Lititure Review on postpartum hemorrhage Essay Example

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Literature Review on Postpartum Haemorrhage (PPH)


Primary postpartum haemorrhage refers to the excessive blooding that occurs 24 hours following delivery. PPH is one of the leading causes of maternal morbidity across the globe (Fan et al. 2017). Currently, no single definition of PPH exists. Diagnosing postpartum haemorrhage entails the estimation of the blood loss as well as the haemodynamic state changes that occur in the woman. In the event of vaginal delivery, PPH is evident only after the blood loss is in excess of 500mL. In the case of caesarean delivery, PPH is evident when the blood loss exceeds 1000mL. Blood loss that is equal to or greater than 1000mL indicates a condition of severe PPH. In the event that the blood loss exceeds 2500mL, the PPH condition is major or extremely severe. In many cases, patients succumb to PPH because of the underestimation of blood loss. Consequently, it is necessary to determine haemodynamic compromise as the other indicator of PPH. Hypotension and increase tachycardia are some of the clinical presentations of PPH. Mild signs of shock following the blood loss in a healthy pregnant woman occur when the blood loss is equal to or in excess of 1000mL (Queensland Clinical Guidelines, 2012). The review identifies the gaps in the existing literature as well as the quality of the literature on postpartum haemorrhage.

The study targets 130 midwives, neonatologists, and obstetricians on the incidence, prevention, and treatment of PPH. The study refers to a list of potential questions associated with the prevention, incidence, and treatment of PPH. The next step would be the review and prioritization of the questions to select the most appropriate questions that would provide insights into gaps in the existing literature on PPH. The study also allocates ratings on a scale of 1 to 9 to each outcome. A question that attains a minimum score of 7 falls under the ‘critical’ category. Questions with scores ranging from 4 to 6 are considered “important but not critical”. Finally, questions with scores of less than 4 are “not important”. The study will use Cochrane systematic reviews as the reference basis for making recommendations. In using the review, the study will focus on reviews that are relevant and potentially relevant. In extracting evidence from the Review, the study will start with the most recent Review Manager files. The next step will entail exporting the file to the grade profiler software followed by the utility of the criteria to appraise the evidence. The final step would entail preparing evidence profiles.

The guideline revealed 32 recommendations for the treatment and prevention of PPH. The recommendations were either new or updated by their authors to include new evidence. Authors of revised recommendations reworded the recommendations to enhance the clarity of the evidence. Twenty-two Cochrane systematic reviews formed the basis of the recommendations. The most up to date recommendations were evident in boxes numbered 1 to 8. The study included remarks linked to the specific recommendations to their respective boxes and used asterisks to mark new recommendations.


Gaps in Literature

It is evident that the ongoing research has tried to identify solutions to the PPH trouble. Irrespective of the research endeavours, PPH has continued to claim the lives of many women following their deliveries (Pichon-Riviere et al. 2015). This implies that the existing research is inadequate to deal with the condition. Consequently, this elicits the need for research that identifies preventive and mitigating solutions. The Active Management of the Third Stage of Labour (AMTSL) aims at reducing the incidence of PPH among women after birth. However, it is evident that 3% to 16.5% of women still experience PPH even after undergoing AMTSL using the recommended interventions (Ashigbie, 2013). Currently, Oxytocin suffices to be the gold standard as an intervention for the condition. However, the fact that administering Oxytocin requires trained personnel and its instability in tropical climates are some of the limitations of the solution.

However, the introduction of Oxytocin-Uniject is a positive advancement in the solution that would eliminate the expertise barrier required to administer Oxytocin. The adoption of Oxytocin-Uniject would become possible in low resource settings as opposed to incidences where Oxytocin remains as the solution to the problem (Diop et al. 2016). However, the issue of stability associated with Oxytocin continues to be a challenge in dealing with PPH. This elicits the need for developing a heat-stable Oxytocin that would remain stable in tropical climates. The instability of the conventional Oxytocin emanates from the fact that low-resource settings lack pre-installed cold chain storage facilities that are essential in storing the formulation in tropical climates (Pantoja et al. 2015). Limited research on the efficiency and quality of new interventions such as condom tamponade and tranexamic acid imply that there is no guarantee of the effectiveness of such solutions in dealing with postpartum haemorrhage.

