Photos by Ian Penwell

Emerging Strategies: Helping Mothers Survive Bleeding After Birth

by Vicki Penwell | June 16, 2023

Midwifery Today, Issue 146, Summer 2023.
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Helping mothers survive … what a compelling mission statement this should be for all midwives! Helping Mothers Survive is also the name of a global program that I have been partnering with since 2014, and which we have incorporated into many of our Mercy In Action CEU courses, including an intensive 4-day Train the Trainer certifying workshop in our post-graduate Diploma in International Midwifery and Maternal/Child Health program.

What is Helping Mothers Survive Bleeding After Birth?

Helping Mothers Survive Bleeding After Birth (HMS-BAB) is a joint project of Jhpiego (a nonprofit organization affiliated with Johns Hopkins University) and Laerdal Global Health (a company that makes Ambu bags and other medical supplies.) HMS-BAB is part of a wider program called Helping Mothers and Babies Survive (HMBS), which offers a suite of evidence-based training modules and creative birth simulation tools designed to equip health care providers with the knowledge and competency needed to manage obstetric and newborn emergencies and provide high-quality, respectful care at every birth. Mercy In Action, the nonprofit international organization I founded, also focuses on improving maternal/child health care for women and families in low-resource settings, and the HMBS modules and corresponding birth simulators are ideally designed to help us in our goal to improve and sustain the critical skills of midwives, nurses, doctors, and birth assistants around the world.

When I received the invitation from Jhpiego in 2014 to attend one of their early “Train the Trainer” sessions at their headquarters in Baltimore, Maryland, I eagerly traveled across the ocean from my home in the Philippines to take advantage of this opportunity to learn new and better ways to predict, prevent, and treat postpartum hemorrhage. Being a midwife and educator of midwives in low-income/high-mortality areas, I jumped at the chance to learn how to more effectively respond to hemorrhage—which remains a top cause of preventable maternal mortality and morbidity worldwide—and to gain resources to train birth attendants in this as well.

Some of the concepts that have helped me better respond to hemorrhage are simply the ability to think differently, comprehend situational awareness, and respect the value of humble roleplaying, simulation, and practice, no matter how experienced the midwife may be. Practice lays down something called muscle memory, and is necessary for both students and experienced birth providers. Here are a few of the newer key concepts that have emerged in recent years to guide us in our postpartum hemorrhage prevention, treatment, and mitigation:

Preparation

One of the concepts we teach our students and diploma scholars is that hemorrhage cannot always be predicted, even in a seemingly low-risk non-smoker with a healthy diet, so we must be prepared at every birth to deal with a potentially life-threatening hemorrhage. This means having the necessary skills, medications, and devices on hand at all times in all birth settings. Some states require their midwives to have special pharmacology training, some even require it at each renewal cycle, which is helpful for ongoing skills practice. The landscape of drugs available to use out-of-hospital for hemorrhage is constantly shifting, and it is vital that we stay current and keep prescriptions up to date.

Ongoing Practice with Objective Structured Clinical Evaluation (OSCE)

The OSCE is one of the best evidence-based training methods, as the evaluation obtained by this method is objective, structured, and makes use of a simulated clinical event to determine if we are ready for the next real-life emergency hemorrhage. As opposed to subjective evaluation—which may subconsciously defer to age, experience, or effort in evaluating preparation to respond to hemorrhage—the OSCE is a set of checklists that need to be met in order to pass, no matter who you are or how long you have practiced. It is a fair, equitable learning tool, and the person being evaluated has the checklist in advance and can practice the steps before the final tests. Hemorrhage may be a surprise at times, but the steps to effectively respond should be practiced until they can be done quickly, in sequence, and with extreme effectiveness every time!

Respond Differently to Third Stage Hemorrhage and Fourth Stage Hemorrhage

The other thing we stress is that there is a big difference in how we respond to a third-stage hemorrhage as opposed to a fourth-stage hemorrhage, and we need to practice these specific scenarios separately. In Mercy In Action, we use two separate training OSCEs for each stage of hemorrhage: one for third stage and another one for when the placenta is already delivered. This is important because the management steps are different with the placenta still inside as opposed to when it is already delivered. One of our tricks is to stress to those we are training the importance of situational awareness: Where am I? Who is in front of me? What stage of labor are we in? What are the vital signs? What are the risk factors? What is my plan of action based on all these facts? And as the situation unfolds, how do I respond to each new event or fact, rather than react by rote?

