1 INTRODUCTION

Postpartum haemorrhage (PPH) accounts for the highest number of maternal deaths globally, comprising 27% of total maternal deaths (World Health Organization [WHO], 2023). PPH refers to blood loss greater than 500 mL after vaginal delivery within the first 24 h. Eighty percent of PPH cases occur within 2 h of delivery and are accompanied by signs or symptoms of hypovolemia (Wormer et al., 2023). The incidence of PPH after vaginal delivery is 3.2% in the United States (Reale et al., 2020), 16% in Nepal (Sharma & Dhakal, 2018) and 10.4% in China (Wei et al., 2020). PPH can result in complications such as hypovolemic shock, disseminated intravascular coagulation, acute respiratory distress syndrome, acute renal failure and decreased fertility; it can also cause long-term psychological effects such as fear, depression and post-traumatic stress disorder, resulting in serious challenges and economic burdens in the global public health sector (American College of Obstetricians and Gynecologists [ACOG], 2017; WHO, 2023). However, most cases of PPH are avoidable or potentially preventable, with the key lying in scientific management. The WHO has recommended a midwife-led continuity of care model (Tuncalp et al., 2017), and studies show that the midwife-led care model can reduce the incidence of PPH (Kalu & Chukwurah, 2022; Zhang et al., 2021).

The International Confederation of Midwives (ICM) issued a joint statement stressing that midwifery plays important roles in promoting reproductive health and ensuring the safety of mothers and infants (Nove et al., 2018). The Lancet Series on Midwifery concluded that midwives could avert about 70% of maternal or infant deaths (Renfrew et al., 2014). Midwives are often the first-line professionals in quantifying blood loss, initiating the early diagnosis of PPH and mobilizing a team response if necessary (Natrella et al., 2018). Multiple government agencies have released guidelines for preventing, treating and managing PPH, but these are applicable to all health care personnel and do not explicitly address the role of midwives (ACOG, 2017; Queensland Health, 2023; WHO, 2023). Renfrew et al. (2014) developed a framework for quality maternal and newborn care and examined effective and ineffective practices in midwifery, from pre-pregnancy and pregnancy to birth and postpartum. However, effective PPH practices only included the use of medications (Renfrew et al., 2014). Another study indicated that in the management of PPH, midwives must assess and intervene as early as possible or during the haemorrhage, initiating emergency treatment or calling for help; however, that study lacked specific descriptions (Mamakou, 2020). Emergency personnel in PPH include obstetricians, anaesthesiologists, midwives, nurses and laboratory personnel. However, in many countries, no clear professional distinction exists between midwives and nurses (Nove et al., 2021). This leads to midwives lacking a clear understanding of the role they play in different settings, hindering the quality of interprofessional communication and collaboration in daily clinical practice (Maier & Aiken, 2016). This situation further affects the success rate of treating PPH and poses challenges to the management of PPH. In addition, midwives' professional qualifications, clinical experience, knowledge level, age, working years and education level are closely related to the prevention and management of PPH (Muthoni et al., 2021; Ramadhani et al., 2020; Voillequin et al., 2022; Wake & Wogie, 2020). Although some studies have investigated the challenges related to PPH, there are no systematic reviews on this topic in particular.

Thus, we conducted a review of the roles of midwives and the challenges faced by them in preventing, diagnosing and managing PPH based on scope to provide a basis for clinical midwifery management, reduce the incidence of PPH and put forward prospects and suggestions for the development of midwives in their professional field.

2 AIM

In this study, we aimed to acquire a comprehensive understanding of the roles of midwives and the challenges faced by them in the prevention, diagnosis and management of PPH following normal vaginal delivery.

3 METHODS

A scoping review was conducted following PRISMA-ScR recommendations (Tricco et al., 2018). The chosen methodological framework was the model designed by Arksey and O'Malley and extended by Levac (Levac et al., 2010). This involved a six-step process: (i) identifying the research questions; (ii) identifying relevant studies; (iii) selecting studies; (iv) charting the data; (v) collating, summarizing and communicating the results and (vi) holding consultations.

4 FINDINGS

4.1 Search and selection process

The initial database search yielded 1969 articles. We removed a total of 131 duplicates and screened 1789 reports according to the title and abstract. Subsequently, the full texts of the remaining 49 references were analysed to determine their eligibility. This led to the exclusion of 21 full texts that were deemed irrelevant to the study objectives for various reasons: 2 articles were in a non-English language, 10 articles were not available in full, and 9 articles did not match the topic. Ultimately, 1810 papers were excluded, and 28 papers were included. The search and selection processes are summarized in Figure 1.

