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The impact of postpartum haemorrhage management guidelines implemented in clinical practice: a systematic review of the literature
European Journal of Obstetrics & Gynecology and Reproductive Biology 178 (2014) 21–26
Postpartum haemorrhage (PPH) is an urgent obstetric condition requiring an immediate response and a multidisciplinary approach. The aim of this study was to review PPH management guidelines implemented in clinical practice, to evaluate their impact regarding prevention, diagnosis and treatment, and to analyze how the numbers of PPH cases changed in the post-intervention period. A systematic search in the PubMed database was performed. The references of all included articles were examined. Studies evaluating the management of PPH and the impact on the numbers of cases of this pathology after the implementation of new or updated guidelines were involved in the analysis. Two reviewers independently examined the titles and abstracts of all identified citations, selected potentially eligible studies, and evaluated their full-text versions. Methodological quality was assessed using a checklist based on the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement. We analyzed seven articles that evaluated the impact of new or updated guidelines for PPH management implemented in clinical practice. In four trials, the numbers of PPH cases declined after the intervention. Guidelines for PPH management can have a positive impact on the reduction of the number of PPH cases.
Keywords: Postpartum haemorrhage, Management, Guidelines, Outcomes.
According to the World Health Organization (WHO), postpartum haemorrhage (PPH) is defined as a condition when the estimated blood loss is >500 ml after vaginal delivery and >1000 ml after caesarean section  . Although WHO reports that PPH complicates about 2% of deliveries  , studies from Israel, India and the Netherlands report incidences of 0.4%, 9.2% and 19% respectively  . PPH is a life-threatening obstetric emergency caused mainly by uterine atony, genital tract trauma, retained placental tissues and coagulopathies  . It is one of the leading direct causes of maternal mortality globally  . One of the Millennium Development Goals of the United Nations is to reduce maternal mortality by 75% by 2015  . Various studies have shown that one of the easiest ways to reach this goal is to reduce the number of PPH cases  . Guidelines for prevention, diagnosis and treatment can standardize proper management of PPH cases. Despite the fact that various guidelines are created by different authors, the main information in them is similar and based on the same principles that are detailed in many books and textbooks  .
The aim of this study was to review PPH management guidelines implemented in clinical practice, to evaluate their effectiveness in prevention, diagnosis and treatment and to analyze how the numbers of PPH cases changed in the post-intervention period.
2. Materials and methods
The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analyses) statement was used to carry out this systematic review of the literature  . The methodology from the WHO Systematic Review on Maternal Mortality and Morbidity  was adapted and used in this review.
2.1. Criteria for including studies
Cohort studies and randomized trials evaluating the management of PPH and the impact on the numbers of cases of this pathology after the implementation of new or updated guidelines were included ( Table 1 ).
|Author (reference)||Country||Setting||Study design||Sample size (number of deliveries)||Guidelines development||Implementation of the guidelines|
|Sheikh et al. ||Pakistan||Hospital (academic centre)||Before-and-after study||4881||4052||Study authors (guidelines available at: http://www.biomedcentral.com/1471-2393/11/28/suppl/S1 )||Theoretical and training sessions|
|Shields et al. ||USA||Hospital||Before-and-after study||2939||2874||Multidisciplinary team (guidelines available at: http://www.cmqcc.org/ob_hemorrhage )||Theoretical and training sessions|
|Skupski et al. ||USA||Hospital (IIIrd level maternity unit)||Before-and-after study||5811||12,912||Multidisciplinary team||Theoretical and training sessions|
|Rizvi et al. ||Ireland||Maternity hospital||Before-and-after study||3176||3300||Study authors||Theoretical and training sessions|
|Audureau et al. ||France||Nineteen hospitals (Ist, IInd and IIIrd level maternity units)||Before-and-after study||17,664||17,722||Multidisciplinary team||Theoretical sessions|
|Althabe et al. ||Argentina, Uruguay||Ten maternity hospitals||Cluster-randomized trial (Current Controlled Trials number ISRCTN82417627)||2963||2587||Obstetrics department staff||Theoretical and training sessions|
|Figueras et al. ||Nicaragua, Peru, the Dominican Republic, Argentina and Guatemala||Five hospitals (academic centre)||Before-and-after study||1008||797||Obstetrics department staff||Theoretical and training sessions|
Studies were not included in this review if they: (i) analyzed the outcomes related to PPH that changed after the audit, (ii) retrospectively analyzed PPH management without introducing new or updated guidelines for it, (iii) analyzed the influence of a certain drug or action on the outcomes related to PPH, (iv) described preparations for future study related to PPH management, (v) were unavailable, (vi) were published in languages other than English, and the amount of information provided by the abstract was insufficient for our analysis.
