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Postpartum hemorrhage (PPH) is the leading cause of maternal death globally.
Every year, more than 14 million cases of obstetric hemorrhage occur, resulting in an estimated 127,000 deaths, as per the World Health Organization (WHO) estimates.
Even though the major contribution of these deaths comes from low-income countries (LICs), PPH is also a great challenge in middle- and high-income countries. PPH is the leading cause of maternal deaths in low-income countries. It is also the primary cause of approximately one-quarter of global maternal deaths.
In 2010, the maternal mortality ratio (MMR) in low and middle income countries was 240 per 100,000 (284,000 total maternal deaths) compared to 16 per 100,000 (2,200 total maternal deaths) in high income countries. Thirty-five countries have been noted as either making insufficient progress or not making any progress at all toward achieving the Fifth Millennium Development Goal (MDG5).
PPH is largely unpredictable. It not only occurs in high-risk pregnancies, but can also happen is low-risk pregnancies where it was never expected. PPH can also cause serious morbidities in the survivors. These ailments are severe, and the issues these women suffer from escalate and compound as time goes on. Among PPH survivors, it was estimated that 12% will suffer from the consequences of severe anemia. Sometimes it may result in blood transfusions which occasionally become lethal due to transfusion reactions.
Major Contributors To PPH
There are several factors which are responsible for increasing PPH mortality. Low-income countries have many home deliveries by unskilled providers. The septic environment adds fuel to the fire. Their belief in untrained people, rather than going to the health facility, is another social barrier. Health facilities, even if there, are either non-functional or lack human resources, necessary commodities, consumables and equipments. The middle-income countries have issues of appropriately functioning health facilities with inadequate vertical integration.
The causes remain same everywhere – THE CLASSICAL 4 Ts (Tone, Tissue, Tear, Thrombin/coagulation) — but the 4 DELAYS are different in different income countries. High-income countries have a different issue altogether; affluence can lead to obesity, hypertension, late marriages, and infertility treatments ending up in multiple pregnancies. The management of PPH at different countries may vary, but there are strong similarities in the basic treatment.
PPH is an obstetric complication that requires effective preventive interventions, tailored to the diverse needs of women and providers in resource-poor settings. There is a huge need to reduce PPH either by preventing it or by reducing its instances by appropriately managing it before it becomes lethal.
Why Reduce PPH
- To reduce maternal mortality ratio
- To reduce the case fatality rate
- To reduce transit deaths
- To reduce severe maternal morbidities associated with PPH
- To reduce surgical interventions associated with the management of PPH
- To reduce massive blood transfusions
- To reduce postpartum anemia
- To reduce the consequences of postpartum anemia leading to puerperal sepsis and other infections
- To provide the women best and respectful maternity care
The New Opportunity
With the rapid uptake of facility birthing care in the last 20 years – and quickly declining rates of home birth – a new opportunity to immediately treat PPH by trained staff has arisen. At the same time, a few cost-effective and simple methods have been fine-tuned and tested. These are the uterine balloon tamponade (UBT), the non-pneumatic anti-shock garment (NASG) and tranexamic acid (TXA) – apart from the previously well-known aorta compression. Responding to PPH at once with basic methods, and these four, can lead to almost complete elimination of PPH deaths. Harnessing this new opportunity requires the standardization of PPH prevention and treatment.
How Do We Act To Achieve This Goal?
The prevention and management of PPH is a joint responsibility of key health administrators at the national, state or province, and district/facility level, along with clinical and paraclinical health staff. The policies based on evidence are developed by administrators in the form of guidelines and should be implemented by the state and district administration in the various health facilities.
To achieve no PPH deaths, or at least a significant reduction in maternal deaths, it is important to have vivid guidelines that consider both non-clinical and clinical aspects in the management of PPH. These two aspects must work in tandem or neither of them will work well. The story of PPH begins with unawareness, unwillingness, nonavailability, untimely approach, unskilled personnel and so on and so forth; it ends in severe complications or death.
