Postpartum haemorrhage (PPH) occurs in approximately 3-5% of all deliveries and, despite concentrated efforts, remains a leading cause of maternal morbidity and mortality. Because most PPH-related deaths are preventable through the implementation of effective interventions, the recent shift from home births to facility births across low-and middle-income countries (LMIC) provides new opportunities for saving women's lives.
Unfortunately, inconsistent and/or delayed use of effective interventions for prevention and treatment of PPH, in addition to other systemic problems in health services (e.g., lack of blood banks, inadequate staffing), has led to continued unacceptable rates of haemorrhage-related maternal deaths.
In 2001, the Institute for Healthcare Improvement (IHI) developed a formal approach to bundling care to increase the quality and efficiency of care delivery. The IHI defined bundles as “small sets of evidence-based interventions for a defined patient population and care setting that, when implemented together, result in significantly better outcomes than when implemented individually”. The “bundles” approach was designed to increase uptake and compliance to recommended interventions. Care bundles have been associated with improved patient outcomes when adherence is high. Care bundles differ from other care packages in that compliance is achieved only when all the bundled interventions are completed and recorded.
In early 2017, WHO decided to explore whether bundling current WHO-recommended evidenced-based interventions for PPH due to uterine atony might accelerate adoption and adherence to PPH guidelines.
Care bundles for postpartum haemorrhage
A- First response PPH bundle
Ø Uterotonic drugs
Ø Isotonic crystalloids
Ø Tranexamic acid
Ø Uterine massage
Notes:Initial fluid resuscitation is performed together with intravenous (IV) administration of uterotonics. If IV uterotonics are not available, fluid resuscitation should be started in parallel with sublingual misoprostol or other parenteral uterotonics. If postpartum haemorrhage (PPH) is in the context of placental retention, the placenta should be extracted and a single dose of antibiotics should be administered.
B-Response to refractory PPH bundle
Ø Compressive measure (aortic compression or bimanual uterine compression)
Ø Intrauterine balloon tamponade
Ø Non-pneumatic anti shock garment
Notes: A continuing dose of uterotonics (e.g., oxytocin diluted in isotonic crystalloids) and a second dose of tranexamic acid should be administered during the application of this bundle.