Postpartum Hemorrhage: Enhancing Outcomes for Mothers by Effective Management

Abstract

Postpartum hemorrhage (PPH) remains a significant contributor to maternal morbidity and mortality worldwide. In India, PPH affects approximately 12% of women. The prevention and management of PPH are the significant challenges in obstetrics, with accurate assessment of blood loss and timely intervention being critical. Active Management of the Third Stage of Labor is a gold standard strategy for prevention. Recent advancements in PPH management include the use of recombinant activated factor VIIa, which has shown promise in decreasing the need for invasive procedures and second-line therapies. Additionally, surgical and radiological interventions have been effective in cases of refractory PPH. Overall, ongoing research and advancements in PPH management continue to enhance the quality of care and maternal outcomes experiencing this potentially life-threatening complication of childbirth. This editorial explores prevention and management of Atonic PPH with encompassing medical and surgical strategies, to enhance understanding and optimize clinical care for mothers at risk of this obstetric emergency.

Introduction

Postpartum hemorrhage (PPH) contributes significantly to maternal morbidity and mortality globally, affecting approximately 1–10% of all deliveries. The incidence varies widely; in high-income countries, it ranges from 1 to 5%, while in low- and middle-income countries (LMICs), it can reach up to 10% [1]. Rural areas, such as those in India, experience particularly high rates, with PPH affecting approximately 12% of deliveries and increasing to 15% in subsequent pregnancies [2]. It is vital to highlight that 54% to 93% of maternal deaths due to obstetric bleeding can be prevented with the implementation of standardized and multidisciplinary programs [3].

According to WHO (2012), PPH is defined as blood loss exceeding 500 ml following vaginal birth and severe PPH is characterized as a loss of more than 1000 ml while in cases of caesarean birth, PPH is defined as blood loss exceeding 1000 ml [4].

Ministry of Health and Family Welfare (MoHFW) of India defines primary PPH as blood loss ≥ 500 ml from the genital tract within 24 h of delivery or a small blood loss that makes the woman hemodynamically unstable and severe PPH of blood loss > 1000 ml within 24 h of delivery [5].

Accurate assessment of blood loss, early identification of risk factors, and timely intervention and bundle approach are crucial in managing PPH. Effective management strategies involve the use of uterotonic agents such as oxytocin and carbetocin, which have proven effective in preventing PPH. Tranexamic acid is an additional strategy in our armamentarium [6]. Additionally, recombinant activated factor VII (rFVIIa) is emerging as a promising treatment for severe and refractory cases [7].

The management of PPH demands swift recognition and intervention, alongside multidisciplinary collaboration, to mitigate adverse outcomes and enhance maternal health. By adopting comprehensive and standardized approaches, we can significantly reduce the incidence and impact of PPH, ultimately saving lives and improving outcomes for mothers globally.

The prevention of PPH should be a primary goal in the care of all pregnant and postpartum women. Uterine atony is a leading cause of PPH, and its management should begin with a pelvic examination, removal of intrauterine clots, bladder emptying, and uterine massage. Prompt administration of uterotonic agents is crucial. Effective PPH management also involves proper care during the third stage of labor, with the delivery of placenta ideally within 30 min to reduce hemorrhage risks [8].

Active Management of the Third Stage of Labor (AMTSL) is considered as the gold standard for reducing PPH incidence. This strategy includes the routine administration of uterotonics after placental delivery, early cord clamping, and controlled cord traction to facilitate placental expulsion, promote uterine contraction, and minimize blood loss.

A comprehensive Cochrane analysis comparing Active Management of the Third Stage of Labor (AMTSL) with expectant management revealed compelling findings. Active intervention significantly lowered the risk of severe primary PPH, as evidenced by data from three studies involving 4636 women (risk ratio [RR] 0.34 [95% CI: 0.14, 0.87]; p = 0.024). Additionally, AMTSL was associated with a reduced incidence of mean hemoglobin levels falling below 9 g/dL, based on data from two studies comprising 1572 women (RR 0.50 [95% CI: 0.30, 0.83]; p = 0.0076). Furthermore, active management resulted in a notable decrease in mean maternal blood loss volume and a reduced necessity for additional uterotonics compared to expectant management [9].

