Use of the E-MOTIVE (Early detection and trigger criteria, Massage of uterus, Oxytocic drug, Tranexamic acid, IV fluids, Examination and Escalation) treatment bundle for early detection and treatment of postpartum hemorrhage (PPH) significantly improved outcomes with 60% reduction in severe bleeding and marked reduction in the need for blood transfusions for bleeding, according to a study of over 200,000 women carried out by researchers from the World Health Organization (WHO) and the University of Birmingham. Mortality risk was also lower. The study findings are published in the New England Journal of Medicine.1,2

The multicenter study compared a clinical intervention for postpartum hemorrhage after a vaginal delivery with usual care. The clinical intervention constituted the use of a calibrated blood-collection drape (with marks to indicate levels of blood loss) for early detection of PPH together with WHO-recommended treatments such as uterine massage, oxytocic drugs, tranexamic acid, IV fluids, examination and escalation to advanced treatment plus an implementation strategy all at once instead of introducing them sequentially.

A total of 210,132 patients who underwent vaginal delivery were randomized to the intervention group or the usual-care group (control). Eighty hospitals in Kenya, Tanzania, South Africa and Nigeria participated in the trial. From August to October 2021, these hospitals initially provided usual care for PPH for a duration of 7 months; they were then assigned to implement the trial intervention or continue with the usual care for 7 months.

There were fewer cases of severe postpartum hemorrhage (blood loss 1000 ml or more), laparotomy for bleeding or maternal death from bleeding, the primary study outcomes, in the intervention group compared to the control group; 1.6% vs 4.3%, respectively with a risk ratio of 0.40. The secondary implementation outcomes were also met in the intervention group with enhanced detection of PPH (500 mL of blood loss) compared with the women who received the usual care; 93.1% vs 51.1%, respectively with rate ratio of 1.58. Adherence to the treatment bundle also improved 91.2% vs 19.4%, respectively (rate ratio 4.94). Postpartum blood transfusion for bleeding was also lower in the intervention group; 1.2% and 1.9%, respectively with a risk ratio of 0.71. A favorable trend in maternal mortality was also noted in the intervention group vs usual care group; 17 cases vs 28 cases (RR 0.73).

Based on these findings, the study concluded that early detection of PPH coupled with use of an intervention bundle reduced the odds of severe PPH, the need for a laparotomy to control bleeding or associated mortality in women undergoing vaginal delivery. The marked reduction in the requirement of blood transfusion in the intervention group in particular bodes well for resource-constrained countries “where blood is a scarce and expensive resource”.²

References

1. Gallos I, et al. Randomized trial of early detection and treatment of postpartum hemorrhage. N Engl J Med. 2023 May 9. doi: 10.1056/NEJMoa2303966.
2. https://www.who.int/news/item/09-05-2023-lifesaving-solution-dramatically-reduces-severe-bleeding-after-childbirth, May 9, 2023. Accessed on May 22.5.23.