Prehospital Handling of Postpartum Haemorrhage- Healthcare Personnel’s Experiences and Perspectives


 Background: Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top five causes of maternal mortality globally. The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects. Timely diagnosis and early management are critical to reduce morbidity, the need for blood transfusion or even mortality. External, manual aortic compression (AC) has been suggested as an intervention that reduce PPH and extend time for control of bleeding or resuscitation. This procedure is not commonly utilized by healthcare personnel. The incidence of home-births is increasing, and competence in PPH handling is essential in prehospital personnel. The objective was to explore prehospital personnel’s competence in PPH and AC, utilizing different tools. Methods: The study was conducted in a county in South-eastern Norway, including five ambulance stations. All prehospital personnel (n=250) were invited to participate in a questionnaire study. The questionnaire included the PPH self-efficacy (PPHSE) and PPH collective efficacy (PPHCE) tools, as well as a developed tool. Descriptive statistics were used to analyse the quantitative data, while quantitative content analysis was used to analyse free-text responses. Results: A total of 87 prehospital personnel responded to the questionnaire, 57.5 percent male, mean age 37.9 years. 80.4 percent were ambulance workers and/or paramedics, and 96.6 and 97.7 percent respectively reported to need more education or training in PPH. Results show that prehospital personnel lack knowledge about what PPH is, how to estimate and handle PPH, and how to perform AC. 82.8 percent reported having experienced PPH, but only 2.9 percent had performed AC. Mean self-efficacy varied from 3.3 to 5.6, while collective efficacy varied from 1.9 to 3.8. Educational background did not seem to have any impact on participants’ responses. Conclusions and implications: This study indicates that prehospital personnel lack knowledge about PPH and AC, and also report to need more education and training. Hence, PPH should be included in educational programs at all levels of the education, as well as in quality improvement initiatives. After the conduction of this study, prehospital personnel attended a digital course in PPH, as well as a practical course in AC.


Background
Postpartum hemorrhage (PPH) is a serious obstetric emergency, and one of the top ve causes of maternal mortality globally [1]. Internationally, the prevalence of severe PPH appears to be rising, with increasing morbidity and need for transfusion therapy, and the mortality rates are high in low-income countries [2][3][4][5][6]. Maternal mortality rates (MMR) in the Nordic countries are among the lowest in the world, but women still die from complications of pregnancy or birth. In Norway, 168 maternal deaths were identi ed between 2005 and 2013 (Maternal Mortality Rate, MMR, 6.6 per 100 000), of whom 14 died due to severe PPH [7]. Page 3/15 The incidence of PPH has been reported to vary between one to ve percent, depending upon the diagnostic criteria applied [2]. Although PPH is traditionally de ned by the volume of blood loss observed, bleeding may not be visible externally or the blood may be mixed with amniotic uid [4]. In 2017, the American College of Obstetricians and Gynecologists revised their de nition of PPH to consist of the following criteria: 1. Cumulative blood loss ≥1000 ml or 2. Bleeding associated with signs or symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery [8] The most common causes of PPH include uterine atony, placental disorders, birth trauma and coagulation defects [9].
Timely diagnosis, appropriate resources and early management are critical to prevent death [9].
According to the World Health Organization, immediate solutions are needed to prevent women from dying of PPH [1]. Maternal mortality reviews have demonstrated that deaths caused by PPH are most likely to be preventable [10,11]. The consistent application of a comprehensive protocol for management of PPH have been demonstrated to result in improved outcomes [12,13]. Other important interventions include uid resuscitation, removal of the placenta, bimanual uterine compression, uterotonics, tranexamic acid, suturing of lower genital tract injury, blood product replacement, balloon tamponade, laparotomy, stepwise uterine de-vascularization, uterine compression sutures and hysterectomy.
Emergency temporizing measures include application of the non-pneumatic anti-shock garment, uterine tourniquet application and aortic compression [14].
External, manual aortic compression (AC) is an emergency manoeuvre proposed to reduce postpartum haemorrhage and extend time for resuscitation and control of bleeding.The technique can be applied immediately to reduce bleeding from the uterus by reducing the blood supply. This again may prevent cardiac arrest from hypovolemia, and allow transfer to de nitive care in-hospital. The Swedish obstetrician Bergstrom has been teaching this life-saving technique for many years in African countries, with great effect on maternal morbidity and mortality [15]. Nevertheless, in many countries, including Norway, manual AC is not actively used by healthcare personnel [16].
There is an increasing incidence of home births in Norway, as in Nordic countries [17,18]. Hence, knowledge of PPH on competence in handling this condition is essential in prehospital personnel.
Consequently, as researchers, healthcare personnel educators, nurse anesthetist and paramedic, we wanted to explore prehospital personnel's knowledge about and self-assessed competence in PPH and AC, their experience with this condition, perceived need for more education and/or training, as well as their perceived self-e cacy and collective e cacy in PPH handling.