Stick to Main Issue Until Resolved

Most of us learned the “Four Ts’” method for categorizing causes of hemorrhage—Tone, Tears, Tissue, and Thrombin—and it is tempting in an emergency to run through these different causes of hemorrhage, similar to how we would run through all the ways to get a shoulder dystocia resolved, moving quickly through our list of things to try. However, the first T, uterine atony, will be the issue in the vast majority of hemorrhages; research tells us that at least 80% of PPH cases are due to uterine atony. During a hemorrhage, in the presence of uterine atony, keep treating for the lack of tone and don’t move on to checking for lacerations or retained fragments until the uterus is firm. If, however, the uterus is hard and bleeding continues, do not keep rubbing the fundus, but look further for the cause of the problem. (Note about the first T for Tone—in medical terminology, the letter “a” in front of any word means the opposite, so atony is literally the lack of tone.)

Low-dose, High-frequency Practice and Laying Down Muscle Memory

Training in Helping Mothers Survive Bleeding After Birth improves birth providers’ abilities and confidence, but research by Jhpiego concluded that while the training improved skills and provider confidence, both skills and confidence quickly fell 10 months after the training concluded. For that reason, the idea of low-dose high-frequency practice was initiated. It is human to forget what we learn, and we are all susceptible to reverting back to old habits if we don’t keep new behaviors fresh in our minds. When Mercy In Action’s trainers teach the course, we stress the importance of the providers meeting again every few months to practice the steps of hemorrhage over and over until it becomes second nature. This should become a regular, ongoing in-service event every few months.

The other obvious advantage of low-dose high-frequency training is that new staff members or student midwives coming into a birth team are going to be organically involved in ongoing hemorrhage preparation. When the inevitable “real thing” hemorrhage occurs, everyone on the team has already practiced working together on the simulation, and the actual crisis can be managed seamlessly by the prepared and cohesive birth team.

Practice the Scenario in the Birth Setting

Ideally, the training will take place where births occur so that providers get a realistic feel for the space they will be working in when a real hemorrhage occurs. This means that those birth providers working in birth centers and hospitals should conduct training, ongoing practice, and evaluation in the actual birth rooms and delivery rooms where they work. Homebirth midwives can use any bedroom to feel right at home; the idea is to work in the surroundings where babies are actually born and practice the steps of management (including quick access to medications, IVs, scales, etc.) in the physical space where a birth followed by hemorrhage may occur.

Mama Natalie—A Responsive Simulation Tool

Mama Natalie is the name of the low-cost but highly-effective simulation model uterus created by Laerdal for Helping Mothers Survive Bleeding After Birth. The amazing thing about Mama Natalie is that she actually bleeds! Even more astounding, Mama Natalie will stop bleeding if the midwife or doctor practicing the simulation does the correct things in the correct order in the correct way. In a word, HMS-BAB training is designed to be responsive and reactive. The trainer wears the Mama Natalie devise and controls how and when the bleeding stops. Trainers can simulate many possible scenarios in the process of a third or fourth stage hemorrhage, so the birth attendant practicing has a real-world effect; if nothing is done or the wrong action step is done at the wrong time in response to a simulated hemorrhage, blood continues to pour out of the Mama Natalie vagina. On the other hand, if the trainee performs the correct skills, bleeding will slow down or stop.

In addition to controlling bleeding, the instructor wearing Mama Natalie controls the firmness of the fundus, so that when the trainee rubs up a contraction appropriately or performs bimanual compression correctly, the uterus “responds” by becoming hard and contracted under the trainee’s hand. Mama Natalie can also be catheterized. Overall, she is a very powerful tool for training our brains and making practice sessions beneficial because we are rewarded for the correct responses in our response to hemorrhage.

