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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/Book"><div class="meta-content fm-sec"><div class="iconblock whole_rhythm clearfix no_top_margin"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng194er9-lrg.png" alt="Cover of Assessment of secondary postpartum haemorrhage" /></a><div class="icnblk_cntnt"><h1 id="_NBK571572_"><span itemprop="name">Assessment of secondary postpartum haemorrhage</span></h1><div class="subtitle">Postnatal care</div><p><b>Evidence review I</b></p><p><i>NICE Guideline, No. 194</i></p><p class="contrib-group"><h4>Authors</h4><span itemprop="author">National Guideline Alliance (UK)</span>.</p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2021 Apr</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4078-3</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div></div></div></div><div class="body-content whole_rhythm" itemprop="text"><div id="niceng194er9.s1"><h2 id="_niceng194er9_s1_">Assessment of secondary postpartum haemorrhage</h2><div id="niceng194er9.s1.1"><h3>Review question</h3><p>How should early signs and symptoms of postpartum haemorrhage be assessed?</p><div id="niceng194er9.s1.1.1"><h4>Introduction</h4><p>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.</p></div><div id="niceng194er9.s1.1.2"><h4>Summary of the protocol</h4><p>Please see <a class="figpopup" href="/books/NBK571572/table/niceng194er9.tab1/?report=objectonly" target="object" rid-figpopup="figniceng194er9tab1" rid-ob="figobniceng194er9tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><p>For further details see the review protocol in <a href="#niceng194er9.appa">appendix A</a>.</p></div><div id="niceng194er9.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <u>Developing NICE guidelines: the manual 2014</u>. Methods specific to this review question are described in the review protocol in <a href="#niceng194er9.appa">appendix A</a>.</p><p>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 <u>conflicts of interest policy</u>. Those interests declared before July 2019 were reclassified according to NICE’s 2019 conflicts of interest policy (see Register of Interests).</p></div><div id="niceng194er9.s1.1.4"><h4>Clinical evidence</h4><div id="niceng194er9.s1.1.4.1"><h5>Included studies</h5><p>A systematic review of the clinical literature was conducted but no studies were identified which were applicable to this review question.</p><p>See the literature search strategy in <a href="#niceng194er9.appb">appendix B</a> and study selection flow chart in <a href="#niceng194er9.appc">appendix C</a>.</p></div><div id="niceng194er9.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review with reasons for their exclusions are provided in <a href="#niceng194er9.appk">appendix K</a>.</p></div></div><div id="niceng194er9.s1.1.5"><h4>Summary of clinical studies included in the evidence review</h4><p>No studies were identified which were applicable to this review question (and so there are no evidence tables in <a href="#niceng194er9.appd">Appendix D</a>). No meta-analysis was undertaken for this review (and so there are no forest plots in <a href="#niceng194er9.appe">Appendix E</a>).</p></div><div id="niceng194er9.s1.1.6"><h4>Quality assessment of clinical outcomes included in the evidence review</h4><p>No studies were identified which were applicable to this review question.</p></div><div id="niceng194er9.s1.1.7"><h4>Economic evidence</h4><div id="niceng194er9.s1.1.7.1"><h5>Included studies</h5><p>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 <a href="#niceng194er9.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng194er9.appg">appendix G</a>.</p></div><div id="niceng194er9.s1.1.7.2"><h5>Excluded studies</h5><p>No economic studies were reviewed at full text and excluded from this review.</p></div></div><div id="niceng194er9.s1.1.8"><h4>Economic model</h4><p>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.</p></div><div id="niceng194er9.s1.1.9"><h4>Evidence statements</h4><div id="niceng194er9.s1.1.9.1"><h5>Clinical evidence statements</h5><p>No evidence was identified which was applicable to this review question.</p></div><div id="niceng194er9.s1.1.9.2"><h5>Economic evidence statements</h5><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.s1.1.10"><h4>The committee’s discussion of the evidence</h4><div id="niceng194er9.s1.1.10.1"><h5>Interpreting the evidence</h5><div id="niceng194er9.s1.1.10.1.1"><h5>The outcomes that matter most</h5><p>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.</p></div><div id="niceng194er9.s1.1.10.1.2"><h5>The quality of the evidence</h5><p>No evidence was identified which was applicable to this review question.</p></div><div id="niceng194er9.s1.1.10.1.3"><h5>Benefits and harms</h5><p>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.</p><p>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 <u>on intrapartum care for healthy women and babies</u> 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 (<a class="bk_pop" href="#niceng194er9.s1.1.ref1">Knight 2014</a>), 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.</p><p>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).</p><p>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.</p></div></div><div id="niceng194er9.s1.1.10.2"><h5>Cost effectiveness and resource use</h5><p>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.</p></div><div id="niceng194er9.s1.1.10.3"><h5>Other factors the committee took into account</h5><p>The committee noted during protocol development that certain subgroups of women may require special consideration due to their potential vulnerability:
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<ul><li class="half_rhythm"><div>young women (19 years or under)</div></li><li class="half_rhythm"><div>women with physical or cognitive disabilities</div></li><li class="half_rhythm"><div>women with severe mental health illness</div></li><li class="half_rhythm"><div>women who have difficulty accessing postnatal care services.</div></li></ul></p><p>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).</p></div></div><div id="niceng194er9.s1.1.rl.r1"><h4>References</h4><ul class="simple-list"><li class="half_rhythm"><div class="bk_ref" id="niceng194er9.s1.1.ref1"><p id="p-51">
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<strong>Knight 2014</strong>
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</p>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