Methods
The study had a cross-sectional design, utilizing a questionnaire to assess prehospital personnel's knowledge, self-assessed competence, self-e cacy and team-e cacy.

Setting
The study was conducted in a county with approximately 317.000 inhabitants, within one hospital catchment area. There are ve ambulance stations in this area. Prehospital personnel include ambulance assistants, ambulance workers (upper high school), bachelor in paramedicine or -nursing (180 ECTs), paramedics (further education, 60 ECTs).

Questionnaire
The questionnaire consisted of three parts: 1. a validated questionnaire in PPH self-e cacy (PPHSE), including eight items, using an eight-point Likert scale that range from 1 (never) to 8 (always) [19]. The items on self-e cacy focus on individual perception of control. Since no validated questionnaire to measure knowledge and self-assessed competence in PPH handling could be identi ed, we developed a questionnaire. Here, we used recommendations from the Delphi technique, which is suitable to obtain expert opinions in a systematic manner, and includes four steps: 1) expert input, 2) interaction with feedback, 3) statistical group responses, and 4) con dentiality [20,21].
Experts were de ned as specialists in their eld, and included six anesthesiologists, three obstetricians and two midwives, knowledgeable in the eld of obstetrics and obstetric anesthesia, and recommended by other experts [22]. The expert group consisted of four males, seven females, mean age was 53 years, and mean years of experience 15. In step 1 and 2, the expert group participated in the development of questions, and gave constructive inputs on clarity, wording, and contents of the whole questionnaire, as suggested by Streiner & Norman [23]. In these steps, experts received the questionnaire in two or three rounds depending on their inputs. In step 3, experts were asked to score the questionnaire regarding relevance, clarity and logic, on a scale from 1=strongly disagree, to 5=strongly agree. Table 1 presents the mean and range of responses to these scorings.
The experts were involved in several rounds until consensus was reached. The nal version of the questionnaire consisted of a) 13 knowledge questions with free-text answers, and two questions with alternatives yes/no/undecided, b) two questions about perceived need for more education and/or simulation, and c) ve questions about experience with PPH and the use of AC.

Analysis
Data were analyzed using the Statistical Package for the Social Sciences (SPSS 26.0) [24]. The descriptive statistics frequency, mean and SD were used to analyse data. Internal consistency for the scales was tested by Cronbach's alpha. There were no missing items in the validated questionnaires. The free-text responses were analyzed through a quantitative content analysis, reading through the responses and searching for similarities and code-words repeated throughout [25].

Results
A total of 87 prehospital healthcare personnel (34.8 percent) responded to the questionnaire. Table 2 gives an overview of respondents' gender, age, educational background and years of experience.
In this study, the Cronbach's alpha was 0.89 on the PPHSE scale, and 0.96 on the PPHCE, which is assumed excellent.

Responses to the developed questionnaire
Knowledge about PPH On the question "How much is normal hemorrhage during birth, and when is it de ned as postpartum hemorrhage?" most of the respondents assumed a hemorrhage of up to 500 ml as normal per-partum. Hemorrhage above 500 ml was interpreted as postpartum hemorrhage by 37 of the respondents. Other answers were 'above 1 litre' (n=17), '2 litres' (n=3), '1.5 litre' (n=1) and '3-4 litres' (n=1). The rest were undecided.
Regarding the question "How do you estimate the amount of hemorrhage during/after birth?" 39 respondents found this 'di cult'. A total of 18 respondents reported to assess the sheets or diapers, how often they needed to be changed, or even to weigh them. In addition, 21 of the respondents reported to assess the patients´ vital parameters or level of consciousness.