Better Predictions and Classification of Risk Factors

Another way to help jog our brains to better predict and manage hemorrhage is a re-classification of risks into timeframes. PRIME Education is currently offering a free CEU course online (which I have listed in the resources) where they have helpfully reclassified the risk factors as follows:

Antepartum Risk Factors

• IVF pregnancy
• Antepartum bleeding
• Intraamniotic infection
• Preeclampsia
• Maternal obesity
• Primiparity
• Grand multiparity
• Prior PPH
• Maternal anemia
• Placenta accreta spectrum

Fetal-Related Risk Factors

• Macrosomia
• Multifetal gestation

Labor-Related Risk Factors

• Augmented labor
• Prolonged labor
• Episiotomy or Tears
• Sutures
• Retained placenta

Risk assessment tools like this may aid in the early identification of those at the highest risk for a hemorrhage and help us remember to reassess risk factors throughout pregnancy, labor, and third stage. But take note: experts say 20% of postpartum hemorrhages occur in patients with no risk factors at all; therefore we must be prepared to manage hemorrhage at every birth!

Early Identification and Intervention Prevents Hypovolemic Shock

Part of early intervention in a case of hemorrhage is early identification, and Mercy In Action teaches the principles of hemorrhage and shock in many of our live seminars and online classes. One thing we know is that denial can be a powerful deterrent to action, so we must quickly break out of any potential disbelief or temptation to minimize the reality of hemorrhage. Here is a quick review of the clinical signs and symptoms of shock.

Clinical SIGNS of hypovolemia you may see or note upon taking vital signs include:

• Tachycardia
• Increased respiratory rate
• Hypotension
• Decreased skin turgor
• Dry mucus membranes
• Loss of consciousness

SYMPTOMS of hypovolemia the mother may report to you include:

• Weakness
• Fatigue
• Dizziness
• Confusion
• Blurry vision
• Muscle cramps
• Feeling cold
• Thirst

If these signs and symptoms are present, the person has likely already lost a considerable amount of blood and may be in clinical shock. Don’t wait for these signs and symptoms to appear before you act when blood loss is happening.

Early identification of hemorrhage requires practice estimating blood loss. Weighing the birth pads and sheets is better than estimating by sight. Best is a direct liquid measurement if we can catch the blood in a bowl or bedpan (as is possible with an upright birth) or a calibrated drape. And of utmost importance is taking vital signs often in the third and fourth stage, whether or not you see blood loss—elevated pulse is an early but invisible sign of shock, so only by checking the pulse often will we avoid a deadly delay in identifying a hidden hemorrhage.

In addition to early identification of hemorrhage, a landmark study released in May 2023 by the New England Journal of Medicine showed that the use of a bundled treatment plan led to a lower risk of severe hemorrhage. Treatments like uterine massage, medication, and IV at the same time—rather than offering treatments sequentially—resulted in dramatic improvements in women’s outcomes. “Time is of the essence when responding to postpartum bleeding, so interventions that eliminate delays in diagnosis or treatment should be gamechangers for maternal health,” said Dr. Arri Coomarasamy of England, who led the trial released in May 2023.

NASG = Instant Low-tech Transfusion to Treat Shock Caused by Hypovolemia

There now exists a safe, easy way to “transfuse” a patient’s own blood from their lower body where there are no vital organs up into the core, where the vital organs are, to prevent or treat shock following hemorrhage. The Non-pneumatic Antishock Garment (NASG), also sometimes called Non-inflatable Antishock Garment, has the ability to safely squeeze blood from the legs up to the oxygen-starved vital organs such as the heart and brain. This redesigned version of the older inflatable Military Anti Shock Trousers (MAST) was created by a PhD-trained midwife to provide an affordable, low-tech device to be used at homebirths around the world to reduce hemorrhage deaths. Studies show that NASG can reduce both mortality and morbidity from hemorrhage in all settings. Mercy In Action has been training out-of-hospital midwives to use the NASG since 2010 and has donated dozens so far to midwives serving in poor countries in Asia, Africa, Latin America, and the Caribbean. During the big typhoon disaster in the Philippines in 2013, my son and I trained local midwives, as well as the medical staff of Doctors Without Borders, to use them in their disaster-response tents.

