Refractory Postpartum Hemorrhage Research Articles

Uterine Artery Embolization Versus Hysterectomy in Postpartum Hemorrhage: A Systematic Review With Meta-Analysis.

The objective of this study is to perform a meta-analysis comparing the effectiveness of uterine artery embolization (UAE) versus peripartum hysterectomy for acute refractory postpartum hemorrhage (PPH) control. We systematically searched 6 medical databases for studies comparing UAE and hysterectomy in PPH. Outcomes examined were mortality, hospitalization duration (HD) in days, and red blood cells (RBC) units utilization. Statistical analysis used RevMan 5.1.7 and random-effects models. Odds ratios (OR) and mean differences (MDs) with 95% confidence intervals (CIs) were used for dichotomous and continuous outcomes, respectively. We included 833 patients from 4 cohort studies, with 583 (70%) undergoing UAE. The UAE population required fewer RBC units (MD: -7.39; 95% CI: -14.73 to -0.04; p=0.05) and had shorter HD (MD: -3.22; 95% CI: -5.42 to -1.02; p=0.004). Lower mortality rates were noted for UAE in the pooled analysis, but no statistical significance. Uterine artery embolization demonstrated lower procedural complications (16.45% vs. 28.8%), in which UAE had less ureter and bladder lesions (OR: 0.05; 95% CI: 0.01-0.38; p=0.004 and OR: 0.02; 95% CI: 0.00-0.15; p<0.001, respectively). Only 35 (6%) required conversion to hysterectomy, while 27 (4.6%) underwent re-embolization with 100% bleeding control. Uterine artery embolization did not hinder fertility, with normal menstruation restored in 19 patients with postoligomenorrhea. Uterine artery embolization for the control of PPH is associated with lower use of RBC units and HD, but similar rates of mortality are noted when compared to hysterectomy. These results associated with uterine preservation could support its importance for refractory PPH management. Uterine Artery Embolization is associated with a shorter hospitalization duration and reduced use of red blood cell units when compared with hysterectomy in refractory postpartum hemorrhage. Although demonstrating similar mortality rates, these findings, together with fertility preservation, support the method incorporation as a valuable option in obstetric services.

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.

Fibrinogen as a potential diagnostic marker for prediction and evaluation of postpartum hemorrhage: a retrospective study

Objective To investigate whether prenatal fibrinogen (FIB) or other related factors could be utilized to evaluate the risk of postpartum hemorrhage (PPH). Methods A retrospective study was conducted in a database from January 2015 to December 2019. A total of 128 patients were enrolled and evaluated with FIB, in which 55 patients were assigned to low FIB and 73 in normal FIB. Results According to the volume of blood loss, the mean of the low FIB group (<4 g/L) was markedly higher than that of the normal FIB group (≥4 g/L). Prenatal FIB was negatively correlated with PPH volume. The receiver operating characteristic (ROC) curve results indicated that the value of prenatal FIB was 0.701 to predict refractory PPH. Conclusions Prenatal FIB was significantly related to thrombin time (TT), which may be an independent factor to predict the coagulation state of prenatal pregnancy.

Engaging National Professional Society to Combat Postpartum Hemorrhage Using Bundle Approach - A FIGO-SAFOG-OGSB-MGH Project: Experience of Implementation in Bangladesh

Objective: To reduce the incidence and death due to post-partum Hemorrhage (PPH) and capacity building of health service providers by using PPH Emergency response using Bundle Approach. Method: Planning and implementation of WHO formulated PPH Bundles [Active Management of Third Stage of Labour (AMTSL), First response Bundle and Refractory PPH Bundle] by Obstetrical and Gynaecological Society of Bangladesh (OGSB) in 14 different levels of public and private hospitals in Bangladesh. After discussion with International Federation of Gynaecology and Obstetrics (FIGO) and South Asian Federation of Obstetrics and Gynaecology (SAFOG) team, a Memorandum of understanding (MOU) was signed; permission from Ministry of Health and Family welfare (MOHFW) was obtained through Directorate General of Health Services (DGHS) and also from all the institutions. The project period was from November 2019 to September 2022 in a spoke-and-hub fashion. A group of master trainers and a technical advisory group were developed comprising of senior obstetricians and gynecologist of Bangladesh. Data were obtained through record keeping of the respective hospitals and Management Information System (MIS) of DGHS, monitoring was done by OGSB and Massachusetts General Hospital (MGH)-FIGO team. Results: Consultative and planning meetings were organized among OGSB, FIGO, SAFOG and MGH: 16 master trainers, 74 trainers were produced and 740 health service providers (Doctor, Nurses, midwives) and 450 non clinical staffs were trained. All clinical and nonclinical bundles were implemented in 14 facilities in spoke-and-hub fashion. Occurrence of PPH, detection rate of PPH, filling up PPH checklist and debrief forms were improved. Data collection system, understanding about data improved a lot. Facility readiness, team work, data monitoring &amp; supervision, network integration and leadership skills were instituted and shown excellent positive changes. Regular simulations were continued which helped old &amp; new service providers to learn and continue proper use of the clinical and non-clinical interventions. Scale up was planned and continued. Conclusion: PPH emergency response using bundle approach was found to be an important practical way to reduce occurrence, death and disability related to PPH. Needs for surgery has reduced also. Quality of services improved in terms of providing standard care, record keeping and reporting. Regular supervision and monitoring; data management and personal motivation are the challenges. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(2): 98-108

