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

Fernando Althabe^{1

2}, Michelle N S Therrien^{3

4}, Veronica Pingray¹, Jorge Hermida⁵, Ahmet M Gülmezoglu², Deborah Armbruster⁶, Neelima Singh⁷, Moytrayee Guha⁸, Lorraine F Garg⁸, Joao P Souza^{2

9}, Jeffrey M Smith¹⁰, Beverly Winikoff¹¹, Kusum Thapa¹², Emmanuelle Hébert¹³, Jerker Liljestrand¹⁴, Soo Downe¹⁵, Ezequiel Garcia Elorrio¹⁶, Sabaratnam Arulkumaran¹⁷, Emmanuel K Byaruhanga¹⁸, David M Lissauer¹⁹, Monica Oguttu²⁰, Alexandre Dumont²¹, Maria F Escobar²², Carlos Fuchtner²³, Pisake Lumbiganon²⁴, Thomas F Burke^{8

25}, Suellen Miller^{3

26}

Affiliations

¹ Department of Mother and Child Health, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
² Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
³ Safe Motherhood Program, University of California, San Francisco, CA, USA.
⁴ HERHealthEQ, New York, NY, USA.
⁵ Quality Performance Institute, University Research Co., LLC, Chevy Chase, MD, USA.
⁶ Maternal and Newborn Division, USAID, Global Health Bureau, Washington, DC, USA.
⁷ Department of Mother and Child Welfare, Indian Institute of Health and Family Welfare, Hyderabad, India.
⁸ Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA, USA.
⁹ Universidade de São Paulo, São Paulo, Brazil.
¹⁰ Jhpiego, Baltimore, MD, USA.
¹¹ Gynuity, New York, NY, USA.
¹² Maternal Child Survival Program and Maternal Health, Jhpiego, Washington, DC, USA.
¹³ International Confederation of Midwives, Montréal, QC, Canada.
¹⁴ Bill and Melinda Gates Foundation, Seattle, WA, USA.
¹⁵ Research in Childbirth and Health Group, University of Central Lancashire, Preston, UK.
¹⁶ Department of Quality and Safety in Healthcare, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
¹⁷ Division of Obstetrics & Gynaecology, St George's University of London, London, UK.
¹⁸ Department of Obstetrics & Gynecology, Martyr's Hospital, Ministry of Health, Ibanda, Uganda.
¹⁹ Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
²⁰ Kisumu Medical and Education Trust, Kisumu, Kenya.
²¹ Research Institute for Sustainable Development, CEPED, Paris, France.
²² Department of Gynecology and Obstetrics, Fundacion Valle del Lili, Cali, Colombia.
²³ FIGO, Viador Pinto, Bolivia.
²⁴ Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
²⁵ T.H. Chan School of Public Health, and HSPH Department of Global Health and Population, Harvard Boston, MA, USA.
²⁶ Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy University of California, San Francisco (UCSF), San Francisco, CA, USA.

PMID: 31709527
PMCID: PMC7064978
DOI: 10.1002/ijgo.13028

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

Fernando Althabe et al. Int J Gynaecol Obstet. 2020 Mar.

. 2020 Mar;148(3):290-299.

doi: 10.1002/ijgo.13028. Epub 2019 Dec 23.

Authors

Affiliations

¹ Department of Mother and Child Health, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
² Department of Reproductive Health and Research, WHO, Geneva, Switzerland.
³ Safe Motherhood Program, University of California, San Francisco, CA, USA.
⁴ HERHealthEQ, New York, NY, USA.
⁵ Quality Performance Institute, University Research Co., LLC, Chevy Chase, MD, USA.
⁶ Maternal and Newborn Division, USAID, Global Health Bureau, Washington, DC, USA.
⁷ Department of Mother and Child Welfare, Indian Institute of Health and Family Welfare, Hyderabad, India.
⁸ Division of Global Health and Human Rights, Massachusetts General Hospital, Boston, MA, USA.
⁹ Universidade de São Paulo, São Paulo, Brazil.
¹⁰ Jhpiego, Baltimore, MD, USA.
¹¹ Gynuity, New York, NY, USA.
¹² Maternal Child Survival Program and Maternal Health, Jhpiego, Washington, DC, USA.
¹³ International Confederation of Midwives, Montréal, QC, Canada.
¹⁴ Bill and Melinda Gates Foundation, Seattle, WA, USA.
¹⁵ Research in Childbirth and Health Group, University of Central Lancashire, Preston, UK.
¹⁶ Department of Quality and Safety in Healthcare, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
¹⁷ Division of Obstetrics & Gynaecology, St George's University of London, London, UK.
¹⁸ Department of Obstetrics & Gynecology, Martyr's Hospital, Ministry of Health, Ibanda, Uganda.
¹⁹ Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
²⁰ Kisumu Medical and Education Trust, Kisumu, Kenya.
²¹ Research Institute for Sustainable Development, CEPED, Paris, France.
²² Department of Gynecology and Obstetrics, Fundacion Valle del Lili, Cali, Colombia.
²³ FIGO, Viador Pinto, Bolivia.
²⁴ Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
²⁵ T.H. Chan School of Public Health, and HSPH Department of Global Health and Population, Harvard Boston, MA, USA.
²⁶ Department of Obstetrics, Gynecology & Reproductive Sciences, Bixby Center for Global Reproductive Health and Policy University of California, San Francisco (UCSF), San Francisco, CA, USA.

PMID: 31709527
PMCID: PMC7064978
DOI: 10.1002/ijgo.13028

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.

Keywords: Aortic compression; Bimanual compression; Intrauterine balloon tamponade; Non-pneumatic antishock garment; Obstetric hemorrhage; Patient care bundles; Postpartum hemorrhage; Tranexamic acid; Uterotonics.

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Conflict of interest statement

The authors have no conflicts of interest. SM received funds from Blue Fuzion. JMS received grants from USAID during the study. The views expressed in the study do not necessarily reflect the views of the WHO, USAID, or the US Government.

Figures

**Figure 1**
Flowchart of phases and procedures performed for the development of PPH care bundles during the technical consultation.

See this image and copyright information in PMC

References

1. Vogel JP, Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”Oladapo OT, Dowswell T, Gülmezoglu AM. Updated WHO recommendation on intravenous tranexamic acid for the treatment of post‐partum haemorrhage. Lancet Global Health. 2018;6:e18–e19. - PubMed
1. Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy‐related deaths: Results of a state‐wide review. Obstet Gynecol. 2005;106:1228–1234. - PubMed
1. American College of Obstetricians and Gynecologists District II . Maternal Safety Bundle for Obstetric Hemorrhage. 2015. https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/HEMSlid.... Accessed January 2, 2018.
1. Goffman D, Nathan L, Chazotte C. Obstetric hemorrhage: A global review. Semin Perinatol. 2016;40:96–98. - PubMed
1. Lappen J, Seidman D, Burke C, Goetz K, Grobman W. Changes in care associated with the introduction of a postpartum hemorrhage patient safety program. Am J Perinatol. 2013;30:833–838. - PubMed

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

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

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Conflict of interest statement

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