4.3 Role of midwives in managing PPH

According to the reviewed studies, midwives have roles in the prevention, diagnosis and management of PPH, covering prenatal, intrapartum and postpartum care (Figure 2).

4.3.1 Prevention of PPH

In the prevention of PPH, midwives play roles such as identifying and managing high-risk factors, managing labour and implementing skin-to-skin contact (SSC).

Identification and management of high-risk factors

Five studies described the role of midwives in identifying and managing high-risk factors (Akter et al., 2022; Beltman et al., 2013; Kalu & Chukwurah, 2022; Loewenberg Weisband et al., 2018; Zhang et al., 2021). In the prenatal period, midwives can establish personalized health cards for pregnant women, conduct health education and provide psychological counselling for pregnant women and their families. This approach aims to improve the mother's physical fitness, reduce anxiety in pregnant women, recognize high-risk factors and decrease the occurrence of PPH (Zhang et al., 2021). The high-risk factors for PPH include a previous history of PPH, a large baby, multigravida, placental problems, anaemia, or a history of coagulopathy (Akter et al., 2022; Kalu & Chukwurah, 2022). The early identification of high-risk factors for PPH and optimizing pregnancy can effectively prevent its occurrence (Escobar et al., 2022). Midwives can guide pregnant women with anaemia to consume folic acid and iron supplements, provide prophylactic malaria treatment and conduct regular blood monitoring, aiming to maintain optimal haemoglobin levels during the antenatal period, thereby enhancing women's ability to cope with PPH if it occurs (Kalu & Chukwurah, 2022). When high-risk factors are severe or uncontrollable, timely referral to a higher level medical facility should be initiated (Beltman et al., 2013).

Management of labour

Midwives can manage labour according to established evidence-based practice. Labour is the process through which a foetus and placenta are delivered from the uterus through the vagina. There are three stages of labour in humans. The roles and functions of midwives during labour are described below.

Labour companion

Continuous one-to-one midwife support throughout the first stage of labour is an essential measure to reduce the risk of complications (Cederfeldt et al., 2016). Two studies have described the midwives' role as a labour companion (Kalu & Chukwurah, 2022; Zhang et al., 2021). The authors noted that during labour and delivery, having the same midwife continuously present at a women's bedside can slightly alleviate the pain through methods like massage, storytelling, reassurance and scientific guidance, thereby reducing the incidence of PPH.

Perineal management

In the second stage of labour, appropriate perineal management techniques are believed to reduce perineal trauma and subsequently reduce the occurrence of PPH. Two studies have explored the techniques of perineal management (Huang et al., 2020; Petrocnik & Marshall, 2015). Petrocnik conducted a systematic review comparing the hands-on and hands-poised techniques of perineal management during the second stage of labour. The review showed that the hands-on technique resulted in higher rates of PPH (Petrocnik & Marshall, 2015). Another study indicated that there was no difference between the hands-on and hands-off/poised techniques regarding the risk of PPH incidence (Huang et al., 2020).

Active management

Three studies described the roles of midwives in the third stage of labour (Begley et al., 2019; Cohain, 2022; de Castro Parreira & Gomes, 2013). Two studies focused on active management in the third stage of labour (AMTSL); the results from both studies showed that AMTSL reduced the risk of PPH (Begley et al., 2019; de Castro Parreira & Gomes, 2013). AMTSL comprises three components: (1) administration of uterotonic agents within 1 min of childbirth and delayed cord clamping; (2) active removal of the placenta by controlled cord traction following signs of placental separation; and (3) uterine massage immediately after removal of the placenta (WHO, 2014). Another study described a novel third-stage protocol. This protocol entails cutting the umbilical cord 1 min after delivery, encouraging the mother to squat 2 min after delivery and having the mother push out the placenta while in the squatting position, followed by a 10-s abdominal massage to promote uterine contractions once the mother is in bed, if consent was obtained before birth. The study found that the protocol resulted in an average blood loss of 100 mL in the first 2 h after birth and no cases of PPH ≥500 mL (Cohain, 2022).