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..

Association of the Kiwi OmniCup system with maternal and neonatal morbidity: A retrospective cohort study.

To discuss the effect of the Kiwi OmniCup system on reducing adverse maternal and neonatal outcomes and provide a reference for assisted vaginal delivery methods. Women who gave birth to singleton term neonates in a cephalic presentation and underwent assisted vaginal delivery from 2017 to 2021 were eligible for inclusion in the study; they were divided into a Kiwi OmniCup system group and a forceps group. Binary logistic regression analysis was used to observe and compare maternal and neonatal outcomes. The primary outcomes were severe maternal and neonatal morbidity. Severe maternal morbidity was defined as the occurrence of at least one of the following outcomes: third- or fourth-degree perineal lacerations, refractory postpartum hemorrhage, thrombotic events, amniotic fluid embolism, admission to the intensive care unit, and maternal death. Severe neonatal morbidity was defined as the occurrence of at least one of the following outcomes: neonatal asphyxia requiring resuscitation or intubation, neonatal head and face injuries, neonatal fracture, and admission to the neonatal intensive care unit for longer than 24 h. The rate of severe neonatal morbidity in the forceps group was significantly higher than that in the Kiwi OmniCup system group, the differences between the two groups were significant (27.2% vs. 42.3%, P < 0.001), and there was no significant difference in the rate of severe maternal morbidity between the two groups (30% vs. 30%, P > 0.05). Binary logistic regression analysis showed that Kiwi OmniCup system-assisted delivery reduced severe neonatal morbidity (adjusted odds ratio 0.49; 95% confidence interval 0.33-0.73) and did not increase severe maternal morbidity compared with forceps-assisted delivery. The Kiwi OmniCup system, which can reduce the incidence of severe neonatal morbidity without increasing the incidence of serious adverse maternal outcomes, is worthy of clinical promotion.

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.

Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage.

Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.

Introduction of the Ellavi uterine balloon tamponade into the Kenyan and Ghanaian maternal healthcare package for improved postpartum haemorrhage management: an implementation research study

ObjectivesUse of intrauterine balloon tamponades for refractory postpartum haemorrhage (PPH) management has triggered recent debate since effectiveness studies have yielded conflicting results. Implementation research is needed to identify factors influencing...

Bakri Balloon for Treatment of Postpartum Hemorrhage: A Real-World 2016-2020 Study in 279 Women from a Single Center.

BACKGROUND Postpartum hemorrhage (PPH) may be primary or secondary and is defined as the loss of 500 ml or more of blood within the first 24 h after birth. The Bakri balloon tamponade (BBT) is an intrauterine device used as an adjunctive treatment for refractory PPH. The aim of this study was to present the real-world experience from a single center on the effectiveness of the BBT for the treatment of PPH. MATERIAL AND METHODS This cohort study of 279 women was conducted in a real-world setting. Patients' characteristics and clinical outcomes between the BBT Success group and BBT Failure group were analyzed by t test or chi-square test. The primary outcome was the success rate of BBT. The secondary outcomes were the perinatal outcomes. RESULTS The success rate of BBT was 88.89% (248/279). A blood transfusion rate of 65.95% (184/279) was observed. After using the BBT, significant differences were observed in intervention (P<0.001), blood loss (P<0.001), indwelling time of BBT (P<0.001), and blood transfusion (P<0.001) between the Success group and Failure group. The Success group showed greater range of descent in blood loss (991.56.15±13.65 mL in Success group vs 816.23±7.57 mL in Failure group). Of the 31 women with BBT failure, 87.10% (27/31) received uterine artery embolization (UAE), 96.77% (30/31) received blood transfusion, and none required a hysterectomy. CONCLUSIONS The findings from this study from a single center in China supported those from previous studies showing that the BBT was an effective treatment to control PPH.

