Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus
Tippawan Liabsuetrakul,
Soo Downe,
Ioannis Gallos,
Fernando Althabe,
Olufemi T Oladapo,
Alexandre Dumont,
Arri Coomarasamy,
Inês Nunes,
Edgardo Abalos,
Pisake Lumbiganon,
Zahida P Qureshi,
María Fernanda Escobar,
Sue Fawcus,
Elliott K Main,
John Varallo,
G Justus Hofmeyr,
Judith Maua,
Catherine Deneux-Tharaux,
Andrew D Weeks,
Caroline Homer,
Brendan Carvalho,
Sabaratnam Arulkumaran,
Mariana Widmer,
Veronica Pingray,
Fadhlun M Alwy Al-Beity,
Ashraf Fawzy Nabhan,
Claudio Sosa,
Caitlin R Williams,
Alejandro Blumenfeld,
Cherrie Evans,
Hadiza S Galadanci,
Diem-Tuyet Thi Hoang,
Ayodele G Lewis,
Francis G Muriithi,
Vanesa Ortega,
Thuan N Q Phan,
Suellen Miller
Affiliations
Tippawan Liabsuetrakul
26 Department of Obstetrics & Gynecology, Prince of Songkla University, Hat Yai, Thailand
Soo Downe
12 THRIVE Centre, School of Heath and Community Studies, University of Central Lancashire, Preston, UK
Ioannis Gallos
45 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Fernando Althabe
45 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Olufemi T Oladapo
45 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Alexandre Dumont
13 CEPED, Université Paris Cité, IRD, INSERM, Paris, France
Arri Coomarasamy
31 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
Inês Nunes
34 Department of Obstetrics and Gynaecology, Gaia/ Espinho Local Health Unit, Vila Nova de Gaia, Portugal
Edgardo Abalos
5 Maternidad Martin, Secretaría de Salud Pública de la Municipalidad de Rosario, Rosario, Santa Fe, Argentina
Pisake Lumbiganon
27 Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
Zahida P Qureshi
40 University of Nairobi Department of Obstetrics and Gynecology, Nairobi, Kenya
María Fernanda Escobar
5 Unidad de Equidad Global en Salud, Fundación Valle del Lili, Cra. 98 no. 18-49, Cali 760032, Valle del Cauca, Colombia
Sue Fawcus
17 Department of Obstetrics and Gynaecology, University of Cape Town, Rondebosch, South Africa
Elliott K Main
28 Department of Obstetrics & Gynecology—Maternal Fetal Medicine, Stanford University, Stanford, California, USA
John Varallo
43 Women`s Health, Global Surgery Foundation, Washington, District of Columbia, USA
G Justus Hofmeyr
21 Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
Judith Maua
30 Liverpool School of Tropical Medicine, Nairobi, Kenya
Catherine Deneux-Tharaux
10 Obstetrical Perinatal and Pediatric Epidemiology Research team, Centre for Research in Statistics and Epidemiology (CRESS) Université Paris Cité INSERM, Paris, France
Andrew D Weeks
38 Department of Women`s and Children`s Health, University of Liverpool, Liverpool, UK
Caroline Homer
23 Burnet Institute, Melbourne, Victoria, Australia
Brendan Carvalho
9 Stanford University School of Medicine, Stanford, California, USA
Sabaratnam Arulkumaran
7 Department of Obstetrics & Gynaecology, St George’s Hospital, London, UK
Mariana Widmer
45 UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
Veronica Pingray
1 Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
Fadhlun M Alwy Al-Beity
3 Department of Obstetrics & Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
Ashraf Fawzy Nabhan
33 Department of Obstetrics & Gynecology, Ain Shams University Faculty of Medicine, Cairo, Egypt
Claudio Sosa
41 Woman and Reproduction Health Unit at Maternal Health at the Latin American Center of Perinatology (CLAP/WR), Pan American Health Organization, Montevideo, District of Columbia, USA
Caitlin R Williams
2 Department of Maternal & Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
Alejandro Blumenfeld
1 Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
Cherrie Evans
16 Technical Leadership & Innovations Office, Jhpiego/USA, Baltimore, Maryland, USA
Hadiza S Galadanci
18 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
Diem-Tuyet Thi Hoang
20 Obstetrics and Gynecology, Hung Vuong Hospital, Ho Chi Minh, Viet Nam
Ayodele G Lewis
24 Amherst College, Amherst, Massachusetts, USA
Francis G Muriithi
31 Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
Vanesa Ortega
37 Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
Thuan N Q Phan
38 Department of Women`s and Children`s Health, University of Liverpool, Liverpool, UK
Suellen Miller
Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF, San Francisco, California, USA
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.