Knowledge about interventions
On the question "Which interventions should be initiated in postpartum hemorrhage?", the responses varied. Reported from most to least frequent response; uterus massage (n=29), uid resuscitation (n=22), put the baby to the breast (n=14), abdominal massage (n=10), establish intravenous access (n=9), add pressure on the abdominal aorta (n=9), elevate legs (n=9), quick transport to hospital (n=8), oxygen treatment (n=7), put pressure to the abdomen (n=5), shock-treatment (n=5), put the st into the woman and add pressure from the inside (n=5), areola massage (n=4), hemorrhage control (n=4), and oxytocin (n=3). Other suggestions were 'add pressure on the inguinal aorta', 'analgesia', 'tranexamacid', 'comfort the mother', 'compression', 'early warning to the hospital'. The questionnaire also included the question "When you observe a life threatening hemorrhage, what do you do rst?» Answers here were similar to those above regarding interventions.
Other When asked what the purpose of AC is, 71 respondents reported 'to stop the hemorrhage'. On the question "How do you assess whether the maneuver is conducted correct?", 35 responded 'when the hemorrhage stops', and 18 responded 'when the pulse in arteria femoralis is absent'. Regarding considerations during drug administration and ongoing AC, ve respondents reported 'side-effects', and one reported 'that drugs are not transported beyond the location of pressure'. A total of 82.8 percent of the respondents reported 'no', 11.5 percent reported 'undecided' and 5.7 percent reported 'yes', to the question about whether there are potential complications related to AC. Suggested complications were 'damage due to ischemia' (n=4), 'reduced blood pressure'(n=3), 'damage to inner organs'(n=1), and 'pain' (n=1).
No relation between educational background and level of knowledge could be identi ed.
Need for education and/or training When asked "Do you want more education in handling postpartum hemorrhage?", 96.6 percent responded 'yes', 1.1 percent responded 'no', and 2.3 percent responded 'undecided'.
Among the respondents, 97.7 percent answered 'yes' that they want more training/simulation in handling postpartum hemorrhage.
Participants that responded 'no' or 'undecided' that they needed more education or training were all assistants or ambulance workers.

Experience
Prehospital personnel's experience with PPH and AC is shown in table 3.
Reasons for not using AC were 'lack of education' (74.7 percent), 'lack of training' (10.3 percent), 'feel unsecure on the procedure' (10.3 percent), and 'di cult to cause the patient pain' (4.6 percent) ( xed response alternatives).

Discussion
Our ndings indicate that prehospital personnel lack knowledge about postpartum hemorrhage (PPH) and manual aortic compression (AC). As much as 82.8 percent had experienced PPH, but only 2.3 percent had utilized AC. Participants scored lower on self-e cacy than on collective e cacy in PPH handling. 96.6 and 97.7 percent respectively reported a need for more education or training in PPH/PPH handling.
Our ndings enlighten the knowledge gap in prehospital personnel regarding PPH and AC. This indicates a need to include this topic in educational programs regardless of educational level. Studies have indicated a need to develop and implement robust clinical research regarding treatment of PPH, to establish an international knowledge platform [26]. Senthiles et al. [27] emphasize a need to reach a broad consensus about the most e cient interventions to prevent and treat PPH. This include PPH prevention initiatives, estimation of blood loss, when and which uterotonica to administer, and use of blood products. Nevertheless, consensus has been reached regarding the main steps for the initial management of PPH: manual exploration of the uterus, visual assessment of genital tract, bladder indwelling catheter, measures to maintain maternal temperature, supplemental oxygen, uterine massage, maintenance of venous access, infusion of crystalloids rather than colloids, continuous monitoring of pulse, blood pressure and respiratory rate, and use of a uterotonic [27].
The participants' self-e cacy was scored lowest on the items «I have experienced being able to act in situations with PPH" (mean score 2.6, SD=1.5) and "I am con dent in how to treat PPH" (mean score 3.5, SD=2.6), while the highest score was on the item "I remain calm when handling PPH" (mean score 5.5, SD=2.1). This may be because prehospital personnel is used to handling acute and unpredictable situations. The lowest score regarding collective e cacy was on the item "I think that every member of the team will express themselves clearly during PPH" (mean score 4.8, SD=2.0), and the highest score on the item "As a team, we help each other prevent excessive PPH" (mean score 6.9, SD=1.4). This may mostly re ect the nature of prehospital personnel's work, rather than PPH itself [28]. In contrast, a recent study including pre-and post-simulation scores of self-and collective e cacy in PPH in intra-hospital personnel, participants scored 5.9 (SD=1.1) on self-e cacy before the simulations, and 6.5 (SD=0.9) after. Scores on collective e cacy in PPH handling increased from 5.8 (SD=0.9) to 6.3 (SD=0.8) [19]. This may indicate that personnel working in obstetric/resuscitation teams in hospital are more trained in this obstetric emergency, which is also natural.
Aronson and Bergström's research [15] indicates that AC may effectively reduce need for blood transfusion, morbidity and mortality. Nevertheless, our participants rarely used this technique. This study, as well as earlier research enlighten the challenges in distributing knowledge to larger groups of personnel, and from high-income to low-income countries. Hence, a PPH digital learning program was developed, in addition to a simulator that enables participants to evaluate the pressure, placement and effect of AC. After the conduction of this study, prehospital personnel attended the course and were given a demonstration and opportunity to apply AC. In addition, a new PPH handling guideline has been implemented in hospital, resulting in that midwives and obstetricians now often arrive to the operating room in the patient's bed, adding AC. In Tanzania, a structured inter-professional simulation program on PPH handling lead to a signi cant reduction in the use of ≥5 units of blood products related to severe bleeding after birth [19]. Moreover, training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debrie ng contributed to reduced blood transfusion rates in this high-risk maternity settings [29]. The same research team conducted a study on the effect of inter-professional simulations to reduce PPH, in a Norwegian university hospital. The researchers emphasized the importance of team training as a learning feature, and that inter-professional simulation enhanced selfe cacy and reduced perception of stress. Here, personnel also experienced an improved competence to provide e cient PPH management [30].