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2014.</div></li></ul></div></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng194er9.appa"><h3>Appendix A. Review protocols</h3><p id="niceng194er9.appa.et1"><a href="/books/NBK571572/bin/niceng194er9-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</a><span class="small"> (PDF, 326K)</span></p></div><div id="niceng194er9.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng194er9.appb.et1"><a href="/books/NBK571572/bin/niceng194er9-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</a><span class="small"> (PDF, 286K)</span></p></div><div id="niceng194er9.appc"><h3>Appendix C. Clinical evidence study selection</h3><p id="niceng194er9.appc.et1"><a href="/books/NBK571572/bin/niceng194er9-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Clinical study selection for: How should early signs and symptoms of postpartum haemorrhage be assessed?</a><span class="small"> (PDF, 219K)</span></p></div><div id="niceng194er9.appd"><h3>Appendix D. Clinical evidence tables</h3><div id="niceng194er9.appd.s1"><h4>Clinical evidence tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.appe"><h3>Appendix E. Forest plots</h3><div id="niceng194er9.appe.s1"><h4>Forest plots for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.appf"><h3>Appendix F. GRADE tables</h3><div id="niceng194er9.appf.s1"><h4>GRADE tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng194er9.appg.et1"><a href="/books/NBK571572/bin/niceng194er9-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence study selection for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</a><span class="small"> (PDF, 444K)</span></p></div><div id="niceng194er9.apph"><h3>Appendix H. Economic evidence tables</h3><div id="niceng194er9.apph.s1"><h4>Economic evidence tables for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.appi"><h3>Appendix I. Economic evidence profiles</h3><div id="niceng194er9.appi.s1"><h4>Economic evidence profiles for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No economic evidence was identified which was applicable to this review question.</p></div></div><div id="niceng194er9.appj"><h3>Appendix J. Economic analysis</h3><div id="niceng194er9.appj.s1"><h4>Economic analysis for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No economic analysis was conducted for this review question.</p></div></div><div id="niceng194er9.appk"><h3>Appendix K. Excluded studies</h3><div id="niceng194er9.appk.s1"><h4>Excluded clinical and economic studies for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4></div><div id="niceng194er9.appk.s2"><h4>Clinical studies</h4><p id="niceng194er9.appk.et1"><a href="/books/NBK571572/bin/niceng194er9-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (299K)</span></p></div><div id="niceng194er9.appk.s3"><h4>Economic studies</h4><p>No economic evidence was identified for this review.</p></div></div><div id="niceng194er9.appl"><h3>Appendix L. Research recommendations</h3><div id="niceng194er9.appl.s1"><h4>Research recommendations for review question: How should early signs and symptoms of postpartum haemorrhage be assessed?</h4><p>No research recommendations were made for this review question.</p></div></div></div><div class="bk_prnt_sctn"><h2>Tables</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="niceng194er9.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK571572/table/niceng194er9.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng194er9.tab1_lrgtbl__"><table class="no_bottom_margin"><tbody><tr><th id="hd_b_niceng194er9.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng194er9.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Women from 24 hours after birth up to 8 weeks after birth.</td></tr><tr><th id="hd_b_niceng194er9.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng194er9.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Systematic strategies to identify secondary postpartum haemorrhage (PPH):</p>
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<p>Intervention 1. Providing information about bleeding to the woman before transfer to community care</p>
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<p>Intervention 2. Checklist used at postnatal care contacts to record observations of early signs and symptoms of postpartum haemorrhage</p>
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<p>Intervention 3. Higher frequency of observations of early signs and symptoms of postpartum haemorrhage than comparator (for example, daily observations)</p></td></tr><tr><th id="hd_b_niceng194er9.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng194er9.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>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:</p>
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<p>Comparator 1. Different way of providing information to the woman</p>
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<p>Comparator 2. Different checklist</p>
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<p>Comparator 3. Lower frequency of observations than intervention</p></td></tr><tr><th id="hd_b_niceng194er9.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng194er9.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><b>Critical:</b>
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<ul><li class="half_rhythm"><div>maternal death due to PPH</div></li><li class="half_rhythm"><div>blood loss 24 hours after birth (≥500 ml)</div></li><li class="half_rhythm"><div>blood transfusion 24 hours after birth</div></li></ul>
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<b>Important:</b>
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<ul><li class="half_rhythm"><div>severe acute maternal morbidity</div></li><li class="half_rhythm"><div>women’s acceptability of and satisfaction with intervention</div></li><li class="half_rhythm"><div>discontinuing breastfeeding.</div></li></ul></td></tr></tbody></table></div><div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_margin">PPH: postpartum haemorrhage</p></div></dd></dl></div></div></div></div></div><div><p>Final</p></div><div><p>Evidence review underpinning recommendations 1.2.3 and 1.2.13 to 1.2.14</p><p>These evidence reviews were developed by the National Guideline Alliance, part of the Royal College of Obstetricians and Gynaecologists</p></div><div><p><b>Disclaimer</b>: 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.</p><p>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.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div></div></div>
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<div class="post-content"><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2021.</div><div class="small"><span class="label">Bookshelf ID: NBK571572</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/34191454" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">34191454</a></span></div></div></div>
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