Research has demonstrated that heat-stable Carbetocin is a highly effective and safe alternative to oxytocin for preventing postpartum hemorrhage (PPH) in women undergoing vaginal delivery as well as during caesarean section. Due to a longer half-life, its prolonged uterotonic effect allows for single-dose administration, reducing the need for repeated interventions and continuous monitoring. This simplifies the protocol and enhances cost-effectiveness by lowering overall healthcare costs. Carbetocin provides a more consistent uterotonic response, reducing the variability seen with oxytocin and improves patient outcomes. These benefits make carbetocin a valuable option for preventing PPH in both high-resource and low-resource settings [10].

Effective Initial Management for Postpartum Hemorrhage (PPH) After Vaginal Delivery

In the event of postpartum hemorrhage (PPH) occurring before the placental delivery, the first step is the manual removal of the placenta. If the placenta has already been expelled, the initial management should include a manual uterine examination, uterine massage, and the immediate administration of appropriate uterotonic therapy, adhering to professional consensus guidelines. These actions are essential for effectively managing PPH and preventing further complications.

If PPH persists despite these initial interventions, or in cases of heightened risk, a comprehensive visual assessment of the lower genital tract with adequate analgesia is recommended. This thorough examination can help identify and address the sources of bleeding, ensuring a multifaceted strategy for effective management.

The early use of tranexamic acid in managing PPH significantly reduces maternal morbidity and mortality. Clinical trials, such as the WOMAN trial [11], have shown that tranexamic acid reduces blood loss by about one-third when administered within three hours of birth. It has a strong safety profile, does not significantly increase the risk of thromboembolic events, and acts quickly to stabilize blood clots and reduce bleeding. It is cost-effective and easy to administer. It is accessible even in low-resource settings and can be used alongside other PPH interventions to enhance overall effectiveness [12].

Appropriate early management decreases the need for costly and lifesaving surgical operations. All health workers at all levels of care, especially in low- and middle-income countries (LMICs), must have access to proper drugs and be trained on PPH prevention and management procedures. Also, prioritizing measures that are cost-effective and resource-appropriate can help to reduce PPH vastly.

Incorporating the EMOTIVE Protocol and Bundle Approach

The EMOTIVE framework endorsed by the WHO presents a comprehensive strategy for managing postpartum hemorrhage (PPH), offering a structured and evidence-based approach to ensure optimal outcomes for mothers. By adhering to the EMOTIVE protocol, healthcare providers can effectively address PPH, reduce complications, and ultimately save lives. EMOTIVE expands as follows: [13]

• Early detection of blood loss: Prompt identification of excessive blood loss through accurate measurement and vigilant monitoring of clinical signs.

• Massage of the uterus: Immediate and continuous massage of the uterus promotes uterine contraction, aiding in the control of bleeding.

• Oxytocic drugs: Timely administration of uterotonic agents such as oxytocin helps to further stimulate uterine contractions and minimize blood loss.

• Tranexamic acid and IV fluids: Tranexamic acid helps to promote clot formation, thus reduces bleeding, while IV fluids maintain hemodynamic stability and optimize tissue perfusion.

• Examination and escalation: A thorough examination of the patient, including assessment of vital signs and clinical status, guides decision making and treatment escalation. Structured escalation protocols ensure a coordinated response to PPH, with timely initiation of advanced interventions as needed.

Embracing EMOTIVE aligns with WHO recommendations represents a proactive step toward enhancing maternal health worldwide.

The bundle approach integrates multiple evidence-based interventions into a cohesive protocol to ensure all aspects of PPH management are addressed systematically. This approach includes [14]:

• First response bundle: Use of IV fluids for resuscitation, uterine massage, administration of uterotonics, identifying and repairing any genital tract trauma, emptying the uterus of remaining part of placenta and membrane and supportive care like emptying the bladder

• Refractory response bundle: involves compression, use of uterine balloon tamponade, antishock garment and implementation of advanced interventions including surgical procedures like B Lynch compression sutures, uterine artery ligation, step-wise devascularization, internal iliac ligation or hysterectomy. These measures are reserved for cases where initial management efforts fail to control hemorrhage or when there are signs of ongoing bleeding despite primary interventions

By combining the EMOTIVE trial's recommendations with the bundle approach, healthcare providers can significantly improve the initial management of PPH, thereby enhancing outcomes for mothers and reducing the risk of severe complications.