Implementation of skin-to-skin contact

SSC is defined as immediate and uninterrupted contact between the woman and her newborn (Moore et al., 2016). Contact, heat and olfactory receptors with strong vagus nerve stimulants during SSC may lead to the release of maternal oxytocin. Oxytocin is one of the most important uterine contraction factors, capable of promoting rhythmic contractions of the uterine muscles, aiding in uterine contraction and detachment of the placenta and playing a crucial role in controlling PPH (Aydin Kartal et al., 2022). Two studies have demonstrated that SSC after delivery can reduce the incidence of PPH (Aydin Kartal et al., 2022; Saxton et al., 2016). Saxtonproposed a new theory based on SSC (Saxton et al., 2016). The theory, named ‘Pronurturance Plus’, posits that by establishing a trusting relationship between the midwife and pregnant woman, providing the pregnant woman with a warm environment, facilitating SSC and enhancing midwife supervision, the secretion of oxytocin is boosted.

4.3.2 Diagnosis of PPH

Midwives are often the first to diagnose PPH via early recognition and blood loss estimation. Midwives recognize PPH through clinical manifestations in women (decreased blood pressure, increased pulse rate, tachypnoea and altered physical and mental state) (Akter et al., 2022). Five studies focused on the assessment of postpartum blood loss (Golmakani et al., 2015; Liu et al., 2021; Natrella et al., 2018; Rosmaria et al., 2019; Wiklund et al., 2022). In Indonesia, midwives have not paid sufficient attention to the evaluation of postpartum blood loss, and physiological parameters are the most applicable method for doing so (Rosmaria et al., 2019). In China, a study that aimed to evaluate the accuracy of visually estimated blood loss in PPH by midwives and nurses showed that the overall accuracy was 30.52% (1763/5776), with 25.3% and 18.0% for PPH (500 mL) and severe PPH (1000 mL), respectively (Liu et al., 2021). The visual assessment was not credible, with both overestimates and underestimates of blood loss noted. Instead, the blood lost should be weighed, especially for bleeding greater than 300 mL (Golmakani et al., 2015; Natrella et al., 2018; Wiklund et al., 2022).

4.3.3 Management of PPH

Midwives' actions in first aid are crucial in determining maternal outcomes in PPH (Natrella et al., 2018). Midwives' roles mainly include mobilizing other professional team members (obstetricians, anaesthetists, laboratory staff and nurses) (Akter et al., 2022), emergency management (intravenous infusion therapy, oxygen inhalation, monitoring vital signs), investigating the cause, enhancing uterine contractions (extrinsic massage, administration of oxytocin and other drugs) and repair of perineal tears (Esan et al., 2022; Moudi et al., 2019; Smit et al., 2014). Transfer to the hospital and referral to a physician are essential when midwives are unable to control PPH, prepare for surgical intervention for those not responding to medical management, or provide support (Kalu & Chukwurah, 2022).

5 DISCUSSION

In the present scoping review, we included 20 studies describing the roles of midwives in managing PPH. Most publications (12 of 20, 60%) reported the roles of midwives in preventing PPH. This result is consistent with the International Federation of Gynecology and Obstetrics (FIGO) guidelines, which state that all attempts should be made to reduce PPH with effective resources and appropriate interventions (Escobar et al., 2022). Fewer studies (5 of 20, 25%) reported midwives' role in diagnosing PPH. Consistent with a previous study, accurate estimation of postpartum blood loss was identified as a major contributor to the improvement of maternal safety and the reduction of PPH-related morbidities (Natrella et al., 2018). The best measure of PPH volume is the weighting method. Only a few studies (3 of 20, 15%) reported midwives' role in the management of PPH. This may be due to the inevitable overlap between the roles and responsibilities of different health care professionals (Wake & Wogie, 2020), resulting in few studies involving only midwives. Future research should focus on the roles of midwives in postpartum on-site management.

In this scoping review, studies on the roles of midwives in PPH covered a total of 16 countries, with five conducted in developing countries and 11 in developed countries. In developing countries, midwives' roles are focused on identification of high-risk factors, acting as a labour companion and assessment of postpartum blood loss; in developed countries, midwives are focused on active management of the third stage of labour and diagnosis and management of PPH. This difference is because, in some countries, the roles of midwives are limited by the health care system and cultural barriers. In Canada and the Netherlands, the midwife's scope of practice is limited to the care of women experiencing uncomplicated pregnancies. In the United Kingdom, New Zealand and Australia, midwives provide care to women who are experiencing medical and obstetric complications in collaboration with medical colleagues (Sandall et al., 2016). For countries in economic transition, like Iran and China, care is primarily led by obstetricians, with midwives mainly responsible for providing care during labour, collaborating with other healthcare professionals and being supervised by an obstetrician (Renfrew et al., 2014). Based on data from 37 countries around the world, most countries (31 of 37, 84%) report that midwives are authorized to perform AMTSL. Fewer studies (29 of 37, 78%) reported that midwives were authorized to administer magnesium sulphate to treat PPH, and still fewer (26 of 37, 70%) reported that midwives were authorized to perform manual removal of the placenta (Smith et al., 2014). In France, midwives provide the initial management of nearly all cases of PPH and can prescribe some drugs, including oxytocin (Voillequin et al., 2022). This shows that the broader the scope of practice for midwives, the more central their role in PPH.