Five critically ill pregnant women/parturients treated with extracorporeal membrane oxygenation

BackgroundMaternal mortality has always been a major medical concern. Recently, the successful application of extracorporeal membrane oxygenation (ECMO) technology in the rescue of near-death patients has been reported.Case presentationThis study retrospectively analyzed 5 cases of critically ill pregnant women/parturients treated with ECMO for respiratory and circulatory failure in the Wuxi People’s Hospital from 2018 to 2020. The mean age of the 5 cases was 30.2 years. Among them, Cases 1 and 5 were treated with Venoarterial (VA) ECMO. Case 1 was diagnosed with congenital heart disease, atrial septal defect, and severe pulmonary hypertension. VA ECMO was applied before cesarean section and was successfully removed after double lung transplantation, but the patient died 10 months after delivery from lung infection. While Case 5 was diagnosed with systemic lupus erythematosus, lupus nephritis, thrombotic vascular disease, HELLP syndrome, and cerebral hemorrhage. VA ECMO was applied 39 days after cesarean section, and the patient died 40 days after delivery due to multiple organ failure. Cases 3 and 4 were treated with Venovenous (VV) ECMO. Case 3 was diagnosed with refractory postpartum hemorrhage, and Case 4 was diagnosed with postpartum hypoglycemic coma, aspiration pneumonia, and shock. They were treated with VV ECMO after delivery, and all survived after successful evacuation. Another Case (Case 2) was diagnosed with postpartum pelvic infection, sepsis and septic shock, and was treated with VA ECMO at 15 days after delivery. The patient changed to VV ECMO at 30 days after delivery due to significant improvement in heart function and poor lung function, but eventually died of multiple organ failure. For the 5 cases, the mean duration of ECMO was 8.7 days, the mean duration of intensive care was 22.0 days, and the mean length of hospital stay was 57.6 days. As a result, 3 patients gradually returned to normal with significant improvement in ventilation and oxygenation after ECMO treatment.ConclusionsECMO technology can be used to treat some of the critical obstetric patients with respiratory and circulatory failure that is ineffective to conventional treatment, but it has no therapeutic effect on the primary disease.

Effectiveness of Uterine Tamponade Devices for Refractory Postpartum Hemorrhage After Vaginal Birth: A Systematic Review

(BJOG. 2021;128:1732–1743) Most postpartum hemorrhage (PPH) deaths occur due to uterine atony. While first-line interventions for PPH such as uterotonics, tranexamic acid, and uterine massage are effective for most patients, 10% to 20% of patients are unresponsive to these and are deemed to have “refractory” PPH. Uterine tamponade devices (UTD) used to treat refractory PPH include uterine balloon tamponade (UBT) and uterine suction tamponade (UST). The World Health Organization has previously issued a conditional recommendation for the use of UBT to treat refractory PPH due to uterine atony, based on case series and studies with no control population. Since then, several relevant studies, including randomized controlled trials, have been published. This systematic review aims to evaluate uterine tamponade devices for safety and effectiveness in treating atonic refractory PPH following vaginal birth and examine the effects of including uterine tamponade devices into institutional PPH protocols.

Tranexamic Acid for Postpartum Hemorrhage Treatment in Low-Resource Settings: A Rapid Scoping Review