So There Is A Great Need To Have A Standardized Approach In The Management Of PPH
The standardized approach includes following steps:
• An awareness about antenatal, intranatal, and postnatal care with special reference to obstetric complications like PPH and its consequences – STRENGTHENING BPCR (Birth Preparedness and Complication Readiness) – for providers as well as pregnant women and their relatives. The universal guidelines of BPCR are to be developed, with special audiovisuals and awareness campaigns to be repeatedly held. This movement will address DELAY ONE.
• An awareness campaign for the various government programs that make the antenatal, intranatal, and postnatal care of mother, child-free, and other insurance schemes benefitting pregnant women. It is common to find that a patient's unwillingness is due to financial constraints, so advocating these programs is critical. This will address the second part of DELAY ONE.
• Awareness campaigns about the availability of government transport system, such as whom to call for ambulance assistance. These campaigns should be done at each local health facility and can be put as graffiti. At local levels, there should be an arrangement of emergency transports. The contact number and person should be also freely available at all times. This intervention will address DELAY TWO which is a major cause identified in MDSR in low and middle income countries.
• Availability of HELP LINES, by phone or WhatsApp, for communication before the woman arrives in the obstetric triage works as savior. The COMMUNICATION, bilateral, works as a feedback loop. It helps the providers arrange things for emergencies and prevent any further delay in management. The golden time to save the women, especially in rural areas, is minimal. Prior communication about the women also helps guide the health provider. The helplines should be advertised and should be available as graffiti. The system should be developed and should be functional where helpline phones are managed and responsive to calls. This again addresses DELAY TWO and beyond
• Referral protocols should be universal with a well-filled referral slip. This will be provided to the accompanying person who is trained in handling the emergency situation with proper communication. This too addresses DELAY TWO and beyond.
• Receiving the women and calling for help is a process and there should be a proper SOP for that too.
• Wherever the women is being referred, the FACILITY READINESS is extremely important. A systematically functioning unit in the form of obstetric triage, where there is a proper team division and each team member is aware of their responsibility, works better and has better outcomes. There is no chaos as all the emergency equipment, drugs, consumables, transport trolley, etc. are well-placed and ready to use. A facility readiness protocol and checklist must be there, as the emergency requirements are nearly the same, so a universal protocol has to be developed and additional equipments and other commodities can be added as per the level of facility. It addressed DELAY THREE.
• RED CODE/BLUE CODE/EMERGENCY RESPONSE TEAM organization, which includes multiple disciplines, should be preformed and should be immediately activated. The HDUs, ICUs, operation theater and blood bank should be well-informed to prevent unnecessary further delay. This addresses DELAY THREE.
• The team should be well-trained in triaging and dealing with emergency situations in obstetric triage itself. Then, a transfer to the specialized unit with a proper transfer protocol is necessary. The specialized unit takes care of further management. The rapid initial assessment and management by the first response proves to be the best in management of PPH cases. Advance management should be done in a specialized unit. A training protocol with SOP must be there for the same.
• CLINICAL PROTOCOLS for the management of a woman with PPH, in obstetric triage, in the critical emergency units and operation theater, should be universal. The addition of sophisticated, evidence-based management protocol can be added as per the facility. These protocols should have general, medical, and surgical management flow charts which can be followed globally. These protocols should be disseminated and should not be just recorded. The training sessions for medical personnel should be repeatedly taken and emergency drills should be conducted so everyone learns the right method of management of PPH.
• DEBRIEFING SESSIONS after each case help find the gaps in treatment. They are very important sessions and should be planned well with checklists.
• The follow up is an important measure to know the direction in which the facility is going. The outcome indicators should be specific so they can be monitored.
• The QUALITY ASSURANCE/QUALITY IMPROVEMENT is extremely important when we talk about STANDARDIZED CARE. The quality monitoring checklists and SOPs should be created and carefully monitored. Quality circle needs to be developed in all the facilities. If there is a scope of improvement it should be discussed. The quality improvement projects can be taken up by the facility and self-assessment can be done to improve their deficiencies.
Numerous Guidelines — Need For Standard Guideline
There are several guidelines developed by various societies and organizations which provide the details of management of PPH. Yet, one standard guideline, which includes the BUNDLE APPROACH, has yet to be developed. There is a need to put together non-clinical and clinical components together and then see the results, as generally the non-clinical components are ignored. These non-clinical components can often be the root cause for several maternal morbidities and mortality.
