Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation

Abstract

Objective To systematically develop evidence‐based bundles for care of postpartum hemorrhage (PPH). Methods An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated “GRADE Evidence‐to‐Decision” framework. Twenty‐three global maternal‐health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6‐month period, the expert panel met online and via teleconferences, culminating in a 2‐day in‐person meeting. Results The consultation led to the definition of two care bundles for facility implementation. The “first response to PPH bundle” comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The “response to refractory PPH bundle” comprises compressive measures (aortic or bimanual uterine compression), the non‐pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements. Conclusion For the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Cost‐effectiveness of uterine tamponade devices for the treatment of postpartum hemorrhage: A systematic review

“…A conceptual framework was developed to clearly identify the role and possible cost consequences of using uterine tamponade in the management of atonic PPH (Fig. 1), informed by current WHO guidance on PPH prevention and management 4 . Extracted data were summarized using tables, and brief narrative summaries of principal results and differences between studies were constructed.…”

“…1), informed by current WHO guidance on PPH prevention and management. 4 Extracted data were summarized using tables, and brief narrative summaries of principal results and differences between studies were constructed. The currency and price year applicable to measures of costs in each study are reported alongside measures of costs, incremental costs and incremental costeffectiveness.…”

“…2,3 Most maternal deaths due to PPH could be avoided by routine use of an effective uterotonic for PPH prophylaxis, as well as prompt and effective PPH management. 4 Interventions recommended by WHO to manage PPH include fluid replacement, treatment with uterotonics and tranexamic acid, and use of non-surgical (bimanual compression, uterine balloon tamponade [UBT], non-pneumatic anti-shock garment, external aortic compression) and surgical (compressive sutures, arterial ligation, or hysterectomy) interventions. 5,6 If bleeding persists despite treatment with uterotonic drugs, tranexamic acid, and non-surgical interventions, surgical intervention should be used without delay.…”

“…5,6 If bleeding persists despite treatment with uterotonic drugs, tranexamic acid, and non-surgical interventions, surgical intervention should be used without delay. 4 WHO's 2012 guidelines on PPH prevention and management recommended that if a woman with PPH due to uterine atony does not respond to treatment using uterotonics (i.e., refractory PPH), or if uterotonics are unavailable, then UBT should be used (weak recommendation, very-low-quality evidence). 5 In this situation, trained, skilled health personnel insert a balloon catheter inside the uterus that (when filled) applies hydrostatic pressure to reduce blood flow and facilitate clotting.…”

“…The majority of these are postpartum hemorrhage (PPH), generally defined as blood loss of 500 mL or more within 24 hours after birth—a condition affecting an estimated 5% of all women who give birth 2,3 . Most maternal deaths due to PPH could be avoided by routine use of an effective uterotonic for PPH prophylaxis, as well as prompt and effective PPH management 4 . Interventions recommended by WHO to manage PPH include fluid replacement, treatment with uterotonics and tranexamic acid, and use of non‐surgical (bimanual compression, uterine balloon tamponade [UBT], non‐pneumatic anti‐shock garment, external aortic compression) and surgical (compressive sutures, arterial ligation, or hysterectomy) interventions 5,6 .…”