Tranexamic acid (TXA) effectively reduces bleeding in women with postpartum hemorrhage (PPH) in hospital settings. To guide policies and practices, this rapid scoping review undertaken by two reviewers aimed to examine how TXA is utilized in lower-level maternity care settings in low-resource settings. Articles were searched in EMBASE, MEDLINE, Emcare, the Maternity and Infant Care Database, the Joanna Briggs Institute Evidence-Based Practice Database, and the Cochrane Library from January 2011 to September 2021. We included non-randomized and randomized research looking at the feasibility, acceptability, and health system implications in low- and lower-middle-income countries. Relevant information was retrieved using pre-tested forms. Findings were descriptively synthesized. Out of 129 identified citations, 23 records were eligible for inclusion, including 20 TXA effectiveness studies, two economic evaluations, and one mortality modeling. Except for the latter, all the studies were conducted in lower-middle-income countries and most occurred in tertiary referral hospitals. When compared to placebo or other medications, TXA was found effective in both treating and preventing PPH during vaginal and cesarean delivery. If made available in home and clinic settings, it can reduce PPH-related mortality. TXA could be cost-effective when used with non-surgical interventions to treat refractory PPH. Capacity building of service providers appears to need time-intensive training and supportive monitoring. No studies were exploring TXA acceptability from the standpoint of providers, as well as the implications for health governance and information systems. There is a scarcity of information on how to prepare the health system and services to incorporate TXA in lower-level maternity care facilities in low-resource settings. Implementation research is critically needed to assist practitioners and decision-makers in establishing a TXA-inclusive PPH treatment package to reduce PPH-related death and disability.

Tamponamento por balão intrauterino no tratamento da hemorragia pós-parto

Abstract Introduction: Postpartum hemorrhage is an obstetric emergency with high prevalence and significant morbidity and mortality, especially in areas with reduced access to specialized health services. Objective: To evaluate the effectiveness of intrauterine balloon tamponade in controlling postpartum hemorrhage, with the aim to reduce the need for emergency surgical interventions and decrease maternal mortality. Methods: A systematic review of randomized clinical trials, guided by the Cochrane Handbook for Systematic Reviews of Interventions and reported through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Randomized clinical trials that evaluated the use of different types of balloons for intrauterine tamponade as a strategy for reducing or stopping postpartum hemorrhage compared to other interventions (pharmacological or surgical) were considered for inclusion. Results: Four studies evaluated 498 patients. In 80% of the reported cases, hemorrhage cessation was observed within a mean interval of 15 min after device insertion. The device permanence time was 24 h. No serious adverse events were reported. Due to clinical heterogeneity between studies, it was not possible to perform a quantitative synthesis. Conclusion: We did not find enough evidence to support the routine use of uterine tamponade devices as a protocol practice in the control of refractory postpartum hemorrhage. However, the use of these devices seems to be promising in cases where first line interventions fail and may play an important role in decreasing maternal morbidity and mortality and in uterine preservation.

Factors Associated with Hysterectomy for Postpartum Hemorrhage: A Case-Control Study

Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality. Hysterectomy is the definitive treatment for refractory PPH and is used as a quality indicator for obstetric care. We aimed to identify factors associated with peripartum hysterectomy among patients experiencing PPH at a single academic hospital with a diverse sociodemographic patient population.

Balloon Tamponade—A Novel Innovation in the Management of Refractory Postpartum Hemorrhage at Tertiary Care Center: A Study from Central India

Balloon Tamponade—A Novel Innovation in the Management of Refractory Postpartum Hemorrhage at Tertiary Care Center: A Study from Central India

"Suction Tube Uterine Tamponade" for treatment of refractory postpartum hemorrhage: Internal feasibility and acceptability pilot of a randomized clinical trial.

To assess feasibility and acceptability of a novel, low-cost "Suction Tube Uterine Tamponade" (STUT) treatment for refractory postpartum hemorrhage (PPH). We allocated patients with refractory PPH by randomly ordered envelopes to STUT or routine uterine balloon tamponade (UBT, Ellavi free-flow system) in 10 hospitals in South Africa. In the STUT group, a 24FG Levin stomach tube was inserted into the uterine cavity and vacuum created with a vacuum pump or manual vacuum aspiration syringe. For this internal pilot study, 12 participants were allocated to STUT and 12 to UBT. Insertion failed in one of each group and was recorded as difficult in 3/10 STUT and 4/9 UBT insertions respectively (five missing data). There were two laparotomies and one intensive care unit admission in the UBT group. Pain during STUT insertion was graded as none/mild in 9/10 and severe in 1/10. The experience of the STUT procedure was graded as fine in 4/11 and "uncomfortable but acceptable" in 7/11. STUT is feasible and acceptable, justifying continuation of our trial. These data will also inform a large World Health Organization trial to test effectiveness of uterine tamponade methods. The numbers are too small to support any clinical recommendation.

