Strategies for optimising early detection and first response management of postpartum haemorrhage at caesarean birth: A modified Delphi-based international expert consensus
Authors: Pingray V , Williams CR , Alwy Al-beity F , Abalos E , Arulkumaran S , Nabhan A , Blumenfeld A , Carvalho B , Deneux-Tharaux C , Downe S , Dumont A , Escobar Vidarte MF , Evans C , Fawcus S , Galadanci H , Hofmeyr GJ , Homer C , Lewis A , Liabsuetrakul T , Lumbiganon P , Main E , Muriithi F , Nunes I , Ong’ayi J , Ortega V , Phan T , Qureshi Z , Sosa C , Tuyet H , Varallo J , Weeks A , Widmer M , Oladapo OT , Gallos I , Coomarasamy A , Miller S , Althabe F. 
Published: September 2023

OBJECTIVE

There are no globally agreed upon strategies on early detection and first response management of postpartum haemorrhage during and after caesarean birth. Our study aimed to develop an international expert’s consensus on evidence-based approaches for early detection and 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 postpartum haemorraghe with diverse backgrounds, and gender, professional, and geographic balance.

OUTCOME MEASURES

Agreement or disagreement on strategies for early detection and first response management of postpartum haemorrhage 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-upon proposed approaches could help improve the detection of PPH in the intra 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.

STRENGTHS AND LIMITATIONS OF THIS STUDY

Strengths

Use of a rigorous and systematic process to identify and synthesise high-quality PPH evidence in the literature.

The selection of the expert panellists ensured a wide range of perspectives to enhance the utility and applicability of this consensus to a wide range of clinical settings.

There was a very low rate of loss to follow-up and the first two rounds of the modified Delphi process were blinded to avoid social acceptability bias, and the hybrid meeting was facilitated to ensure that all panellists had equal opportunity to contribute to the discussion.

Limitations

Due to the dearth of quality evidence on PPH related to caesarean birth, experts often had to extrapolate from evidence on interventions recommended for PPH in vaginal birth or make decisions based on their experiences. This sometimes led to omitting interventions that might be useful for early detection or first-response management.

Given the highly technical content, we did not include recipients of these interventions, or their representatives, among the panellists.

Since our systematic review, three updated PPH guidelines have been published, with some guidance relevant to PPH during or after caesarean birth. They mostly align with previously published guidance included in our study, with the exception of an increased focus on concealed haemorrhage assessment and one guideline recommending the use of prophylactic tranexamic acid for women at high PPH risk.