Postpartum Hemorrhage

The phrase "Networks of Care" seems familiar but remains poorly defined. A health system that exemplifies effective Networks of Care (NOC) purposefully and effectively interconnects service delivery touch points within a catchment area to fill critical service gaps and create continuity in patient care. To more fully elaborate the concept of Networks of Care, we conducted a multimethod scoping study that included a literature review, stakeholder interviews, and descriptive case studies from five low-and middle-income countries. Our extended definition of a Network of Care features four overlapping and interdependent domains of activity at multiple levels of health systems, characterized by: 1) Agreement and Enabling Environment, 2) Operational Standards, 3) Quality, Efficiency and Responsibility, and 4) Learning and Adaptation. There are a series of key interrelated themes within each domain. Creating a common understanding of what characterizes and fosters an effective Network of Care can drive the evolution and strengthening of national health programs, especially those incorporating universal health coverage and promoting comprehensive care and integrated services. An understanding of the Networks of Care model can help guide efforts to move health service delivery toward goals that can benefit a diversity of stakeholders, including a variety of health system actors, such as health care workers, users of health systems, and the wider community at large. It can also contribute to improving poor health outcomes and reducing waste originating from fragmented services and lack of access.

Background Postpartum hemorrhage (PPH) is the principal cause of maternal death. Blood loss during delivery is often underestimated. The aim of this study was to evaluate the validity of using an underbuttocks collection pouch in the diagnosis of PPH. Methods The study included a prospective series of 122 patients, over a period of 6 months, from May to October 2008. Variations in levels of hemoglobin and hematocrit during the 48 h following the childbirth confirmed the diagnosis of PPH. The graduated underbuttocks pouch allowed us to evaluate blood loss. The diagnostic value of the pouch was analyzed. Results Mean age of the patients was 29.3 years. Mean pregnancy duration was 39.5 weeks of amenorrhea. Mean blood loss was 233.15 ml. Eighteen patients (14.7%) presented PPH and uterine arteries were embolized in two cases (1.6%). For a volume of 500 ml, the sensitivity of the pouch was 6.7%, and the specificity was 94.2%, The positive predictive value (PPV) was 66.7% and the negative predictive value (NPV) was 94.2%. For a threshold of 300 ml, sensitivity was 88.9%, specificity was 82.7%, the PPV was 47.0% and the NPV was 97.7%. Conclusion The underbuttocks collection pouch is a simple, cheap and effective way to make an early objective diagnosis of PPH. It allows medical staff to implement appropriate therapy quickly thus avoiding risks due to delay. The diagnostic threshold to ensure optimal management remains to be determined.

A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example. We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal co...

Background The disparity between current evidence and practice on active management of third stage of labour (AMTSL) demands assessment of providers’ knowledge on the subject. Objective To assess the level and determinant(s) of accurate knowledge of obstetric providers regarding AMTSL. Methods Questionnaire-based survey of 361 labour and delivery professionals in public tertiary obstetric centres in southwest Nigeria. Results Female nurses at different cadres accounted for most of the respondents. Majority (90.6%) of the respondents reported being aware of AMTSL as an obstetric intervention and 49.7% were aware of FIGO/ICM recommendation on AMTSL. Out of 13 potential third stage interventions, 102 respondents (28.3%) correctly and exclusively identified the components of AMTSL as defined by FIGO/ICM. Many procedures reserved for treatment of complicated third stage of labour such as manual placental removal (37.7%), blood transfusion (20.2%), bimanual uterine compression (24.7%) and uterine artery ligation (13.9%) were also selected as AMTSL components. Multivariate logistic regression analysis indicated that being in administrative position (adjusted OR: 2.68; CI 1.19–6.02) and frequent compared to rare or no consultation of books, journal and internet sources for information (adjusted OR: 2.58; CI 1.21–5.52) increased the odds of having accurate knowledge of AMTSL while being a nurse/midwife (adjusted OR: 0.15; CI 0.05–0.39), matron (adjusted OR: 0.25; CI 0.08–0.79) or intern (adjusted OR: 0.07; CI 0.01–0.29) compared to postgraduate resident doctors reduced the odds of having accurate knowledge of AMTSL. Conclusion AMTSL was a familiar but poorly understood intervention among obstetric care providers in this region. Improvement in healthcare quality and practitioners’ adherence to recommended guidelines on AMTSL urgently requires educational interventions that target those who provide routine delivery care and organisation of the health care delivery system in such a way that enables providers to act on acquired knowledge.

To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta. A retrospective study of 9 patients with placenta previa accreta who underwent a conservative management protocol. The protocol consists of preventive radiological catheterization of the descending aorta, cesarean delivery, use of Affronti endouterine square hemostatic sutures, and placement of an intrauterine Bakri balloon in conjunction with B-Lynch suture. In the event of failure of the protocol, subsequent management employs ligation and/or reversible embolization of the uterine arteries followed by hysterectomy if unsuccessful. Conservative management of PPH was successful in all 9 patients evaluated and avoided the need for ligation and/or reversible embolization of the uterine arteries. Management of PPH is dictated by several considerations including hemodynamic status and desire to preserve fertility. The initial results of this conservative protocol for treatment of PPH in high-risk patients with placenta previa accreta are encouraging.

Despite the strong interest of international health agencies, worldwide maternal mortality has not declined substantially over the past 10 years. Postpartum hemorrhage (PPH) is the most common cause of maternal death across the world, responsible for more than 25% of deaths annually. Although effective tools for prevention and treatment of PPH are available, most are not feasible or practical for use in the developing world where many births still occur at home with untrained birth attendants. Application of many available clinical solutions in rural areas would necessitate substantial changes in government infrastructure and in local culture and customs surrounding pregnancy and childbirth. Before treatment can be administered, prompt and accurate diagnosis must be made, which requires training and appropriate blood measurement tools. After diagnosis, appropriate interventions that can be applied in remote settings are needed. Many uterotonics known to be effective in reducing PPH in tertiary care settings may not be useful in community settings because they require refrigeration and/or skilled administration. Moreover, rapid transfer to a higher level of care must be available, a challenge in many settings because of distance and lack of transportation. In light of these barriers, low-technological replacements for treatments commonly applied in the developed-world must be utilized. Community education, improvements to emergency care systems, training for birth attendants, misoprostol, and Uniject have shown promise as potential solutions. In the short term, it is expedient to capitalize on practical opportunities that utilize the existing strengths and resources in each community or region in order to implement appropriate solutions to save the lives of women during childbirth.