Strategies for optimising early detection and first response management of postpartum haemorrhage at caesarean birth: A modified Delphi-based international expert consensus

OBJECTIVE There are no globally agreed upon strategies on early detection and first response management of postpartum haemorrhage during and after caesarean birth. Our study aimed to develop an international expert’s consensus on evidence-based approaches for early detection and first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN Systematic review and three-stage modified-Delphi expert consensus. SETTING International. POPULATION Panel of 22 global experts in postpartum haemorraghe with diverse backgrounds, and gender, professional, and geographic balance. OUTCOME MEASURES Agreement or disagreement on strategies for early detection and first response management of postpartum haemorrhage at caesarean birth. RESULTS Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman’s haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology, and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman’s haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION These agreed-upon proposed approaches could help improve the detection of PPH in the intra and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step. Strengths Limitations ### Competing Interest Statement Disclosure forms provided by the authors are available with the full text of this article. ### Funding Statement This study was funded by the Bill & Melinda Gates Foundation (INV-001393) through a grant to the University of Birmingham, United Kingdom, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the WHO. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: ETHICAL CONSIDERATIONS: Authors confirm that this exercise was conducted according to relevant guidelines and regulations with respect to the Helsinki Declaration. Experts were advised that participation was voluntary and indicated informed consent. Given the consultative nature of the exercise which involved consenting experts in their work capacity, ethical clearance was not required. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Extensive data are presented in the supplementary materials. Given the small sample size, datasets will be available upon reasonable request.