Use of rFVIIa in Massive PPH

Recombinant factor VIIa (rFVIIa) is proving to be a valuable treatment for severe and refractory postpartum hemorrhage (PPH). It promotes effective hemostasis by directly activating the coagulation cascade, even in the presence of coagulopathy, making it particularly useful when traditional methods fail. Clinical studies have shown that rFVIIa can reduce the need for surgical interventions like hysterectomy, preserving fertility and saving lives. Its rapid action is crucial in emergencies, helping to stabilize patients quickly. The primary outcome was to assess reduction in PPH, hence the need for decrease in second-line therapies. It was found that rFVIIa significantly decreased this requirement compared to standard care (52% vs. 93%). Additionally, rFVIIa can be used alongside other PPH treatments, such as uterotonics and tranexamic acid, to provide a comprehensive approach. In cases where bleeding persists despite standard interventions, rFVIIa significantly reduces blood loss and improves patient outcomes, making it an essential tool in managing life-threatening PPH. It is strategic to keep recombinant factor VIIa available in the hospital stock, so that it can be appropriately used in emergency [15, 16].

Surgical Interventions

Surgical intervention for managing postpartum hemorrhage (PPH) should be promptly employed following unsuccessful drug therapy, ideally within the ‘golden hour.’ In these situations, vascular ligation and uterine compression sutures are prioritized over hysterectomy to preserve fertility and minimize morbidity. Step-wise wise devascularization is the mainstay of surgical management. Additionally, evolving devascularization techniques may further enhance surgical outcomes. Combining uterine compression sutures with uterine artery ligation enhances the overall effectiveness of surgical PPH treatment by providing mechanical compression to the uterus and reducing bleeding. However, we should remember that in case of massive hemorrhage, rapidly performing a peripartum hysterectomy can prove lifesaving and should be quickly resorted to. When a patient with PPH enters the lethal triad of hypothermia, acidosis, and coagulopathy, damage control surgery becomes necessary. This approach focuses on temporarily controlling bleeding and stabilizing the patient, with definitive surgery planned once the patient's condition is stabilized [17].

Adopting Innovations

The SR canula is a promising innovation in the management of PPH, offering several advantages in effectively controlling bleeding and improving patient outcomes. The canula's design allows for rapid and efficient evacuation of blood and clots from the uterine cavity, facilitating the control of hemorrhage and enhancing visualization for further intervention. As a minimally invasive device, the SR canula can be swiftly deployed at the bedside without the need for complex surgical procedures, making it particularly advantageous in emergency situations [18].

Implementing effective PPH management protocols faces several challenges, particularly in low-resource settings. Limited access to essential medications, inadequate training of healthcare providers, and a lack of standardized guidelines contribute to suboptimal outcomes. Additionally, cultural and logistical barriers may hinder timely access to care for many women, further complicating efforts to manage PPH effectively.

Recommendations

Several key recommendations should be considered to enhance the management of atonic PPH and improve maternal health outcomes. Firstly, the adoption of standardized evidence-based guidelines for PPH management is crucial. These guidelines should be disseminated widely and supported by robust training programs for healthcare providers. A multidisciplinary approach, involving Obstetricians, midwives, anesthesiologists, and other professionals, is essential to ensure comprehensive care. Moreover, increasing access to affordable medications and promoting community and patient education can help to raise awareness and improve early recognition and treatment of PPH.

Conclusion

Addressing postpartum hemorrhage requires a concerted effort to implement standardized management protocols, enhance training and education, and improve access to essential treatments. By adopting a multidisciplinary approach and focusing on both healthcare provider and patient education, we can significantly reduce the incidence and severity of PPH, ultimately saving lives and enhancing outcomes for mothers worldwide. Immediate action is needed from all stakeholders to make maternal health a priority and to ensure that no mother is lost to preventable postpartum hemorrhage. This aligns with the Sustainable Development Goals (SDGs), particularly SDG 3, which aims to ensure healthy lives and promote well-being for all ages. By prioritizing maternal health and implementing effective strategies for managing PPH, we contribute to the global effort to achieve these critical health objectives and improve maternal outcomes on a global scale.