Actions for organisations and systems
The actions for organisations and systems are upstream: they involve putting in place the right conditions to reduce risk of PPH and enable effective clinical care.
To find out more about these upstream activities, see the free PPH EmC using the Bundle Approach online training in the resources section.
Using a standardised approach
A standardised approach to preventing and managing PPH highlights best practice across the system: upstream and downstream. At clinical level, care bundles offer particular benefits, highlighting actions for clinical health teams. These must take place alongside action to remove barriers in the wider system. That means involving non-clinical staff, such as key health administrators at the national, state, province, district and facility level, too.
Many of these involve small steps to reduce unnecessary delay as the ‘golden time’ to save a woman with PPH is minimal – especially in rural areas.
A standardised approach should include the following actions:
Birth preparedness and complication readiness
Make providers, pregnant women and their relatives aware of what happens before, during and after the birth. This should highlight potential complications such as PPH, using the universal strengthen birth preparedness and complication readiness guidelines, with audio-visual materials and awareness campaigns.
Government insurance schemes
Run awareness campaigns for the various government programmes responsible for insurance schemes covering care before, during and after the birth. Often, when women are unwilling to receive an intervention, this is due to financial constraints, so advocating these programmes is critical.
Put in place emergency transport arrangements and a 24-hour contact number, supported by awareness campaigns about the availability of government transport system (such as how to call an ambulance) at each local health facility, through graffiti.
Set up telephone or WhatsApp helplines that are managed and responsive to calls, widely advertised through graffiti. Helpline calls enable providers to make arrangements for emergencies before the woman arrives in obstetric triage and prevents further delay in management.
Standard operating protocols
Set up universal protocols. For example, a referral protocol should include a well-filled referral slip that can be provided to an accompanying person who is trained in handling the emergency situation, with proper communication. Receiving the women and calling for help is another process for which there should be a proper standard operating protocol.
Teams, pre-formed by red code, blue, code or emergency response and including multiple disciplines, should be activated immediately as soon as an emergency arises. Keep high-dependency and intensive care units, operating theatres and blood banks well informed to prevent unnecessary further delay.
Training in obstetric emergency and triage
The team should be well trained in triaging and dealing with emergency situations in obstetric triage itself. They should have a proper transfer protocol for transferring the patient to the special unit. After this transfer, the special unit takes care of further management. When managing PPH cases, rapid initial assessment and management is best carried out by the first response team, while advance management should be carried out in a special unit. A training protocol with standing operating procedures must be in place.
Make sure universal clinical protocols are in place for managing women with PPH – in obstetric triage, critical emergency units and operating theatres alike. Individual facilities may add their own sophisticated, evidence-based management protocols, with general, medical and surgical management flowcharts that can be followed globally. Make sure these protocols are disseminated – not just recorded. Medical staff should receive repeated training, with emergency drills conducted so that everyone knows the correct way to manage PPH.
After each case, carry out a debriefing session. This is very important as it help identify the gaps in treatment. Plan the session well, using checklists.
Follow up is another important measure as it reveals the direction in which the facility is going. Set specific outcome indicators that can be monitored over time, with clear processes and schedules for recording and analysis.
When it comes to standardised care, assessing quality and identifying areas for improvement is extremely important. Create quality monitoring checklists and standard operating protocols and monitor them carefully. Develop a participatory problem-solving approach such as quality circles in all facilities. Where this highlights areas for improvement, discuss these openly. Individual facilities should take on quality improvement projects, with self-assessment to assess progress – or, where wider issues arise, may require working alongside other system partners.
See also Facility readiness
PPH requires organisations across healthcare networks and related infrastructure to embed change. Change and organisational culture comes from the top, which means that leadership and change management skills play an essential role in tackling PPH. This includes leadership among local facility staff needing to implement change and problem-solve challenges. [I’ve added this - not sure sure what to say here]
Planning In any country, the responsibility for PPH prevention and treatment guidelines and the national maternal and neonatal health programme strategy lies with the Ministry of Health. But many different stakeholders can raise the issue of PPH to help the ministry start revisiting the national guidelines, strategy and programmes.
Often, health professionals with an interest in PPH (including some doctors, specialist obstetricians, gynecologists, midwives or nurses) become national champions and raise the issue – perhaps with
the help of their professional association. Revisiting the national PPH strategy is a first step to tackling deaths from PPH.
Data Monitoring and evaluation are essential for healthcare organisations and systems, to strengthen provision and ensure continual improvement over time, and these depend on good quality data. Strong systems for regular gathering and analysis of data are also essential for resource planning at local, regional and national level.
Whatever facility the women is being referred to, its readiness is extremely important. ‘Facility readiness’ is defined as achieving and maintaining a state of preparedness in a healthcare facility, to ensure that it is possible to consistently provide high-quality PPH emergency care, 24 hours a day, seven days a week. Achieving this readiness encompasses not only supplies and commodities, but factors that determine the ways people work, such as team readiness, availability of clinical and ancillary services, and postpartum monitoring protocols.
The best outcomes are found in units that function systematically, using obstetric triage and proper team division, where each team member is aware of their responsibility. In this situation, there is no chaos as all the emergency equipment, drugs, consumables and transport trolley are well placed and ready to use. This requires a facility readiness protocol and checklist to be in place, with a universal protocol developed and additional equipment and other commodities added according to the level of facility.
Teamwork and communication
Work to tackle PPH spans multiple levels – in local communities, in specialist healthcare facilities, and within non-clinical organisations (such as governmental bodies) and wider systems. This ensures that everyone has access to accurate data and that referrals and transfers are managed smoothly. This requires skills such as teamwork, communication, to ensure shared learning and care coordination beyond individual organisations and across healthcare networks, and to develop shared emergency response protocols , with regular drills and simulations.
PPH requires facilities to have the right supplies resourced at the right time. This process begins with national procurement and ends with delivery to local facilities. A reliable logistics system is needed to monitor stocks nationally and regionally to maintain supplies and ensure reliable storage - for example, where refrigeration is needed.