Remarks Assessment of postpartum blood loss

• Visual estimation of postpartum blood loss is frequently inaccurate, meaning that PPH often goes unrecognized or is identified when it is too late to provide a life-saving intervention. Objective methods of quantifying blood loss, which are superior to visual estimation, are more likely to detect PPH. For women who have had a vaginal birth, most of the available evidence on postpartum blood loss measurement comes from the use of a calibrated drape.
• Blood loss measurement is particularly critical in the first few hours after birth. Women should also be regularly monitored for early warning signs of excessive blood loss (e.g. tachycardia or hypotension).
• To be effective, measurement of postpartum blood loss must be linked with a standardized treatment approach or protocol, and vice versa. Detecting PPH, in the absence of prompt initiation of treatment, is unlikely to improve a woman’s health outcomes.
• The available studies have been conducted in women giving birth vaginally. However, the measurement of blood loss in women undergoing a caesarean section is also clinically important.
• The process for postpartum blood loss measurement should ensure that a woman’s customary or cultural requirements, including choice of birth position, are respected and maintained.
• Birth-related bleeding risks and the signs and symptoms of excessive blood loss should be discussed with women across the birth continuum (including antenatally) to foster shared decision-making.
• There should be consideration and investments made into the development and use of sustainable and climate-friendly drapes.

Care bundle for the treatment of PPH

• All interventions included within the PPH treatment bundle are individually recommended in the existing 2012 and 2017 WHO PPH guidelines.
• In the context of this recommendation, the GDG emphasizes the need for a consistent use and interpretation of the term “bundle” as a clinical care bundle for the treatment of PPH. This should not be misconstrued with the usage of this term in other contexts.
• To ensure the maximal success of the PPH treatment bundle, early detection of PPH is a key and indissociable component of the first-response intervention. The available evidence on postpartum blood loss measurement is largely from trials that used calibrated drapes for women who had a vaginal birth (see Recommendation 1).
• Clinical judgement is important to guide PPH treatment decision-making. In a large trial, the treatment bundle was initiated when measured blood loss was 500 ml or greater, or when measured blood loss was 300 ml or greater with early warning signs of excessive blood loss (see Recommendation 1).
• The trial underlying this recommendation included multiple implementation and health system strengthening strategies that helped to achieve a high coverage in the consistent use of the treatment bundle. These included ensuring availability of the required human resources, strengthened by dedicated research staff, regular health-care facility-level audit and feedback, designated facility champions to oversee change, restocking of PPH trolleys or carry cases so that all necessary medicines and equipment were readily available in one place, and training for health workers.
• The PPH treatment bundle requires standardized and timely use of all included interventions. All bundle treatment interventions should ideally be initiated within the first 15 minutes after a diagnosis of PPH. However, health system readiness (e.g. availability of staff, equipment) varies across different settings. In the event that not all bundle interventions are available, available components should be initiated in a timely and standardized manner.
• In cases of refractory postpartum bleeding – where a woman has received all interventions within the PPH treatment bundle yet continues to bleed – prompt escalation to a higher-level healthcare facility or a senior clinical provider capable of providing further management is critical. WHO has made recommendations on the treatment of refractory PPH.
• The GDG acknowledges that the evidence supporting a treatment bundle is largely from trials on vaginal birth, and does not have any clear evidence to refute that the findings would be different for a caesarean section. The individual PPH treatment interventions included in the PPH treatment bundle are also recommended by WHO for women undergoing a caesarean section (see the 2012 WHO recommendations for the prevention and treatment of postpartum haemorrhage [14]). However, the group acknowledged that additional research is required to confidently recommend bundle care for caesarean section births.
• National, regional, subregional and district-level health systems must be strengthened so that sufficient resources are available, ensuring the sustainability of treatment bundle implementation. Adequate numbers of staff and availability of commodities are essential to achieve the benefits of treatment bundles (for further details, see Chapter 4, section 4.2: Implementation considerations).
• The supporting evidence has largely been generated from studies conducted in secondary-level health-care facilities. However, prompt recognition and treatment of PPH for women who give birth in primary care settings, in the community or at home are equally relevant. Appropriate resources and health worker training integrated with setting-specific implementation strategies are necessary to facilitate this.
• Engagement with women and their communities is paramount to promote women’s human rights and agency in their health, and foster their participation in shared decision-making around PPH treatment