%). Logistic regression analysis showed that general anaesthesia and the use of oxytocin were significant risk factors for all PPH (≥500 mL); general anaesthesia, in vitro fertilisation, antepartum haemorrhage, placental abruption, and placenta praevia were significant risk factors for major PPH (>1000 mL); in vitro fertilisation, placenta praevia, and obesity were significant risk factors for severe PPH (>1500 mL). Women with twin pregnancies who have obesity, conception by in vitro fertilisation, or placenta praevia exhibit a high risk of severe PPH. They should deliver in obstetric units with readily available blood product transfusions and the appropriate expertise for prompt management of severe PPH.