Out-of-hospital care of postpartum hemorrhage: a scoping review

Objective: Given the paucity of information on managing out-of-hospital postpartum hemorrhage, this scoping review aimed to systematically map current literature on the scope, depth, and key concepts on the topic, as well as identify gaps and areas for further study. Introduction: Postpartum hemorrhage is characterized by blood loss after childbirth that endangers hemodynamic stability of the mother. It can cause rapid deterioration if not managed promptly and remains the leading cause of maternal morbidity and mortality worldwide, particularly in resource-limited, out-of-hospital settings; however, knowledge about its management is limited. Methods: The JBI scoping review methodology was utilized for this review. A comprehensive search strategy was employed across MEDLINE (Ovid), CINAHL Complete (EBSCOhost), Embase (Ovid), Scopus, Web of Science Core Collection, as well as gray literature databases ProQuest Dissertations and Theses and EBSCOhost Open Dissertations. A Google search and a hand-search of relevant, peer-reviewed journals were also performed. Inclusion criteria were applied to identify appropriate literature. Studies that described emergency out-of-hospital care of either primary or secondary postpartum hemorrhage in women regardless of age, ethnicity, parity, or comorbidities were considered. Of these, only those published in English after 1988 were included. Selection of sources for inclusion was determined by 2 independent reviewers; discrepancies in outcomes were discussed with a third reviewer. The reference lists of all included sources were screened and authors were contacted before data were extracted and reported, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guideline. Results: The search yielded 311 unique records, of which 43 were included in the review. All the included studies were published literature, the majority of which were primary studies and secondary reviews. A significant proportion of the included studies were published by authors from the United States, the United Kingdom, and Australia. Across the literature, care of patients with out-of-hospital births includes actively managing the third stage of labor, involving pharmacological and mechanical measures to facilitate placenta delivery. When postpartum bleeding compromises hemodynamic stability of the mother, current practices include standard hemorrhage protocols alongside measures to reverse the cause of the hemorrhage. However, our findings indicate substantial inconsistencies in recognition and management of out-of-hospital postpartum hemorrhage. This can be attributed to variabilities in identification methods and interventions, gaps in practitioner knowledge and skill sets, lack of clinical practice guidelines, social determinants affecting health care access, and logistical challenges of providing timely medical support. Such variabilities pose detrimental effects on maternal health and outcomes. Conclusions: Current evidence on the care of out-of-hospital postpartum hemorrhage is largely made up of published studies representing countries with diverse economic standards. The concept of actively managing the third stage of labor appears to be increasingly recognized and implemented; however, it remains apparent that out-of-hospital care of postpartum hemorrhage is not well-established, creating room for complications. To improve standardization in clinical practice, further research to establish best practices, customized to environmental and resource availabilities, is warranted. Further investigation on practitioner training and education would also be valuable in ensuring a qualified workforce. Review registration: Open Science Framework https://osf.io/dmjcg