Postpartum Haemorrhage: Causes and Care

Introduction

Postpartum haemorrhage (PPH) refers to increased maternal blood loss (500mls or more within 24 hours),following childbirth (Salati et al. 2019).Postpartum Haemorrhage can occur due to mismanagement of the third stage of labour by health professionals (Salati et al. 2019). Therefore, in this study, the postpartum haemorrhage management in regard to midwifery and nursing care for pregnant women will be explored. For this purpose, a rationale is provided along with literature is reviewed to gather evidence for discussion and recommend the evidence-based practice.

Rationale of the topic

Postpartum haemorrhage (PPH) which creates increased blood loss while giving birth may lead to shock or even maternal death (Mousa et al. 2014). The statistics regarding PPH in MBRACE informs that in 2014-16 nearly 9.8 women out of 100,000 died due to complication after pregnancy. It is reported that 8 out of 100,000 white women, 15 out of 100,000 Asian women and 40 out of 100,000 Black women die each year due to PPH during pregnancy in the UK (MBRACE, 2018). This indicates that though the numbers of death due to PPH are low but they are significant and creates issues of patient safety among women during pregnancy. Moreover, PPH is regarded as the third leading cause of death among pregnant women (Royal College of Obstetricians and Gynaecologists, 2016). Therefore, it indicates that postpartum haemorrhage management and prevention is to be ensured so that maternal deaths can be prevented and safety can be assured to women while giving birth from experiencing any adverse health condition.

Aim

The aim of the study is to explore postpartum haemorrhage management and its effect on patient safety.

Learning Outcomes

Explore the evidence surrounding the management of PPH

Make recommendations to improve the management of PPH to improve patient safety

Literature Review

A literature search was performed to identify five pieces of evidence that could be critiqued to address the aim of this study. An electronic search was performed through searching databases i.e. Google Scholar, CINAHL, NIH, Cochrane Library and others. The keywords used for researching and finding literature include 'postpartum haemorrhage', "management of postpartum haemorrhage', 'medication for postpartum haemorrhage' and others. The literature published after 2016 was included to provide the most contemporary evidence surrounding the management of PPH (Cooper et al. 2018). On the basis of the research, the five pieces of literature to be reviewed are Muñoz et al. (2019), Pickering et al. (2019), Nelissen et al. (2017), Angelina et al. (2019) and Vogel et al. (2019).

Article 1:

The study by Muñoz et al. (2019) provided information on the position of Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) along with European Board and College of Obstetrics and Gynaecology (EBCOG), the International Federation of Gynaecology and Obstetrics (FIGO) and the European Society of Anaesthesiology (ESA). The target sample for whom the recommendations are provided include the clinical practitioners involved in perinatal care for pregnant women in all settings and policy-makers involved in upgrading the clinical practice for healthcare institutions. The research article is a descriptive study in which patterns of management of postpartum haemorrhage in women are examined. The advantage of descriptive studies is that it allows the researchers to clearly present the information in in-depth manner ensuring a holistic understanding regarding the study topic is able to be gathered from the piece of study (Çalik et al., 2018). It allows presentation of clarified information about patient blood management in postpartum haemorrhage to improve clinical decision-making by the clinical staffs about the activities to be done to avoid the safety issues faced due to the condition among the women (Muñoz et al., 2019). Muñoz et al. (2019) mentioned that patient blood management (PBM) is evidence-based surgical and medical concept that are framed for maintaining adequate concentration of haemoglobin, optimise haemostasis and lower loss of blood in the effort to enhance patient outcomes. The aim of the study is to provide recommendations regarding the control and management of postpartum haemorrhage as part of patient blood management in the obstetrics unit. The findings in the study mention that risk factors which influence the risk of postpartum haemorrhage are to be differentiated according to the time of their occurrence and their frequency are to be determined. This is because it would help clinicians be aware of the factors to be controlled to avoid safety issues related to occurrence postpartum haemorrhage among women. The findings also mentioned that to prevent postpartum haemorrhage (PPH) in women with risk of anaemia, they are to be treated for the condition prior to giving birth and are to be advised to give birth in hospital (Muñoz et al., 2019). This is because it would allow the clinical staffs to implement the multimodal protocol to manage postpartum haemorrhage. It is also mentioned that if case compatible blood is not present for the patients at risk of postpartum haemorrhage, the pre-operative autologous blood donation is to be made to ensure adequate compatible blood is present for transfusion to control postpartum haemorrhage.