As a single occupational group, midwives have great potential to contribute to the reduction of maternal and neonatal mortality as part of a multidisciplinary team operating within an enabling environment (Nove et al., 2021). The WHO has recommended a midwife-led continuity of care model in which a known midwife or a small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum (Tuncalp et al., 2017). However, midwives face challenges in the management of PPH, which mainly include insufficient knowledge and skills, poor teamwork skills, insufficient resources and experiencing negative emotions.

Improvements can be made at the level of midwives, health care system managers and the government. Midwives must improve their knowledge, skills and teamwork abilities. Studies have shown that mentorship in the management of PPH increases the knowledge and self-efficacy of midwives in managing PPH (Musabwasoni et al., 2020). Therefore, a one-to-one tutorial system can be used to improve midwives' clinical skills. Simulation can be thought of as an educational modality and can encompass approaches such as mental rehearsal, verbal simulation, computer or screen-based simulation, task trainers, or team training experiences using equipment that ranges from low to high fidelity. Such simulations can improve team performance and reduce the incidence of PPH (Brazil et al., 2022; Gerard et al., 2024). For health care system managers, to increase AMTSL coverage in facilities with limited staff, task shifting for uterine massage and postpartum assessment to unskilled attendants or delivered women could be considered (Raams et al., 2018). Furthermore, improving the hospital supply chain of specialized first-aid consumables and drugs requires strengthening cooperation between the equipment department, pharmacy and obstetrics department. It is important to distinguish between general and first-aid modes, achieve differentiated management of consumables and drugs, set up a list of first-aid supplies and establish production and storage management mechanisms. Governments should provide adequate support to midwives and health care system managers to overcome challenges, including those related to inadequate resources such as human resources. For example, expanding the range of roles for midwives will enable them to provide needed services, thereby addressing the primary causes of maternal mortality (Smith et al., 2014). Finally, optimizing the ambulance management model ensures that ambulances can respond rapidly in emergency situations (Ramavhoya et al., 2021).

6 LIMITATIONS

This scoping review has some limitations. First, eight databases were searched in this study, and only full-text English published articles were included; unpublished guidelines, grey literature and non-full-text publications were not included. In terms of literature type, the included studies were mainly cross-sectional studies, qualitative interviews and secondary analyses; few randomized controlled studies were included.

7 CONCLUSION

Overall, the findings of this scoping review suggest that midwives play crucial roles in preventing, diagnosing and managing PPH during vaginal delivery, covering prenatal, intrapartum and postpartum care. In the prevention of PPH, midwives' roles involve identifying and managing high-risk factors, managing labour and implementing SSC. In the diagnosis of PPH, midwives have roles such as early recognition of PPH and blood loss estimation. In the management of PPH, midwives participate in mobilizing other professional team members, emergency management, investigating the cause, enhancing uterine contractions, repairing perineal tears, arranging transfers and preparing for surgical intervention. However, midwives face some challenges, including insufficient knowledge and skills, poor teamwork skills, insufficient resources and experiencing negative emotions. Midwives must improve their knowledge, skills and teamwork abilities. To this end, health care system managers and the government should give full support to midwives. Future research should focus on developing clinical practice guidelines for midwives for managing PPH and providing standardized guidance and best practices for midwives to ensure safer and more effective care for patients.

AUTHOR CONTRIBUTIONS

Xiao Yao contributed to the research design, data analysis and original draft. Shan-Shan Shan and Yue-Hong Li conducted a literature review and extracted data from studies. Yin-Yi Zhao and Rong Huang participated in supervision and review, project administration. All authors approved the final version for submission.

FUNDING INFORMATION

2022–2023 Nursing Research Project of Chinese Medical Association Publishing House (CMAPH-NRG2022047). ‘Reservoir’ Talent Development Program of Shanghai First Maternity and Infant Hospital.“The Yuying”Talent Development Program of Shanghai First Maternity and Infant Hospital.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

Not applicable.