2.2. Search strategy
A systematic literature search was conducted using the electronic PubMed database. No data limit was applied. The following key words were used: ‘postpartum’, ‘haemorrhage’, ‘protocol’ and ‘guidelines’. Key references from analyzed articles were examined for additional material. The following journals were hand-searched: BJOG: An International Journal of Obstetrics and Gynaecology, European Journal of Obstetrics & Gynaecology and Reproductive Biology, Acta Obstetricia et Gynecologica Scandinavica, Obstetrics & Gynecology and Lancet. Relevant publications from the (i) World Health Organization, (ii) International Federation of Gynecology and Obstetrics (FIGO) and (iii) Cochrane database were checked. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom was also analyzed  .
2.3. Screening and data extraction
Two reviewers independently evaluated the titles and abstracts of all identified citations for eligibility. Studies that directly addressed our aim were included. Review articles, recommendations, guidelines, statements and studies not directly related to the implementation of the guidelines for the management of PPH were excluded from this review ( Fig. 1 ). When a title or an abstract provided insufficient information required to decide on inclusion/exclusion, the full-text articles published in English were retrieved.
The methodological quality of all included studies was assessed ( Table 2 ). Based on the STROBE statement  , we used the following criteria: description of (i) study period, (ii) study setting, (iii) data collection, (iv) population characteristics, (v) statistical methods, (vi) guidelines for the management of PPH: prevention, diagnosis or treatment, (vii) criteria for PPH, and (viii) interpretation of the results related to the change in PPH. Each positively answered criterion scored 1 point. The studies were ranked in three quality categories: high (10 points), moderate (9–7 points) and low (6–0 points). No additional criteria were used for the randomized trial included in this study, because we evaluated only the control group and the results before and after the intervention. All eligible articles were independently analyzed by two reviewers. All discrepancies were discussed and resolved by consensus or by a third reviewer.
|Study period||Study setting||Data collection||Population characteristics||Statistical methods||Description of guidelines||PPH criteria||Interpretation of PPH change||Quality of the study|
|Sheikh et al. ||Yes||Yes||Yes||No||Yes||Yes||Yes||Yes||Yes||Yes||Moderate|
|Shields et al. ||Yes||Yes||Yes||No||Yes||Yes||Yes||Yes||Yes||Yes||Moderate|
|Skupski et al. ||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||High|
|Rizvi et al. ||Yes||Yes||Yes||Yes||No||Yes||Yes||Yes||Yes||Yes||Moderate|
|Audureau et al. ||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes||High|
|Althabe et al. ||Yes||Yes||Yes||Yes||Yes||Yes||No||No||Yes||No||Moderate|
|Figueras et al. ||Yes||Yes||Yes||No||Yes||Yes||No||No||No||No||Low|
PPH, postpartum haemorrhage.
2.4. Data processing
Data regarding the guidelines for PPH management and the change in the numbers of PPH were extracted and analyzed. We evaluated data that were presented in graphs and figures in the form of numbers (or percentages) or described in the text. Specification of some data was needed from authors in California. The analyzed studies were original, and therefore no search was made for data duplication.
We identified 277 articles using the keywords mentioned above. After the review of titles and abstracts, 238 studies were excluded. Those were studies not directly related to the implementation of the guidelines for PPH management (52.5%), review articles (38.5%), and recommendations, guidelines or statements (9%). Thirty-nine citations were potentially eligible for further evaluation. After the analysis of full texts, seven studies were included for data abstraction.
Most of the trials were cohort studies and only one study was a randomized trial. Studies were performed in European, Asian, and North and South American countries. They took place in one or several hospitals.
The authors of the trials performed in Pakistan and the USA fully described the implemented guidelines in their articles , , and . Rizvi et al. and Audureau et al. described only the main steps of their standards  and . The guidelines published by Althabe et al. and Figueras et al. were presented inadequately for analysis  and .
The most common step in the management of PPH was prevention through active management of the third stage of labour ( Table 3 ). As a preventive tool, evaluation of PPH risk before delivery was highlighted in two guidelines developed in the USA  and .
