Roles and challenges encountered by midwives in the management of postpartum haemorrhage following normal vaginal delivery: A scoping review.

AIMS: To establish a comprehensive understanding of the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of postpartum haemorrhage (PPH) following normal vaginal delivery. DESIGN: We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR) recommendations. METHODS: We considered studies related to the roles of midwives and the challenges they encounter in the prevention, diagnosis and management of PPH during vaginal delivery. We excluded guidelines, consensuses, abstracts of meetings and non-English language studies. Databases, including the Cochrane Library, PubMed, Web of Science, Ovid, Medline, Embase, JBI EBP and BIOSIS Previews, were searched on January 1, 2023, with no time limitations. RESULTS: We included 28 publications. Midwives play important roles in the prevention, diagnosis and management of postpartum haemorrhage during vaginal delivery. In the prevention of PPH, midwives' roles include identifying and managing high-risk factors, managing labour and implementing skin-to-skin contact. In the diagnosis of PPH, midwives' roles include early recognition and blood loss estimation. In the management of PPH, midwives are involved in mobilizing other professional team members, emergency management, investigating causes, enhancing uterine contractions, the repair of perineal tears, arranging transfers and preparation for surgical intervention. However, midwives face substantial challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and the need to deal with their negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. Health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for preventing, diagnosing and managing postpartum haemorrhage.

Evaluating the Quality of Postpartum Hemorrhage Nursing Care Plans Generated by Artificial Intelligence Models.

BACKGROUND: With the rapidly advancing technological landscape of health care, evaluating the potential use of artificial intelligence (AI) models to prepare nursing care plans is of great importance. PURPOSE: The purpose of this study was to evaluate the quality of nursing care plans created by AI for the management of postpartum hemorrhage (PPH). METHODS: This cross-sectional exploratory study involved creating a scenario for an imaginary patient with PPH. Information was put into 3 AI platforms (GPT-4, LaMDA, Med-PaLM) on consecutive days without prior conversation. Care plans were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. RESULTS: Med-PaLM exhibited superior quality in developing the care plan compared with LaMDA ( Z = 4.354; P = .000) and GPT-4 ( Z = 3.126; P = .029). CONCLUSIONS: Our findings suggest that despite the strong performance of Med-PaLM, AI, in its current state, is unsuitable for use with real patients.

Game-Based Learning and Nursing Students' Clinical Judgment in Postpartum Hemorrhage: A Pilot Study.

BACKGROUND: Nurse educators are searching for ways to deliver and evaluate the clinical judgment model (CJM) into undergraduate education to adequately prepare students for the Next Generation NCLEX project. METHOD: A game-based learning (GBL) activity, including seven postpartum hemorrhage (PPH) stations, was developed and implemented in an undergraduate nursing course. Following the design of the Minute to Win It® game show, teams of students participated in timed challenges to facilitate engagement with the CJM. RESULTS: Student scores improved significantly for every aspect of the CJM applied to PPH (recognition, analysis, action, evaluation) from the pre- to posttest after using the PPH Minute to Win It. The teaching-learning strategy was positively received by students for the purposes of enhancing engagement and retaining knowledge. CONCLUSION: GBL is effective for incorporating the CJM into the classroom and enhances exposure, knowledge, and retention for specific topics such as PPH. Students associate GBL with increased engagement and learning related to complex course content. [J Nurs Educ. 2021;60(3):159-164.].

Assessing the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage.

Background Despite medical technology advancement, postpartum hemorrhage remains the top universal cause of maternal mortality. Factors note the inconsistency in recognition and timely treatment of women experiencing it, which suggests healthcare professionals' mentorship about postpartum hemorrhage. Methods The study recruited 141 nurses and midwives and used instruments adapted to knowledge and self-efficacy to assess the impact of mentorship on nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage. Results There was an increase in knowledge from 68% prior to mentorship up to 87% and self-efficacy from 6.9 to 9.5 average score out of 10. Knowledge and self-efficacy correlated moderately positive at pre-mentorship (r=0.214) and strongly positive at post-mentorship (r=0.585). The number of mentorship visits attended was associated with post-mentorship knowledge scores (r=0.539) and post-mentorship self-efficacy (r=0.623). Conclusions Mentorship about management of postpartum hemorrhage increases nurses' and midwives' knowledge and self-efficacy in managing postpartum hemorrhage.

Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales).

BACKGROUND: Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales. INTERVENTION: A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures. RESULTS: Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%-76%), objective measurement of blood loss (52%-88%) and POC testing for coagulation for PPH ≥1500 mL (38%-59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit's management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23-6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively. CONCLUSIONS: A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.

Effect of Quantification of Blood Loss on Activation of a Postpartum Hemorrhage Protocol and Use of Resources.

