Birth is a maddening time. It’s emotional, stressful and messy—and when a patient begins to bleed, an easy birth can quickly spiral into a dangerous one. Postpartum hemorrhaging (PPH) can occur during delivery or even days after and is one of the leading causes of maternal mortality during childbirth. Hysterectomies are the default treatment, and while they are sometimes the best or only choice, these invasive procedures introduce more trauma and difficulty onto the patient than may be necessary.
Uterine artery embolization (UAE) is a proven alternative to hysterectomy in many cases, and its minimally invasive nature can decrease the morbidities and costs associated with PPH, as well as preserve future fertility. But when an obstetrician is faced with a dangerous bleed that could lead to loss of life, it often seems faster and safer to conduct a hysterectomy, rather than take the perceived risk of waiting for an IR.
OBs shouldn’t have to weigh the risks of waiting for additional help, and mothers should be afforded a robust support system in the case of an emergency. Like with any other equivalent trauma, when a patient begins to hemorrhage, there should be a built-in response team that can offer the patient the best care for her specific situation.
The need for a PPH response team
IRs have seen the success of the pulmonary embolism response team (PERT) framework. The PERT model was born from the fact that a PE can rapidly kill a patient and requires a multidisciplinary approach to treatment. It took work to convince the relevant parties, but now when a person has a massive PE and is hemodynamically unstable, there is no question as to what to do. We have lifted the burden of personal responsibility off individual physicians and worked together to better treat a serious medical emergency, using the knowledge of other disciplines and the minimally invasive therapies of IR. There is no reason why PPH should not be treated the same. However, there are questions and steps to be addressed before such a team could become effective.
How to build a team
Collaboration
A successful PPH response team will be large, requiring anesthesiologists, obstetricians, midwifes, nurses, IRs and their teams. But building this team requires collaboration. I believe that most OBs want partnership, because a PPH is one of the most frightening situations they face, and at the end of the day, they want to save their patient. However, there are misconceptions that IRs can’t activate fast enough, or don’t understand the severity of the clinical scenario. As IRs, we know that isn’t true—but there are ways to prove that a PPH team with IR at the lead can mobilize and be effective, such as putting on simulations of how these teams can work dynamically under stress.
Lexicon
When I’m called and told there is a patient in trauma bay one, that’s all the information I need. That language alone activates the IR team and trauma surgeons, and an operating room is held open. We know the CT scanner will be available. The prep work is done and no one has to question the process, because everyone involved knows what will happen. This preparedness needs to be translated to obstetrical trauma.
I serve on the maternal mortality review committee at a tertiary inner-city hospital. We review morbidities and mortalities every month, and one case stuck out to me as the perfect example of why lexicon is key. A woman had a baby and hemorrhaged, and six doctors were trying to get her to the OR for a hysterectomy. At no point did anyone think to call an IR. When a nurse involved was discussing the urgency of the situation, she said, “It’s not like the patient was bleeding. She was bleeding.”
We don’t currently have a lexicon for how OBs or nurses can communicate with us to say a patient is bleeding. How do we objectify that? Trauma teams have code blues, and obstetrical response teams need to figure out their own equivalent, so the parties involved do not have to rely on emotional enunciation to activate a multidisciplinary team that could save the life of the mother and reduce morbidity around this disease process.
The benefits of a PPH team
Lessening trauma
When women are preparing for a baby, they work with their health care provider to plan and check everything—they plan names and nurseries, prepare birthing plans, check their blood levels and glucose and run dozens of tests. But there is often no discussion about trauma. There isn’t often a conversation about what to do if things go wrong.
PPH is unannounced. It can happen to anyone, anywhere, at any time. Many patients don’t know they’re at risk until they are suffering a serious bleed. Some risk factors can be identified in advance. The most predictive factor is that if a patient has had a PPH before, they are at high risk of having one again. There are other indicators that OBs watch for, such as tone and contractility in the uterus and coagulation. Abnormal placentation is another risk factor which has increased in recent years as more mothers plan cesareans, and there is the consideration of trauma during birth. Lacerations caused during delivery or abnormal bleeding disorders also increase risk of hemorrhage.
We need to create a system that discusses risk factors and possible dangers and creates a plan of action accordingly—and PPH must be part of that discussion. If the potential for PPH becomes a normal part of the planning process, then if something goes wrong, the mother and her partner will have been presented with options well in advance. In addition, knowing the patient’s preference—for example, if they prefer a hysterectomy or would like UAE if viable—helps the health system plan for the birth as well, and allocate resources accordingly for an at-risk patient.
Improving data
When a woman is at risk and there isn’t a quick trauma response, conducting a hysterectomy is the correct path. However, there are gray zones where UAE is a great choice—but OBs may not know about UAE or be willing to confidently identify when UAE may be the best choice.
As we have seen from the PERT model, a collaborative response team has allowed the community to share their data to improve patient outcomes. A PPH response team would do the same, creating more standardized data to create better evidence-based guidelines, so providers know how to respond when a woman is in a gray zone.
There is so much here to study: the path of physiology for a woman who has just given birth, or the causes of preeclampsia, hypertension or hypotension. We currently define our blood loss based on trauma data, but we don’t know if these parameters still apply to a woman who has had increased blood volume due to carrying a child. One of the benefits of a PPH team would be to collect data on blood loss to help future providers more effectively determine what stage of blood loss the mother is in—and thus make treatment decisions tailored to her specific situation. We don’t just need a response team. We need a data registry to help everyone at all stages of obstetrical trauma be better informed, make better plans and know when to call for help.
A future of maternal support
As a society, we often underestimate the emotional and psychological trauma that happens from a situation like PPH, and we underestimate the impact on families and spouses. This trauma isn’t something that just effects babies and mothers. A patient’s partner is left to have the difficult discussions at the hospital, and if the worst happens, that partner becomes a single parent. Traumatic births have ripple effects throughout the entire family system.
We also cannot discount the impact of racial disparities on the health care process and the disproportionately high maternal death rate among the Black community. Combatting these systemic disparities require systemic solutions, and while PPH response teams may not solve the problems with access, they can improve the provider-patient relationship.
These problems cannot be solved in silos, and because hysterectomy is a known solution to PPH, we as doctors and researchers have taken our eyes off the prize. We must work together so that hysterectomy is not the only solution considered in the setting of postpartum hemorrhage. UAE offers a less invasive and irreversible alternative and mobilizing response teams and data registries are crucial in creating a future of safer, less traumatic deliveries. We are now on a cusp: It’s time to stop talking about this
future and begin building it.
