目的:集束化护理是降低产后出血相关发病率和死亡率的一种有前景的方法。我们评估了护理束预防和/或治疗产后出血的有效性和安全性。
方法:我们搜索了MEDLINE,Embase,科克伦中部,妇幼保健数据库,以及全球指数Medicus(始于2023年6月9日)和ClinicalTrials.gov以及国际临床试验注册平台(过去5年),采用分阶段搜索策略,结合产后出血的术语和护理捆绑。
方法:纳入评估产后出血相关护理服务的同行评审研究。护理捆绑被定义为包括集体实施的≥3个组件的干预措施,同时,或快速连续。随机和非随机对照试验,中断的时间序列,且前后研究(对照或未对照)均符合条件.
方法:使用RoB2(随机试验)和ROBINS-I(非随机研究)评估偏倚风险。对于对照研究,我们报告了二分结局的风险比和连续结局的平均差异,确定使用等级确定的证据。对于不受控制的研究,我们使用效果方向表,并对结果进行了叙述总结。
结果:纳入22项研究进行分析。对于仅预防的捆绑(2项研究),低确定性证据表明减少失血可能有好处,住院时间,和重症监护室停留,和母亲的幸福。对于仅治疗束(9项研究),高确定性证据表明,电子运动干预降低了复合严重发病率的风险(风险比,0.40;95%置信区间,0.32-0.50)和输血出血,产后出血,严重的产后出血,意味着失血。一项非随机试验和7项对照研究表明,其他产后出血治疗方案可能会减少失血和严重产后出血。但这是不确定的。对于联合预防/治疗束(11项研究),低确定性证据表明,加州产妇优质护理协作护理捆绑可能会降低严重的产妇发病率(风险比,0.64;95%置信区间,0.57-0.72)。十项不受控制的研究显示了可能的益处,没有影响,或其他捆绑类型的危害。几乎所有不受控制的研究都没有使用合适的统计方法进行单组前测-后测比较,因此应谨慎解释。
结论:E-MOTIVE干预可改善阴道分娩妇女的产后出血相关结局,和加州产妇优质护理合作捆绑可能会降低严重的产妇发病率。在考虑实施之前,其他束设计需要进一步的有效性研究。
Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment.
We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles.
Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible.
Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies, we used effect direction tables and summarized results narratively.
Twenty-two studies were included for analysis. For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution.
The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.