Article 2:

The studyby Pickering et al. (2019) has the key objective to determine the most cost-effective uterotonic drug to be used for prevention of postpartum haemorrhage (PPH) so that patient safety can be assured. In this respect, the study mentioned that Carbetocin use is the most effective strategy for controlling postpartum haemorrhage to save the lives of pregnant women. This is because it is heat tolerant making it easier to be used in resource-poor settings and has greater biological effect compared to oxytocin that is usually used in managing PPH (Pickering et al., 2019). This study is a model-based economic evaluation to determine impact of data from the meta-analysis and is set in the United Kingdom. The results inform that incremental ratio of cost-effectiveness for Carbetocin when compared with ergometrine and oxytocin to prevent PPH, revealed that the former needed £1889 per case of PPH ≥ 500 mL avoided while the later required £928 per case of PPH ≥ 500 mL avoided. This informed that oxytocin with ergometrineis the least cost-effective strategy to be used for the prevention of PPH compared to Carbetocin. However, Carbetocin use could be preferred in management of PPH in case its cost it is reduced as it provides better biological impact in preventing and managing PPH compared to oxytocin use (Pickering et al., 2019).

Article 3:

The study by Nelissen et al. (2017) informed that postpartum haemorrhage (PPH) is the key health issue responsible for mortality among pregnant women while giving birth. The study aims to examine the impact of obstetric simulation-based training on managing PPH and clinical performance for primary delivery management. This study is a prospective educational intervention which is executed in rural referral hospital which is based in Tanzania. The prospective educational design is beneficial because it lead the research to reflect on support needed by clinicians in clinical environment to accomplish their tasks (Yoshidaet al., 2020). Thus, the use of this design is helpful for the study to mention the skills to be acquired by the clinical staffs to prevent and manage risk and safety of health out of PPH in women. In the study, 3622 births prior to the intervention and 5824 birth after the intervention were analysed. The results informed that PPH reduced from 2.2% in births to 1.3% after the intervention (Nelissen et al., 2017). There was significant increase of controlled removal of placental cord from 96.5% to 98.8%, oxytocin use from 87.8% to 91.7% and uterine massage after birth from 93% to 99% in preventing and managing PPH. This indicated that involvement of simulation training among the obstetrics staff is effective to enhance their skills and knowledge required in taking actions to manage PPH in women and assure their safety from blood loss that leads towards mortality. It is evident as 38% decrease in postpartum haemorrhage among women is seen and enhanced better clinical performance along with safety for the patients is seen after the training intervention in the study (Nelissen et al., 2017).

Article 4:

The study by Angelina et al. (2019) mentioned that postpartum haemorrhage is one of the key health issues for death among pregnant women during delivery. This is evident as 25% of maternal deaths occur as a result of postpartum haemorrhage in Tanzania. The study focuses to identify the factors that could influence skill and knowledge of the nurses for management of postpartum haemorrhage and assure patient safety. The study is executed by considering 172 nurses as sample who is working on Dodoma, Tanzania. The study is executed by implementing cross-sectional study design which is beneficial as using it leads the researcher to identify the prevalence of multiple factors under examination (Moustafa et al. 2017). The cross-sectional study design is appropriate for this study as it helps to examine the impact or extent of efficiency of measures taken in managing the disease or health complication overtime (Moustafa et al. 2017). The results inform that registered nurses who are over 40-years-old are 11 times more skilled compared to nurses of 20-29 years working within the maternity ward to prevent postpartum haemorrhage. Moreover, nurses who have minimum of 3 years of professional training are found 4 times more efficient compared to others who have less than 3 years of training in managing postpartum haemorrhage for ensuring patient safety. The nurses with 5 years of experience of working in a maternity ward are seen to have 9 times more effective ability to predict and manage postpartum haemorrhage compared to those who have less than 5 years of working experience. Thus, findings by Angelina et al. (2019) indicated that nurse’s age, experience and training are effective factors to be considered for postpartum haemorrhage management. This is because these factors lead nurses to have enhanced theoretical and practical experience, skill and knowledge to determine ways in which postpartum haemorrhage can be managed to prevent mothers from dying due to excessive loss of blood after giving birth (Angelina et al., 2019).