OBJECTIVE: To determine if quantification of blood loss (QBL) would result in fewer activations of postpartum hemorrhage (PPH) protocols than visual estimation of blood loss (EBL) after cesarean birth and to track the use of related resources. DESIGN: Prospective observational trial. SETTING: A tertiary academic medical center in the midwestern United States. PARTICIPANTS: A total of 42 cases of cesarean birth. METHODS: We visually estimated blood loss during cesarean birth and quantified blood loss with colorimetric testing after the surgery. We compared EBL to QBL in four categories, from no hemorrhage to severe PPH, and documented resources used for women placed on the institutional PPH protocol by EBL who did not meet criteria for PPH by QBL. RESULTS: The median EBL was 1,275 ml (interquartile range = 1,100-1,510 ml), and the median QBL was 948 ml (interquartile range = 700-1,267 ml, p < .001). Twenty-four (57%) instances of PPH based on visual EBL would not have been classified as such based on QBL. The most frequently used resources in these cases included laboratory testing and administration of uterotonics. CONCLUSION: Use of QBL during cesarean births would have reduced the number of identified PPHs by more than 50% over visual EBL and may have reduced the resources used as part of care.

Where there is no nurse: an observational study of large-scale mentoring of auxiliary nurses to improve quality of care during childbirth at primary health centres in India.

OBJECTIVE: Clinician scarcity in Low and Middle-Income Countries (LMIC) often results in de facto task shifting; this raises concerns about the quality of care. This study examines if a long-term mentoring programme improved the ability of auxiliary nurse-midwives (ANMs), who function as paramedical community health workers, to provide quality care during childbirth, and how they compared with staff nurses. DESIGN: Quasi-experimental post-test with matched comparison group. SETTING: Primary health centres (PHC) in the state of Bihar, India; a total of 239 PHCs surveyed and matched analysis based on 190 (134 intervention and 56 comparison) facilities. PARTICIPANTS: Analysis based on 335 ANMs (237 mentored and 98 comparison) and 42 staff nurses (28 mentored and 14 comparison). INTERVENTION: Mentoring for a duration of 6-9 months focused on nurses at PHCs to improve the quality of basic emergency obstetric and newborn care. PRIMARY OUTCOME MEASURES: Nurse ability to provide correct actions in managing cases of normal delivery, postpartum haemorrhage and neonatal resuscitation assessed using a combination of clinical vignettes and Objective Structured Clinical Examinations. RESULTS: Mentoring increased correct actions taken by ANMs to manage normal deliveries by 17.5 (95% CI 14.8 to 20.2), postpartum haemorrhage by 25.9 (95% CI 22.4 to 29.4) and neonatal resuscitation 28.4 (95% CI 23.2 to 33.7) percentage points. There was no significant difference between the average ability of mentored ANMs and staff nurses. However, they provided only half the required correct actions. There was substantial variation in ability; 41% of nurses for normal delivery, 60% for postpartum haemorrhage and 45% for neonatal resuscitation provided less than half the correct actions. Ability declined with time after mentoring was completed. DISCUSSION: Mentoring improved the ability of ANMs to levels comparable with trained nurses. However, only some mentored nurses have the ability to conduct quality deliveries. Continuing education programmes are critical to sustain quality gains.

Avaliação da assistência de enfermagem na hemorragia pós-parto / Evaluation of nursing care in post-partum hemorrhaging

Objetivo: avaliar a assistência de enfermagem na hemorragia pós-parto. Método: trata-se de um estudo quantitativo, descritivo e exploratório. Compôs-se por 33 enfermeiros plantonistas que atuavam nos setores de assistência às puérperas. Coletaram-se os dados com questionário, em seguida, tabulados por meio do Programa Microsoft Excel 2016, analisados estatisticamente por frequências absolutas e relativas e apresentados em tabelas. Resultados: mostrou-se que todos os enfermeiros 28 (84,85%) referiram conhecer causas da hemorragia pós-parto; 23 (69,70%), as medidas preventivas; 24 (72,73%), as medidas de controle e 13 (39,39%) responderam que já atenderam algum caso de hemorragia, porém, 18 (54,55%) referiram que não há ações sistematizadas, instituídas no local de trabalho, para a prevenção. Conclusão: acredita-se que o estudo se mostrou relevante por constatar que a hemorragia pós-parto exige uma assistência por profissionais especializados e, mesmo assim, há dificuldades que envolvem conhecimentos, manejo na assistência e local de trabalho podendo refletir, de forma negativa, na redução da morbimortalidade materna.(AU)

The more you lose the more you miss: accuracy of postpartum blood loss visual estimation. A systematic review of the literature.

Midwives and nurses have a key role in monitoring postpartum period. They represent the first line professional figure in quantifying blood loss, initiating early diagnosis of obstetric hemorrhage, and mobilizing a team response, if needed. These actions are crucial in determining maternal outcome in postpartum hemorrhage (PPH). In our review we aimed to: (1) Provide a picture of PPH including its pathophysiology, epidemiology, and associated complications; (2) Discuss diagnosis of this dangerous postpartum event; and, (3) Especially evaluate the efficiency of the employment of visual blood loss estimation as a rapid way to suspect PPH and activate the patient assessment.