The various guidelines are:
- Royal College of Obstetricians and Gynaecologists (RCOG): This guideline provides information about the prevention and management of postpartum hemorrhage (PPH), primarily for clinicians working in obstetric-led units in the UK; recommendations may be less appropriate for other settings where facilities, resources and routine practices differ.
- World Health Organization (WHO) 2012 recommendations: This guideline covers the prevention and treatment of postpartum hemorrhage. Also refer to the 2017 guideline which talks about the use of tranexamic acid.
- WHO Guidelines for the Management of Postpartum Hemorrhage:
One of the Millennium Development Goals set by the United Nations in 2000 was to reduce maternal mortality by three-quarters by 2015. Beyond this, countries need evidence-based guidelines on the safety, quality, and usefulness of the various interventions. These will provide the foundation for the strategic policy and program development needed to ensure realistic and sustainable implementation of appropriate interventions. PPH is generally defined as blood loss greater than or equal to 500 ml within 24 hours after birth, while severe PPH is blood loss greater than or equal to 1000 ml within 24 hours. PPH is the most common cause of maternal death worldwide. Most cases of morbidity and mortality due to PPH occur in the first 24 hours following delivery and these are regarded as primary PPH whereas any abnormal or excessive bleeding from the birth canal occurring between 24 hours and 12 weeks postnatally is regarded as secondary PPH.
- ACOG Expands Recommendations to Treat Postpartum Hemorrhage:
ACOG recommends that all hospitals put organized, systematic processes in place to help coordinate the response and management of postpartum hemorrhage. In an effort to reduce rates of maternal mortality and morbidity nationwide, ACOG partners with 24 organizations to implement the Alliance for Innovation on Maternal Health (AIM), which includes the implementation of consistent maternity care practices for several conditions including obstetric hemorrhage. Today, 13 states and three health networks, representing 1.5 million births, are active participants."The important thing is for providers to be able to recognize the signs and symptoms of excessive blood loss earlier and to have the resources at hand for the prompt escalation to more aggressive interventions if other therapies fail," said Aaron Caughey, M.D., Ph.D., one of the authors of the updated Practice Bulletin and professor and chair of Obstetrics and Gynecology at Oregon Health & Science University.
- Management of Postpartum Hemorrhage (PPH – RANZCOG GUIDELNES)
H) Objectives: To provide advice on the management of postpartum haemorrhage. Outcomes: Minimizing risks for the patient associated with postpartum hemorrhage. Target audience: All health practitioners providing maternity care and patients. Values: The evidence was reviewed by the Women’s Health Committee (RANZCOG), and applied to local factors relating to Australia and New Zealand. Background: This statement was first developed by Women’s Health Committee in March 2011 and the last full review was conducted in March 2014, July 2017. Minor amendments were made in May 2015 and February 2016. Funding: The development and review of this statement was funded by RANZCOG.
But no guidelines talk about the bundle approach, which is evidence-based and is need of the hour. So, there is a great need for formulating standardized guidelines using a bundled approach for the management of PPH.
- World Health Organization (WHO) Reducing the global burden: postpartum haemorrhage. Making Pregnancy Safer. 2007;1(4):8
- World Health Organization (WHO) WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage.Geneva: WHO; 2012.
- World Health Organization (WHO) WHO recommendations on tranexamic acid for the treatment of postpartum haemorrhage. Geneva: WHO; 2017.
- Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum haemorrhage: United States, 1994–2006. American Journal of Obstetrics and Gynecology. 2010 Apr;202(4):353.e1–353.e6.
- Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle M-H, Ford JB, et al. Trends in postpartum haemorrhage in high resource countries: a review and recommendations from the International Postpartum Haemorrhage Collaborative Group. BMC Pregnancy and Childbirth. 2009;9(1):55
- Lutomski J, Byrne B, Devane D, Greene R. Increasing trends in atonic postpartum haemorrhage in Ireland: an 11-year population-based cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119(3):306–14.
- Haeri S, Dildy III GA. Maternal Mortality From Haemorrhage. Seminars in Perinatology. 2012 Feb;36(1):48–55