It is also evidently that timely medical treatment is effective in reducing the incidence of PPH among women. On the contrary, many women still succumb to PPH because of the delays in accessing medical treatment. Several factors are responsible for the delays in receiving medical treatment. Actors in the family such as the spouse, relatives, and individuals could contribute to delayed medical treatment. Other factors include the individual statuses of women, the physical accessibility of the medical facilities offering the treatment (Munjanja et al. 2012), opportunity and financial costs, the previous experience with healthcare delivery in the medical facility, and the general quality of care. Consequently, research should focus on addressing the risk factors that cause PPH in the quest to reduce its incidence among pregnant women. The understanding of the factors leading to delays in accessing medical treatment is also essential in the reduction of PPH incidence among women. The factors include the distribution of facilities, time required to travel from home to the facility, the cost and availability of transportation, and road conditions that could increase the time taken to move from homes to the facility (Essendi et al. 2015).

Research also needs to expound on the factors that lead to delayed medical interventions at the healthcare facility. Some of the factors that require addressing include shortage of supplies, the referral system, the competence of hospital personnel and the availability of equipment. Other causes of delays in accessing medical treatment include the non-availability of proper technologies such as Oxytocin-Uniject, Oxytocin packaged using the TTI technology, and heat-stable Oxytocin. Moreover, lower cadre healthcare providers in low resource facilities are unable to use the latest technologies and formulations used to manage the condition (Pantoja et al. 2015). One of the solutions is the training of lower cadre healthcare professionals and the use of misoprostol by the professionals at the community level. Such interventions would be critical in reducing the delays associated with the treatment of PPH during labour (Ashigbie, 2013).

Research should also focus on the identification of risk pathways in order to understand the factors that appear, accumulate over time, and dominate in the field of PPH such as subsequent pregnancies. Apparently, the findings would play a massive role in identifying the ‘red flags’ associated with the training and management of PPH. Currently, the available clinical tools are only applicable to blood loss that is equal to or greater than 500mL. This calls for the need to remain vigilant on the part of clinicians on the identification and response to the accumulating risks. Research should also expand on abnormal bleeding to enable clinicians to detect abnormal bleeding at early stages. This enables the implementation of immediate intervention measures. In the assessment of blood loss, the available instructional material should be capable of informing clinicians to eschew threshold avoidance and preference to reduce mortality caused by PPH. Emphasising on the need of maintaining records on cumulative blood loss is effective in the detection of thresholds that require prompt intervention.

Current instructional materials should also emphasise on the prompt examination of expedient suturing and genital tract trauma to as essential aspects in monitoring the condition. Double entry is evident in the current data entry process. However, it is the responsibility of healthcare professionals to ensure the complete and accurate transcription of data from paper to electronic records. Handling potentially modifiable risk factors is the other area that requires intensive research. Research should also focus on interventions aimed at addressing obesity and aging individuals that are still reproductive. Since PPH stands out as an important metric that determines the quality of care in a healthcare setting, it is proper to improve research on standard procedures, PPH incidence, and the accuracy of the recorded data. The implementation of clinical improvements and the transferability of innovations in trauma care is the other area of potential research (Briley et al. 2014). This includes recording of cumulative blood loss, the use of staff reminders, and staff training.

Quantity and Quality of Literature

Despite the rising number of pregnant women that succumb to PPH during labour, it is evident that the existing literature is inadequate to provide sufficient instructional information and materials to deal with the condition. The effective management of PPH requires the adequate availability of information and instructional material on PPH prevention, treatment, and organisation of care. High-quality materials refer to instructional materials that address each intervention measure, provides its level of effectiveness, and states whether it is proper to use the intervention measure or not.