Article 5:

In the study of Vogel et al. (2019), the aim is to mention the WHO recommendation of using uterotonics in managing postpartum haemorrhage. The study is descriptive in nature which is effective for the presentation of information in this article as it provided detailed information about the recommendations for managing postpartum haemorrhage in women (Vogel et al., 2019). It is mentioned that use of uterotonic in the third stage of labour during birth is effective to prevent and manage postpartum haemorrhage along with assuring patient safety. This is evident as active management and use of uterotonics in women lead to reduction of anaemia and PPH in 1572 women after birth.The findings mentioned that use of oxytocin as uterotonic is to be done for managing and prevention of postpartum haemorrhage in all nature of births. This is because it leads the uterus to contract in quicker manner as well as the contraction is seen to last for long-term ensuring patient safety by avoiding blood loss out of relaxed uterus after giving birth. The findings mention that Carbetocin is to be used for prevention of postpartum haemorrhage in condition where expenses for the treatment are needed to be low. This is because it is cost-effective way of managing postpartum haemorrhage compared to oxytocin but is not effective like oxytocin to provide long-term prevention. It is also mentioned that uterotoniclike ergometrine is to be used for births in patients expect those who suffer from the hypersensitive disorder (Vogel et al., 2019). In condition, where oxytocin is not available the use of other uterotonics are to be made or administration of oral misoprostol is to be made orally for preventing postpartum haemorrhage to ensure patient safety. This is because the use of following medications are going to act in lowering blood loss after giving birth, in turn, ensuring the patient's safety to live a healthy life. The study mentioned that injectable prostaglandins are not to be used for prevention and management of postpartum haemorrhage. This is because it is found that they are unable to be effective like oxytocin in controlling blood loss along with are cost in nature and have increased adverse side-effects on the heath of the patients that compromises with their safety and well-being(Vogel et al., 2019).

Discussion

The existing literature reviewed informed that postpartum haemorrhage to be leading cause of maternal deaths. In the study by Angelina et al. (2019), it is mentioned that insufficient skills and knowledge among the nurses and midwives during labour management and birth are responsible for the incidence of mortality and patient safety issues in postpartum haemorrhage. This is because lack of hands-on experience and skills through training and working experience leads the healthcare staff develop confusion regarding the way postpartum haemorrhage is to be managed so that the excessive blood flow can be immediately controlled. The fact is supported by the study of Evans et al. (2014) where it is mentioned that prolonged training at work leads the nurses and midwives to develop effective critical analysis skills to adequate recognise and treat the condition without any confusion. Further, the study mentioned that high frequency stimulated practice contributes to enhanced skill retention among nurses for managing postpartum haemorrhage in an effective way for patient safety from death. The existing literature by Vogel et al. (2019) informs that use of oxytocin is to be made for managing postpartum haemorrhage as it is the most effective uterotonic in controlling bleeding in this condition and ensure patient safety. The fact is also supported by the WHO guidelines where it is mention that 10 IU, IM/IV amount of oxytocin is to be used in all nature of births to control postpartum haemorrhage and ensure safety from mortality to the patient (WHO, 2017). The study of Pickering et al. (2019) mentioned that use of oxytocin is the most effective way of controlling and management postpartum haemorrhage as it provides immediate impact to control blood flow by contracting uterus. Therefore, oxytocin is the primary uterotonic agent to be used for patient safety and reduction of mortality caused by postpartum haemorrhage. The study by Vogel et al. (2019) has mentioned that injectable prostaglandins are not to be used in managing postpartum haemorrhage. The fact is also supported in the WHO recommendation for management of postpartum haemorrhage (WHO, 2017). This study has also mentioned that carbetocin to be used as uterotonic in managing postpartum haemorrhage under cost-effective condition. The fact is supported by the study of Pickering et al. (2019), where it is mentioned that Carbetocin is the cost-effective way of controlling and managing postpartum haemorrhage to assure patient safety. The fact is also supported in the study of Voon et al. (2018) where it is reported that use of Carbetocin in managing postpartum haemorrhage for caesarean birth lead to cost $20,925.30 compared to $25,354.03 for use of oxytocin in this condition. Thus, Carbetocin could be used postpartum haemorrhage management and ensure safety from mortal condition of the patients in cost-effective way.

The study by Nelissen et al. (2017) reported that simulation-based training is effective in managing and preventing postpartum haemorrhage among patients to ensure safety from death. This is evident as 38% reduction in incidence of postpartum haemorrhage in the setting was seen after the introduction of the training. The fact is supported by the study of Egenberg et al. (2017) where pre and post-intervention results on training to control postpartum haemorrhage is taken. The study revealed that there is a 47% drop in postpartum haemorrhage incidence among patients ensuring greater safety. In this study, similar information is provided regarding the impact of training in the process as mentioned in the study by Nelissen et al. (2017). This is evident in this study it was reported that during training, debriefing session is organised where discussion regarding the way of actions in managing postpartum haemorrhage is done for future implication. It led to enhanced critical thinking like mentioned in the previous study for effectively managing postpartum haemorrhage among mothers and prevent them adverse health condition. In the study by Muñoz et al. (2019), it is mentioned that risks of postpartum haemorrhage among women are to be determined early for their safe healthcare and to avoid mortality. The risks identified are multiple pregnancy, pre-labour caesarean section, episotomy and others. In support, the study by Basoraet al. (2018) mentioned that episiotomy is performed in second stage labour for immediate opening of the uterus for passing the baby. In this case, the trauma sustained in the process may lead to considerable loss of blood leading to cause postpartum haemorrhage. Thus, episotomy is evident to be considered as one of the risks of postpartum haemorrhage. The study by Muñoz et al. (2019) like the previous studies of Vogel et al. (2019) and WHO (2017) also mentioned oxytocin to be potential uterotonic in managing and preventing postpartum haemorrhage. In similar to the study by Muñoz et al. (2019), the article by Park (2013) mentioned that Haemoglobin determination of mother with antenatal anaemia at the initiation of labour is to be checked so that adequate arrangement of blood transfusion can be made to ensure prevention of postpartum haemorrhage and safety from mortality of the patients.

Conclusion

The above discussion mentioned that postpartum haemorrhage is a potential patient safety issues because in the UK it is considered as third most common reason for death among mothers while giving birth. Further, it creates deteriorated impact in psychological health of the patients making them suffer adverse health condition. The existing literature mentions that postpartum haemorrhage management includes use of oxytocin as key uretonics and it ensures patient safety as it creates quick and long-term impact on controlling contraction of uterine to avoid excessive loss of blood. Moreover, it is mentioned that patient blood management is required for effective control of postpartum haemorrhage to assure safety from mortality of the mothers while giving birth.

Recommendations

The reviewed literature recommends that effective training and education to the nurses and midwives are to be provided regarding postpartum haemorrhage so that they have adequate knowledge and critical thinking skills in recognising patients to be at risk of the condition. Moreover, the training is required by the nurses for postpartum haemorrhage management so that they can develop hands-on experience in controlling the condition and ensure successful safety of health of the patients. It is further recommended that oxytocin is the initial choice of uterotonic to be made and in case of cost-effectiveness condition to manage postpartum haemorrhage, the Carbetocin is to be used. The future recommendation is that Hb (haemoglobin) concentration in blood of the pregnant mothers before entering labour is to be checked. Moreover, risk assessment of pregnant mothers for experiencing postpartum haemorrhage is to be determined by nurses so that they can remain alert to take actions, in case of blood loss, while giving birth and assure safety from death of the patients.