|Author (reference)||Principles of the guidelines||Definition|
|PPH risk evaluation||PPH prevention (AMTSL)||PPH diagnosis||PPH treatment pointed at||PPH||Severe PPH|
|Sheikh et al. ||No||Yes||Blood loss calculation||• Uterotonics||Not specified||• Blood loss > 1500 ml|
|• Placental tissues|
|• Blood transfusion|
|• Conservative operations|
|Shields et al. ||Yes||Yes||Blood loss calculation, vital signs evaluation||• Uterotonics||• Blood loss > 500 ml after vaginal delivery||• Blood loss ≥ 1500 ml|
|• Placental tissues||• Blood loss > 1000 ml after caesarean section|
|• Blood transfusion|
|• Conservative operations|
|Skupski et al. ||Yes||Related to placental pathology||Blood loss calculation, interventions||Multidisciplinary approach||Not specified||At least one of the following criteria:|
|• blood loss ≥ 1500 ml,|
|• need for blood transfusion,|
|• need for uterine packing,|
|• performance of uterine artery ligation,|
|• performance of caesarean hysterectomy|
|Rizvi et al. ||No||Yes||Blood loss calculation||• Uterotonics||Not specified||At least one of the following criteria:|
|• Placental tissues||• postpartum haemorrhage > 2500 ml,|
|• Trauma||• blood transfusion 8 units,|
|• Blood transfusion||• development of disseminated intravascular coagulation|
|• admission to the High Dependency Unit|
|Audureau et al. ||No||Yes||Blood loss calculation||• Uterotonics||Not specified||At least one of the following criteria:|
|• Placental tissues||• blood transfusion of at least one unit,|
|• Trauma||• arterial embolization, arterial ligation, or other conservative uterine surgery,|
|• Blood transfusion||• hysterectomy,|
|• peripartum haemoglobin delta of 4 g/dl or more|
|• maternal death|
|Althabe et al. ||No||Yes||Not specified||Not specified||Blood loss > 500 ml after vaginal delivery||Blood loss > 1000 ml after vaginal delivery|
|Figueras et al. ||No||Not specified||Not specified||Not specified||Not specified||Not specified|
PPH, postpartum haemorrhage; AMTSL, active management of the third stage of labour.
The main criteria for defining postpartum or severe postpartum haemorrhage were described in six trials , , , , , and . Most often they included blood loss and transfusion of blood products. When defining severe PPH, the authors of different trials based the same diagnosis on different amounts of blood loss ranging from 1000 ml to 2500 ml. The quantity of transfused blood products ranged from 1 to 8 units.
The treatment of PPH was detailed by the authors of the trials performed in Ireland, France, Pakistan and the USA , , , , and . Treatment based on a multidisciplinary approach was highlighted in the studies from the USA. The most common treatment principles, such as additional uterotonic drugs, evaluation of the placenta and birth canal, and blood transfusion, were mentioned in all of these guidelines. In a Californian trial, PPH treatment based on changes in vital signs was also highlighted  .
The number of postpartum or severe postpartum haemorrhage cases declined in four trials after the new or updated guidelines were implemented ( Table 4 ) , , , and . In all these studies, new or updated guidelines were implemented during theoretical and training sessions. In the trials performed by Rizvi et al. (analysis of severe PPH cases), Althabe et al. (analysis of PPH and severe PPH cases) and Figueras et al., the number of PPH cases declined after the intervention by 73.5% (p < 0.001), 62.9% (p = 0.03) and 73.3% (p = 0.007), and 61% (p < 0.05), respectively , , and . An insignificant decrease of 19% (p > 0.05) was reported in the trial performed in California  . In the studies performed in Pakistan and France, the number of PPH cases slightly increased after the intervention, by 28% (p = 0.79) and 7.5% (p = 0.62), respectively  and . The reported number of PPH cases in the study from New York (USA) doubled (p = 0.02) during the post-intervention period  .
|Author (reference)||Number (%) of PPH cases||Number (%) of severe PPH cases|
|Before study||After study||Before study||After study|
|Sheikh et al. ||Not analyzed||Not analyzed||0.5%||0.64%|
|Shields et al. ||6.3%||5.1%||Not analyzed||Not analyzed|
|Skupski et al. ||Not analyzed||Not analyzed||0.19%||0.4%|
|Rizvi et al. ||Not analyzed||Not analyzed||1.7%||0.45%|
|Audureau et al. ||Not analyzed||Not analyzed||0.8%||0.86%|
|Althabe et al. ||18.6%||6.9%||3%||0.8%|
|Figueras et al. ||12.7%||5%||Not analyzed||Not analyzed|
PPH, postpartum haemorrhage.
The analyzed guidelines differed in various ways, but active management of the third stage of labour was common to all the studies. This management was suggested by the WHO and updated in the latest recommendations published in 2012  . It was also suggested by the ICM/FIGO Global Initiative on the Prevention of Post-Partum Haemorrhage  . The efficacy of active management has been proven by a comparison involving randomized and quasi-randomized controlled trials  .