There is some training involved to apply and remove the NASG, but overall, it is a user-friendly, low-tech tool that can be used in any setting to prevent and treat shock following hemorrhage during childbirth. We have found from our own studies in Mercy In Action birth settings that using the NASG stabilizes vital signs so well that transfer to a hospital is avoided in about half the cases we encounter of shock following hemorrhage. Witnessing what a profound improvement the NASG can make in reversing shock-induced vital signs is why we teach the use of the anti-shock garment, with corresponding OSCE, in most of our Mercy In Action seminars, including “Expect the Unexpected,” “IV Therapy and Shock for Midwives,” and others.

Our Mercy In Action midwives are so convinced of their benefit that we have NASG stocked in all of our birth centers, and even used them in our USA birth center which was less than 10 minutes from a hospital. We love to train the local EMS in their use, as well.

Mercy In Action’s Global Education Opportunities

Mercy In Action is committed to reducing the preventable causes of maternal and newborn mortality and morbidity around the world. For this reason, we regularly offer seminars and workshops to teach Helping Mothers and Babies Survive training materials. Using Helping Mothers Survive Bleeding After Birth as one part of our Train the Trainer workshop in our Diploma in International Midwifery & Maternal/Child Health program, we have certified hundreds of midwives, doctors, nurses, and primary health care providers in the USA, Philippines, and Australia who are now serving all over the world. We also welcome allied medical providers, doulas, and non-medical advocates into our diploma program, so that anyone with a heart to help can serve as a health educator. Our hands-on workshops and seminars, teaching the principles I have talked about in this article, are open to everyone, whether or not they are enrolled in our Diploma program.

The goal of all Mercy In Action’s educational programs is to empower maternity health care providers everywhere in the world with the knowledge and skills needed to provide high-quality, respectful care during childbirth. Our motto that we seek to live out daily is: “Safe Motherhood and Newborn Survival: One Good Birth at a Time.”

References:

• Gallos, I, et al. 2023. “Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage.” NEJM. www.nejm.org/doi/full/10.1056/NEJMoa2303966.
• Ersdal, HL, et al. 2017. “Successful implementation of Helping Babies Survive and Helping Mothers Survive programs—An Utstein formula for newborn and maternal survival.” PLOS ONE 12(6): e0178073. doi.org/10.1371/journal.pone.0178073.
• Evans, CL, R Kamunya, and G Tibaijuka. 2020. “Using Helping Mothers Survive to Improve Intrapartum Care.” Pediatrics 146(Suppl 2): S218–22. doi.org/10.1542/peds.2020-016915M
• Bogren, M, et al. 2021. “Impact of the Helping Mothers Survive Bleeding After Birth learning programme on care provider skills and maternal health outcomes in low-income countries—An integrative review.” Women and Birth : Journal of the Australian College of Midwives 34(5): 425–34. doi.org/10.1016/j.wombi.2020.09.008.
• Alwy Al-Beity, FM, et al. 2022. “Health workers’ experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework.” BMC Health Services Research 22(1): 1240. doi.org/10.1186/s12913-022-08605-y.

Mercy In Action Resources:

• Mercy In Action Global Seminars and Workshops
  www.mercycollegeofmidwifery.edu/hands-on-seminars
• Mercy In Action Continuing Education Online
  www.mercycollegeofmidwifery.edu/online-ceu
• Diploma in International Midwifery and Maternal/Child Health
  www.mercycollegeofmidwifery.edu/diploma-international-midwifery

Other Resources:

• Helping Mothers and Babies Survive
  https://hmbs.org/
• Helping Mothers Survive
  https://hms.jhpiego.org/training-materials/index.html
• Helping Babies Survive
  www.aap.org/en/aap-global/helping-babies-survive/
• Laerdal Global Health
  https://shop.laerdalglobalhealth.com/
• PRIME Online CEU: Novel Approaches in the Management of Postpartum Hemorrhage
  https://primeinc.org/online/novel-approaches-management-postpartum-hemorrhage