Advances in the Treatment of Postpartum Hemorrhage

Alison M El Ayadi; Nuriya Robinson; Stacie Geller; Suellen Miller


Expert Rev of Obstet Gynecol. 2013;8(6):525-537. 

In This Article

Staying Prepared

Ensuring that obstetric care providers are adequately prepared for handling hemorrhagic emergencies should be accomplished through high quality medical, nursing and midwifery education, with ample opportunities to practice managing rare events and by verifying that all tools and materials required for PPH intervention are readily available. It is also important that standardized protocols and/or guidelines be adopted and monitored to ensure that facility-level practices are evidence-based.

The California Maternal Quality Care Collaborative (CMQCC) established evidence-based guidelines in 2010 to improve the treatment of OH by both identifying women who may be at higher risk of developing OH and producing a set of best practice steps to guide clinicians through OH management, beginning with prenatal assessment and planning through severe OH presentation.[95] This model supplies materials for a quality improvement-team to conduct a needs assessment and develop a facility-specific OH care guideline. These standards are in place for all California facilities, have been adopted by several other states, and are freely available.[202] Peripartum risk stratification, defined by maternal characteristics and conditions clinically associated with OH, is an important component of these guidelines and is used to determine prenatal pre-transfusion testing recommendations. A recent validation of the risk stratification supported assessment of peripartum risk upon delivery admission.[96] Results recommended typing and screening high-risk women at admission to improve preparedness. Other states have implemented similar guidelines.

Simulation-based team training (drills) to ensure preparedness for obstetric emergencies can be used to train providers to be prepared for clinical situations, which are infrequent but that have a high potential for morbidity or mortality, such as PPH. Obstetric emergencies are characterized by significant time challenges and the need to manage both mother and child simultaneously. Drills allow for the identification of system weaknesses and strengths, provide the opportunity to test policies and procedures for hemorrhage management and help improve teamwork among staff. RCTs of teamwork training via simulation for acute obstetric situations report increases in knowledge, practical skills, communication and team performance; but have not adequately assessed effectiveness on maternal and neonatal outcomes.[97] Recent developments include birth simulators such as PartoPants™ and Mama Natalie™ to improve fidelity to real-life situations.[98]

The establishment and maintenance of obstetrical hemorrhage 'carts' or 'boxes' can improve preparedness through rapid access to supplies, medications and surgical instruments designed to treat PPH.[99] The supply cart/box contains all equipment and instruments used to treat PPH prior to consideration of hysterectomy, including equipment for IV administration, laceration repair and tamponade. Carts/boxes should include job aids such as flow charts or management algorithms. Maintenance of an OH medication kit in an accessible refrigerated storage location and a PPH surgery tray in the operating room is also recommended.[99] Case studies suggest easy access to treatment tools may reduce delays in surgical management of PPH, and need for blood transfusion and hysterectomy.[100] The UK Haemostatis and Thrombosis Task Force recommends maintaining sample tubes for cross-matching, full blood count and clotting studies within labor ward refrigerators so that they are rapidly available.[101]

A number of international and national organizations such as WHO, FIGO, CMQCC, RCOG and ACOG have developed and distributed updated guidelines for the management of PPH over the past few years.[6,27,72,93,95] These guidelines reflect the current state of knowledge around best practices for prevention and treatment of PPH and should be integrated into facility and community practices with local modifications as necessary. The WHO recommends the adoption of standardized protocols, as they are considered useful and unlikely to be harmful.[6] Evidence-based recommendations have recently been assembled by the multi-center Safe Childbirth Checklist Collaboration, which is currently evaluating the effectiveness of the checklist on provision of minimum care standards during childbirth. Previous research has demonstrated the difficulty of sustainable behavior change interventions; however, information access, use of role models, skill development and improved resources may be effective ways to overcome barriers to changing obstetric care.[102]