In the studies from Ireland, Spain, Pakistan and California, the definition of PPH was based only on blood loss. When introducing the new guidelines, the personnel were first trained to estimate it accurately , , , and . Inaccurate estimation of blood loss may lead to misdiagnosis and improper management of PPH. Overestimation may lead to an unnecessary blood transfusion. Underestimation may lead to a delay in diagnosis and treatment. A study from the United Kingdom has shown that the most accurate estimations of blood loss are in the range of 100–400 ml, while small volumes (25 or 50 ml) are usually overestimated, and the likelihood of underestimation grows with the increase in the amount of blood lost  . To avoid misdiagnosis, weighing of blood-soaked pads is recommended. Yet, there is a possibility of overestimation as well: amniotic fluid and urine may misrepresent the real situation  .
In the studies carried out in France and Ireland, blood transfusion was one of the criteria in defining severe PPH  and . This criterion is also of limited value. Some patients requiring blood transfusion do not consent to it, e.g. Jehovah's witnesses. In other cases, physicians may rush to offer blood transfusion in order to avoid possible complications. Therefore, the importance of the evaluation of changes in vital signs is highlighted in some guidelines, e.g. those of the Royal College of Obstetricians and Gynaecologists and Austrian Society for Gynaecology and Obstetrics  . The Modified Early Obstetric Warning Scoring System (MEOWS) has also been recommended  . This system involves the recording of temperature, blood pressure, heart and respiratory rate, oxygen saturation (SpO2), CNS response and urine analysis  . Studies show that the sensitivity of this system for postpartum haemorrhage is 89%, while the specificity is 79%  . Among the studies we analyzed, the Californian guidelines highlighted the importance of the evaluation of vital signs  . According to the authors, more accurate management for PPH is required if blood loss causes changes in vital signs >15%, if the heart rate is ≥110, the blood pressure is ≤85/45 or the SpO2 is <95%  .
PPH is an urgent life-threatening situation that requires an immediate response. Clearly formulated, comprehensible and accessible guidelines might improve the management of PPH. WHO has presented its guidelines as a list of recommendations that should be followed in the case of PPH (available at: www.who.int )  . FIGO has also prepared a prevention and treatment protocol for PPH (available at: http://www.figo.org/publications/PPH_Guidelines )  . Although it was created for health care specialists of low-resource countries, it can be followed in other countries as well. It contains all the necessary aspects of PPH management: prevention, diagnostics and treatment according to different situations. Only three of the articles we analyzed contained a clear description of the course of action to be followed in a case of PPH , , and . Although the guidelines developed in Pakistan and California  and  are more detailed, they are similar to those that were presented by FIGO. The guidelines from New York  focus exceptionally on placental pathology and management of severe PPH and would not be suitable for everyday use. More than half of the studies we analyzed provide insufficient information about the guidelines themselves. A further analysis of the strengths and weaknesses and of a logical course of action was unavailable in the guidelines.
The numbers of PPH cases peaked in the pre-intervention period and significantly decreased in the post-intervention period in those countries where guidelines were unavailable before the intervention  and . This improvement might be attributed to the active management of the third stage of labour, which was the only intervention mentioned and therefore probably the only compulsory intervention to be performed. A reduction in the numbers of PPH cases after the intervention was also reported by authors from Ireland and California, although guidelines already existed in those countries  and . During the intervention in the said countries, attention was focused on a multidisciplinary approach and the improvement of the existing standards in order to not only to reduce the number of PPH cases but also to improve the outcomes related to them. In the studies conducted in Pakistan, New York and France, the number of severe PPH cases increased , , and . In France, the guidelines were introduced theoretically by the local authorities, which may not be enough to achieve the main goal of reducing the number of PPH cases  . The authors from Pakistan and New York state that one of the possible reasons of the increase may be the growing caesarean section rate and a possible impact on future pregnancies  and . Also, more accurate diagnosis after training sessions might have led to better detection and registration of PPH.
We analyzed studies conducted in developing and developed countries. No evidence-based guidelines were available for health care specialists in developing countries, while in developed countries standards already existed in the pre-intervention period. The starting points in these groups were therefore different. The second problem was that more than half of the guidelines were unavailable for evaluation. Moreover, authors from different countries based the same diagnosis on different criteria. It is possible that the results of this review would change if the criteria for the same diagnosis were unified. The last limitation was that some articles analyzed only PPH cases while others focused only on severe PPH cases. We analyzed all of them.
Although there are no unified recommendations for the management of PPH, unique standardized guidelines also lead to a logical course of action and can have a positive impact on the reduction of the number and severity of PPH cases.
Active management of the third stage of labour using oxytocin is recommended as a tool for preventing PPH in all the guidelines. The most common principles for PPH treatment were an additional uterotonic, evaluation of placenta and birth canal, and blood transfusion.
Conflict of interest
None of the authors has any conflict of interest to disclose.
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