In the prevention of PPH, there should be adequate literature on all interventions that are effective in preventing PPH. For instance, the use of uterotonics in preventing PPH in both types of deliveries is effective and strongly recommended. In the quest to encourage healthcare providers to use the intervention, literature should indicate the intervention as highly recommended besides attaching the evidence of the quality associated with the use of the intervention. For instance, it is proper for literature to strongly recommend the use of uterotonics, Oxytocin, misoprostol in preventing PPH. Besides recommending the use of the interventions, the literature should also indicate the moderate to high quality evidence associated with the use of the interventions.

Conclusion and Recommendations for future studies

The quality of evidence also requires the indication of specific instances where the use of each intervention is appropriate. For instance, birth attendants should use injectable uterotonics in instances where Oxytocin is unavailable. On the other hand, misoprostol is effective in community healthcare facilities that lack skilled professionals. In the event that skilled birth attendants are available, the literature should recommend the use of CCT for vaginal births where the parturient woman and the care provider identify a slight reduction in blood loss. However, instructional materials should forbid the use of CCT in situations where there are no skilled birth attendants. In order to initiate simultaneous essential care of the newborn, literature should recommend the use of late cord clamping performed 1 to 3 minutes following the delivery (Ayadi et al. 2013). Literature should not recommend the use of early-cord clamping unless in the event of asphyxiation of the neonate that requires resuscitation.


Ashigbie, B. P. (2013). Background Paper 6.16 Postpartum Haemorrhage. Priority Medicines for Europe and the World.

Ayadi, A. M. E., Robinson, N., Geller, S., & Miller, S. (2013). Advances in the treatment of postpartum hemorrhage. Expert Review of Obstetrics & Gynecology, 8(6), 525-537.

Briley, A., Seed, P. T., Tydeman, G., Ballard, H., Waterstone, M., Sandall, J., … & Bewley, S. (2014). Reporting errors, incidence and risk factors for postpartum haemorrhage and progression to severe PPH: a prospective observational study. BJOG: An International Journal of Obstetrics & Gynaecology, 121(7), 876-888.

Diop, A., Daff, B., Sow, M., Blum, J., Diagne, M., Sloan, N. L., & Winikoff, B. (2016). Oxytocin via Uniject (a prefilled single-use injection) versus oral misoprostol for prevention of postpartum haemorrhage at the community level: a cluster-randomised controlled trial. The Lancet Global Health, 4(1), e37-e44.

Essendi, H., Johnson, F. A., Madise, N., Matthews, Z., Falkingham, J., Bahaj, A. S., … & Blunden, L. (2015). Infrastructural challenges to better health in maternity facilities in rural Kenya: community and healthworker perceptions. Reproductive health, 12(1), 103.

Fan, D., Xia, Q., Liu, L., Wu, S., Tian, G., Wang, W., … & Liu, Z. (2017). The incidence of postpartum hemorrhage in pregnant women with placenta previa: a systematic review and meta-analysis. PloS one, 12(1), e0170194.

Munjanja, S. P., Magure, T., & Kandawasvika, G. (2012). 11 Geographical Access, Transport and Referral Systems. Maternal and perinatal health in developing countries, 139.

Pantoja, T., Abalos, E., Chapman, E., Vera, C., & Serrano, V. P. (2015). Oxytocin for preventing postpartum haemorrhage (PPH) in non-facility birth settings. Cochrane Database of Systematic Reviews, (2).

Pichon-Riviere, A., Glujovsky, D., Garay, O. U., Augustovski, F., Ciapponi, A., Serpa, M., & Althabe, F. (2015). Oxytocin in uniject disposable auto-disable injection system versus standard use for the prevention of Postpartum Hemorrhage in Latin America and the Caribbean: a cost-effectiveness analysis. PloS one, 10(6), e0129044.

Queensland Clinical Guidelines. (2012). Primary postpartum haemorrhage. Maternity and Neonatal Clinical Guideline.

World Health Organization. (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization.