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Assessment of secondary postpartum haemorrhage
Evidence review I
NICE Guideline, No. 194
Authors
National Guideline Alliance (UK).Assessment of secondary postpartum haemorrhage
Review question
How should early signs and symptoms of postpartum haemorrhage be assessed?
Introduction
Secondary postpartum haemorrhage (PPH) is an important complication postnatally which requires prompt action from professionals. This review was intended to identify the most effective ways of assessing blood loss and identifying those instances where medical intervention would be indicated.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
For further details see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s 2014 conflicts of interest policy until March 2018. From April 2018 until June 2019, declarations of interest were recorded according to NICE’s 2018 conflicts of interest policy. From July 2019 onwards, the declarations of interest were recorded according to NICE’s 2019 conflicts of interest policy. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).
Clinical evidence
Included studies
A systematic review of the clinical literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review with reasons for their exclusions are provided in appendix K.
Summary of clinical studies included in the evidence review
No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D). No meta-analysis was undertaken for this review (and so there are no forest plots in Appendix E).
Quality assessment of clinical outcomes included in the evidence review
No studies were identified which were applicable to this review question.
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
No economic studies were reviewed at full text and excluded from this review.
Economic model
No economic modelling was undertaken for this review because, although the review question was considered priority for modelling, no clinical evidence that would allow development of an economic model was identified.
Evidence statements
Clinical evidence statements
No evidence was identified which was applicable to this review question.
Economic evidence statements
No economic evidence was identified which was applicable to this review question.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee rated maternal death as a critical outcome because secondary PPH is a life-threatening complication. Early identification of symptoms and signs of secondary PPH would enable early intervention, which could in turn reduce the amount of blood loss and the need for a blood transfusion to replace lost blood. Therefore, blood loss of 500 ml or more and blood transfusion 24 hours after birth were rated as critical outcomes. Severe acute maternal morbidity, which would be a consequence of major haemorrhage, was rated as an important outcome. Women’s acceptability of and satisfaction with intervention were also rated as important outcomes because the committee wanted to support women-centred care. Discontinuing breastfeeding was considered an important outcome because major haemorrhage could lead to separation of mother and baby because of the need for clinical care and thus could affect breastfeeding opportunities. It could also be a traumatic experience that might influence breastfeeding uptake.
The quality of the evidence
No evidence was identified which was applicable to this review question.
Benefits and harms
On the basis of their expertise the committee agreed that some women may not realise they are experiencing early signs and symptoms of secondary PPH, because they mistake them for normal features of the postpartum experience. Therefore, discussion with women should focus on what to expect in terms of vaginal bleeding and identifying possible symptoms and signs of secondary PPH. The committee mentioned the following symptoms and signs of secondary PPH that would warrant the woman to seek medical advice: sudden and very heavy vaginal bleeding, increasing vaginal bleeding, passing clots or placental tissue or membranes, strong or unpleasant odour of vaginal bleeding or discharge indicating an infection, or other symptoms of infection such as fever, chills, abdominal pain, headache or muscle aches. Retained products of conception (RPOC) is a common cause of secondary PPH and an infection could be an indication of RPOC. The committee also recognised the importance of responding to the concerns of the woman about postpartum bleeding. The committee agreed that this recommendation would benefit women by improving awareness of symptoms and signs of secondary PPH, enabling women to seek advice early on, which would lead to early intervention and reduce the likelihood of secondary PPH resulting in adverse outcomes.
Although all women are at risk of secondary PPH, some women are at higher risk, and so the committee recommended to take into account specific risk factors when assessing the severity of blood loss. The committee acknowledged that the antenatal and intrapartum risk factors for PPH in the NICE guideline on intrapartum care for healthy women and babies applied to postnatal women, therefore the committee agreed to cross refer to this guideline for the assessment of severity and risk factors for secondary PPH. The committee also noted that the risk of adverse outcomes is higher even with a small amount of bleeding in women with anaemia or lower body weight. The cut-off for booking weight of 50 kg is based on table 4.2 on page 49 in the report (Knight 2014), illustrating estimated blood volumes and the corresponding proportionate losses according to body weight. The committee agreed that this recommendation would benefit women by identifying those with a higher risk of secondary PPH, therefore prompting women to seek help and for healthcare professionals to assess bleeding sooner, which could lead to early intervention and reduce the likelihood of secondary PPH resulting in severe adverse outcomes.
The committee agreed that there is a risk that women would consider normal what is in fact abnormal bleeding. Therefore, they recommended that midwives should assess and specifically ask about vaginal discharge and bleeding and any possible signs or symptoms of anaemia, such as fatigue, feeling faint or dizzy at postnatal contacts. The committee agreed that this recommendation was best placed in the recommendations on the assessment and care of the woman as it is important for midwives to assess at each postnatal contact (see also evidence review F).
The committee agreed that overall the anticipated benefits of these recommendations, for example increased awareness by women and assessment by healthcare midwives outweighed the potential harms. Harms considered included potential additional visits to appropriate health professionals, anxiety of possible short term separation from baby and its potential impact on breastfeeding.
Cost effectiveness and resource use
No economic evidence is available for this review question. The committee agreed that spending time at postnatal contacts to ask women about vaginal bleeding and any concerns they may have, and to assess the severity and risk of vaginal bleeding has low-to-modest resource implications (health professional time). However, it may lead to significant benefits for the woman and cost-savings to the health service if secondary PPH that requires intervention is identified early. This is because late identification, when secondary PPH has become more severe, is associated with higher mortality and morbidity for the woman, and more intensive interventions, such as surgery, and increased length of hospitalisation may be needed. On the other hand, if women are given adequate information and reassurance about normal postpartum vaginal bleeding, they avoid unnecessary concerns and unplanned visits to health services for further evaluation and investigations. Therefore, the committee agreed that the recommendations ensure efficient use of healthcare resources.
Other factors the committee took into account
The committee noted during protocol development that certain subgroups of women may require special consideration due to their potential vulnerability:
- young women (19 years or under)
- women with physical or cognitive disabilities
- women with severe mental health illness
- women who have difficulty accessing postnatal care services.
A stratified analysis was therefore predefined in the protocol based on these subgroups. However, considering the lack of evidence for these sub-groups, the committee agreed not to make separate recommendations and that the recommendations they did make should apply universally as long as communication with the women are tailored according to their needs (this is covered by another section in the guideline, see evidence report G).
References
Knight 2014
Knight, M., Bunch, K., Tuffnell, D., Jayakody, H., Shakespeare, J., Kotnis, R., Kenyon, S., Kurinczuk, JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012. Oxford National Perinatal Epidemiology Unit, University of Oxford 2014.
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Clinical study selection for: How should early signs and symptoms of postpartum haemorrhage be assessed? (PDF, 219K)
Appendix D. Clinical evidence tables
Clinical evidence tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No evidence was identified which was applicable to this review question.
Appendix F. GRADE tables
GRADE tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Economic analysis for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No economic analysis was conducted for this review question.
Appendix K. Excluded studies
Excluded clinical and economic studies for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
Clinical studies
Download PDF (299K)
Economic studies
No economic evidence was identified for this review.
Appendix L. Research recommendations
Research recommendations for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?
No research recommendations were made for this review question.
Tables
Table 1Summary of the protocol (PICO table)
| Population | Women from 24 hours after birth up to 8 weeks after birth. |
|---|---|
| Intervention | Systematic strategies to identify secondary postpartum haemorrhage (PPH): Intervention 1. Providing information about bleeding to the woman before transfer to community care Intervention 2. Checklist used at postnatal care contacts to record observations of early signs and symptoms of postpartum haemorrhage Intervention 3. Higher frequency of observations of early signs and symptoms of postpartum haemorrhage than comparator (for example, daily observations) |
| Comparison | Interventions compared to standard care or to ‘no intervention’. In addition, intervention 1 will be compared to comparator 1, 2 will be compared to comparator 2, and intervention 3 will be compared to comparator 3: Comparator 1. Different way of providing information to the woman Comparator 2. Different checklist Comparator 3. Lower frequency of observations than intervention |
| Outcomes | Critical:
|
PPH: postpartum haemorrhage
Final
Evidence review underpinning recommendations 1.2.3 and 1.2.13 to 1.2.14
These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.