Role of bilateral internal iliac artery ligation in controlling refractory post partum hemorrhage

Background: Post Partum Hemorrhage (PPH) is a life threatening emergency that needs to be managed timely. Refractory PPH is treated surgically. Bilateral internal iliac artery ligation is one of the surgical procedures performed to control bleeding.Objective: We analyzed the effectiveness of Bilateral IIAL in controlling bleeding in PPHMethodology: It was a retrograde cross-sectional study conducted at Lady Aitchison hospital, Lahore from data during January 2018 to December 2020. After applying inclusion and exclusion criteria, data of patient including demographics, history, examination, ultrasound, procedure details and post-operative complications were recorded. All the data was analyzed using SPSS version 23.0.Results: All the patients (44) survived and success rate was 100 %. Uterine atony was present in 29 (65.9%) patients as a cause of PPH, placental abnormality, uterine rupture and coagulopathy in 7(15, 9), 4 (9.1%) and 4 (9.1%) patients respectively. 17 patients did not develop any complication. Most common Post-operative complication was wound infection (22.75%) followed by pneumonia (20.5%), paralytic ileus (9.1%) and DIC with renal failure (9.1%).Conclusion: Bilateral IIAL was found to be an effective and preferred life saving procedure, preserving fertility.  Â

Effectiveness of uterine tamponade devices for refractory postpartum haemorrhage after vaginal birth: a systematic review.

ObjectivesTo evaluate uterine tamponade devices’ effectiveness for atonic refractory postpartum haemorrhage (PPH) after vaginal birth and the effect of including them in institutional protocols.Search strategyPubMed, EMBASE, CINAHL, LILACS, POPLINE, from inception to January 2021.Study selectionRandomised and non‐randomised comparative studies.OutcomesComposite outcome including surgical interventions (artery ligations, compressive sutures or hysterectomy) or maternal death, and hysterectomy.ResultsAll included studies were at high risk of bias. The certainty of the evidence was rated as very low to low. One randomised study measured the effect of the condom‐catheter balloon compared with standard care and found unclear results for the composite outcome (relative risk [RR] 2.33, 95% CI 0.76–7.14) and hysterectomy (RR 4.14, 95% CI 0.48–35.93). Three comparative studies assessed the effect of including uterine balloon tamponade in institutional protocols. A stepped wedge cluster randomised controlled trial suggested an increase in the composite outcome (RR 4.08, 95% CI 1.07–15.58) and unclear results for hysterectomy (RR 4.38, 95% CI 0.47–41.09) with the use of the condom‐catheter or surgical glove balloon. One non‐randomised study showed unclear effects on the composite outcome (RR 0.33, 95% CI 0.11–1.03) and hysterectomy (RR 0.49, 95% CI 0.04–5.38) after the inclusion of the Bakri balloon. The second non‐randomised study found unclear effects on the composite outcome (RR 0.95, 95% CI 0.32–2.81) and hysterectomy (RR 1.84, 95% CI 0.44–7.69) after the inclusion of Ebb or Bakri balloon.ConclusionsThe effect of uterine tamponade devices for the management of atonic refractory PPH after vaginal delivery is unclear, as is the role of the type of device and the setting.Tweetable abstractUnclear effects of uterine tamponade devices and their inclusion in institutional protocols for atonic refractory PPH after vaginal delivery.

Managing postpartum haemorrhage with free-flow pressure-controlled uterine balloons

Background/aims Uterine balloon tamponade is an accepted management method for refractory postpartum haemorrhage. A previous case series was conducted in Cape Town, South Africa with a uterine balloon tamponade used by doctors, where the success rate was 78.9%. The next step was the roll out of the skill to midwives in midwife obstetric units, which was investigated in this study. Methods A case series was conducted in six midwife obstetric units in Metro-East, Cape Town. Hands-on training workshops and one-to-one training sessions were conducted, that aimed at 80% coverage. Following this training, the devices were made available to midwife obstetric units at no cost, along with instructions for their use. Structured interviews were conducted with midwives that used the device during the study period. The interview included questions about correct placement of the uterine balloon, ease of placement and effect on uterine bleeding. Results Training saturation ranged between 92% and 100%. A total of 12 cases with 10 attempted placements were reported, of which eight were performed by midwives. In all eight cases, the bleeding stopped quickly following inflation of the uterine balloon. Use of the uterine balloon tamponade for postpartum haemorrhage treatment was received with enthusiasm by midwives and the skill was easy to acquire. The additional management option for postpartum haemorrhage was welcomed. Conclusions The skill of using a uterine balloon tamponade was easily acquired by the midwives. This device should be included in the postpartum haemorrhage management bundle, as it will reduce blood loss in refractory cases, resulting in safer transfers.