EVIDENCE FOR PPH MANAGEMENT PROTCOLS AS SYSTEMS ISSUES
- 1Access: Has the patient had the opportunity to seek timely prenatal care to have risk factors optimized (example: identification and treatment of peripartum anemia)? Did they deliver in a non-hospital setting (e.g., home) due to lack of access to hospital care, resulting in delayed management?
- 2Structure: Does the hospital have equipment in place to address hemorrhage, such as provision of standardized hemorrhage carts and ready access to uterotonics? Are hospital teams prepared to respond to PPH via participation in team trainings and simulations for PPH management? Does the hospital have a standardized stage-based management protocol that teams have been trained to follow?
- 3Process: How is blood loss measured and communicated to team members during acute hemorrhage?
Delays in PPH Recognition and PPH Response
PPH PROTOCOLS IMPROVE SYSTEMS OF CARE, BUT ARE DEPENDENT ON IMPLEMENTATION
GUIDANCE ON BENCHMARKS FOR PPH MANAGEMENT
PROPOSED BENCHMARKS AND FURTHER DIRECTIONS
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|For hemorrhage involving uterine atony, administration of a second uterotonic (after Pitocin) without delay once PPH is recognized, typically either methylergometrine or carboprost unless contraindicated.|
|For patients with PPH, administration of TXA as rapidly as feasible after diagnosis.|
|For patients whose PPH due to atony and is refractory to a second uterotonic, early placement of an intrauterine tamponade balloon (e.g., Bakri balloon) or intrauterine vacuum device (e.g., Jada device) before blood loss exceeds 1.5 L.|
|Auditing of PPH cases to ensure teams are following PPH bundles and stage-based protocols, with corrective action plans to include re-education and simulation when compliance is suboptimal; with escalation to processes such as peer review reserved for cases in which specific providers do not alter practice patterns despite re-education.|
Publication stageIn Press Accepted Manuscript
Declaration of Competing Interest
The authors report no conflicts of interest.
Dr. Federspiel is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002553. Dr. Eke is supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health under Award Number K23HD104517. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Clinical Trial Registration: Not applicable
This paper was presented in preliminary form at the 2022 Society for Maternal Fetal Medicine meeting (held virtually January 31-February 5, 2022).
Overall support for this work was provided by the National Center for Advancing Translational Sciences under Award Number TL1TR002555 and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) under the Award Number K23HD104517. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.