Limitations
Due to the small sample size, ndings here may not be generalizable to other countries or settings. Nevertheless, research support our ndings, stating a need for more knowledge and competence in PPH and PPH handling internationally. Two validated tools were used to measure self-e cacy and collective e cacy, which increase the reliability of the study. Moreover, the new questionnaire was developed in-line with recommendations from the Delphi technique, and face-and content validity were high.

Conclusion
Postpartum haemorrhage is a critical medical emergency, that may occur prehospital due to the increasing amount of home-births. External, manual aortic compression may e ciently reduce morbidity and mortality. This study indicates a need for more education and training in PPH and PPH handling in prehospital personnel, to be able to identify and intervene in PPH.

Implications for further research
Responses on the free-text questionnaire in this study will be used to develop a tool for assessment of healthcare personnel's knowledge about PPH and AC that can be used in other settings to assess knowledge gaps and what to focus on in quality improvement initiatives. The study was approved by the Norwegian Centre for Research Data (NSD) (project no.740937). The study was based on the research ethical principles in the Declaration of Helsinki [31], on willing participation, consent to participate implicated by completion and submission of questionnaire, anonymity and con dentiality.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests Funding The study was funded by Østfold University College. The funding body did not take part in design of the study, collection, analysis, and interpretation of data or in writing the manuscript.
Authors' contributions ACL participated in planning the study, facilitated the expert-group inputs, development of the questionnaire, datacollection, analysis, and writing and approval of the whole draft of the manuscript.
LEU participated in planning the study, facilitating the intervention, datacollection, and critical revisions of the manuscript, and approval of the nal version of the manuscript.
AKH participated in planning the study, development of the questionnaire, datacollection, analysis, and writing and approval of the whole draft of the manuscript.
VAG participated in planning the study, development of the questionnaire, datacollection, analysis, and writing and approval of the whole draft of the manuscript. Abbreviations: a) relevance to assess knowledge about PPH, b) relevance to assess competence in PPH handling, c) relevance to assess knowledge about manual aortic compression (AC), d) relevance to assess competence in performing AC, e) whether questions were clear, relevant and understandable, and f) whether the questionnaire was logic. 1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, 5=strongly agree. I= rst round, II=last round.    As a team, we are able to carry out the necessary actions to treat PPH 5.7(2.4) I think the team will share tasks in an appropriate way during PPH 6.5(1.7) The team can handle PPH 5.0(2.1) I think that every member of the team will express themselves clearly during PPH 4.8(2.0) As a team we can cope with PPH 5.6(2.1) The team usually has clear leadership in emergency situations like PPH 6.1(1.7) When PPH arises, our team is able to take action 5.1(2.2) As a team we communicate clearly and e ciently whenever PPH arises 5.5(2.1) Everyone knows what to do during an ongoing PPH situation 5.9(1.9) We are able to identify PPH at an early stage 5.9(2.0) We as a team remain calm during situations involving PPH 5.3(2.0) We are supportive of each other when we are in high-pressure situations 5.6(2.0) Total score 5.6(1.6) PPH= postpartum hemorrhage. Scored on a Likert scale from 1=never, to 8= always.