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. 2024 May 8;14(5):e079713.
doi: 10.1136/bmjopen-2023-079713.

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

Verónica Pingray  1 , Caitlin R Williams  2   3 , Fadhlun M Alwy Al-Beity  4   5 , Edgardo Abalos  6   7 , Sabaratnam Arulkumaran  8 , Alejandro Blumenfeld  2   9 , Brendan Carvalho  10 , Catherine Deneux-Tharaux  11 , Soo Downe  12   13 , Alexandre Dumont  14 , Maria Fernanda Escobar  15   16 , Cherrie Evans  17 , Sue Fawcus  18 , Hadiza S Galadanci  19   20 , Diem-Tuyet Thi Hoang  21 , G Justus Hofmeyr  22   23 , Caroline Homer  24 , Ayodele G Lewis  25 , Tippawan Liabsuetrakul  26   27 , Pisake Lumbiganon  28 , Elliott K Main  29   30 , Judith Maua  31 , Francis G Muriithi  32   33 , Ashraf Fawzy Nabhan  34 , Inês Nunes  35   36   37 , Vanesa Ortega  38 , Thuan N Q Phan  39   40 , Zahida P Qureshi  41 , Claudio Sosa  42   43 , John Varallo  44 , Andrew D Weeks  39   45 , Mariana Widmer  46 , Olufemi T Oladapo  46 , Ioannis Gallos  46 , Arri Coomarasamy  32 , Suellen Miller  47 , Fernando Althabe  46
Affiliations

Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus

Verónica Pingray et al. BMJ Open. .

Abstract

Objective: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth.

Design: Systematic review and three-stage modified Delphi expert consensus.

Setting: International.

Population: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance.

Outcome measures: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth.

Results: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach.

Conclusion: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Keywords: clinical decision-making; maternal medicine; obstetrics; postpartum period; systematic review.

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Conflict of interest statement

Competing interests: Disclosure forms provided by the authors are available with the full text of this article.

Figures

Figure 1
Figure 1
Technical consultation flow chart. CB, caesarean birth; PPH, postpartum haemorrhage.
See this image and copyright information in PMC

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