Autologous Blood Transfusion for Postpartum Hemorrhage.

Postpartum hemorrhage (PPH) is a leading contributor to maternal morbidity and mortality in the United States and globally. Although the rate of PPH is generally decreasing nationally, severity of PPH appears to be increasing, potentially related to the various comorbidities associated with women of childbearing age. There is increasing evidence of risks associated with allogeneic blood transfusion, which has historically been the classic therapeutic approach for treatment to PPH. Pregnant women are particularly susceptible to the implications of sensitization to red cell antigens, a common sequela to allogenic blood transfusion. Autologous blood transfusion eliminates the potential of communicable disease transmission as well as the conceivable threat of a blood transfusion reaction. Recent technological advances allow cell salvage coupled with the use of a leukocyte filter to be used as an alternative approach for improving the outcome for women experiencing a PPH. Modest changes in standard operating procedure and continued training in use and application of cell salvaged blood may assist in minimizing negative outcomes from PPH. Salvaged blood has been demonstrated to be at least equal and often superior to banked blood. We discuss nursing implications for application of this technology for women with PPH. Continued research is warranted to evaluate the impact that application of cell salvage with filtration has on the patient experiencing a PPH.

Inversión uterina puerperal. A propósito de un caso / Puerperal uterine inversion: report of a case

La inversión uterina puerperal es una complicación grave y poco frecuente que supone una verdadera emergencia obstétrica. La matrona debe conocer sus signos y síntomas y saber cómo actuar si se presenta esta situación. A continuación se expone un caso clínico de una inversión uterina que tuvo lugar en enero de 2015 en el Hospital de Mérida (Badajoz) (AU)

Puerperal uterine inversion is a serious and rare complication that means a true obstetric emergency. The midwife must know its signs and symptoms and how to act if this situation happens. A case of uterine inversion that took place in January 2015 in the Hospital de Mérida (Badajoz) will be exposed below (AU)

Factors contributing to postpartum blood-loss in low-risk mothers through expectant management in Japanese birth centres.

OBJECTIVE: To describe aspects of expectant midwifery care for low-risk women conducted in midwifery-managed birth centres during the first two critical hours after delivery and to compare differences between midwifery care, client factors and postpartum blood loss volume. METHOD: As a secondary analysis from a larger study, this descriptive retrospective study examined data from birth records of 4051 women who birthed from 2001 to 2006 at nine (21%) of the 43 midwifery centres in Tokyo. Nonparametric and parametric analyses identified factors related to increased blood loss. Interviews to establish sequence of midwifery care were conducted. FINDINGS: The midwifery centres provided care based on expectant management principles from birth to after expulsion of the placenta. Approximately 63.3% of women were within the normal limits of blood loss volume under 500g. A minority of women (12.9%) experienced blood loss between 500 and 800g and 4% had blood loss exceeding 1000g. Blood loss volume tended to increase with infant birth weight and duration of delivery. The total blood loss volume was significantly higher for primiparas than for multiparas during the critical two hours after delivery and for immediately after delivery, yet blood loss volume was significantly higher for multiparas than for primiparas during the first hour after delivery. Preventive uterine massage and umbilical cord clamping after placenta expulsion resulted in statistically significant less blood loss. Identified were two patterns of midwifery care based on expectant management principles from birth to after expulsion of the placenta. The practice of expectant management was not a significant factor for increased postpartum blood loss. CONCLUSION: These results detail specific midwifery practices and highlight the clinical significance of expectant management with low risk pregnant women experiencing a normal delivery.

Pictorial estimation of blood loss in a birthing pool--an aide memoire.

The aim of this article is to share some photographic images to help midwives visually estimate blood loss at water births. PubMed, CINAHL and MEDLINE databases were searched for relevant research. There is little evidence to inform the practice of visually estimating blood loss in water, as discussed further on in the article. This article outlines a simulation where varying amounts of blood were poured into a birthing pool, captured by photo images. Photo images of key amounts like 150mls, 300mls and 450mls can be useful visual markers when estimating blood loss at water births. The speed of spread across the pool may be a significant factor in assessing blood loss. The author recommends that midwives and educators embark on similar simulations to inform their skill in estimating blood loss at water births.

Developing protocols for obstetric emergencies.

There is potential for important steps to be missed in emergency situations, even in the presence of many health care team members. Developing a clear plan of response for common emergencies can ensure that no tasks are redundant or omitted, and can create a more controlled environment that promotes positive health outcomes. A multidisciplinary team was assembled in a large community hospital to create protocols that would help ensure optimum care and continuity of practice in cases of postpartum hemorrhage, shoulder dystocia, emergency cesarean surgical birth, eclamptic seizure and maternal code. Assignment of team roles and responsibilities led to the evolution of standardized protocols for each emergency situation.