Methods
We developed algorithms for four case scenarios, based on findings of a
rapid review on third stage abnormalities, identification of the most
common deviations, severity of related complications or clinical
outcomes, and discussion with the WHO technical working group. These
were as follows: Approach to Postpartum haemorrhage (PPH) after vaginal
delivery, Diagnosis and management of uterine atony, Diagnosis and
management of genital tract trauma, Diagnosis and management of retained
placenta. A detailed description of the methodology used for the
development of the algorithms is provided in Chapter 2
Search strategies The search was directed at research databases
(Cochrane, Medline and CINAHL) for evidence based information on the
identification and management of third stage abnormalities in
low-resource settings, with a focus on PPH. In addition, international
and national guidance documents were identified and reviewed (FIGO,
RCOG, NICE, ACOG, SA-NCCEMD, ANZCOG, SOGC). Published systematic reviews
were also searched and identified. The search was limited to English
language literature. Where high quality evidence was lacking, individual
trials and some case series were examined.
The literature review was guided by the hierarchy of evidence and
prioritised WHO guidelines followed by other international or national
guidelines using GRADE methodology. In the absence of guidelines on a
case scenario, a combination of existing studies and expert opinion was
used to determine key points for consideration in the algorithm. The
highest level of evidence found was used to support the decisions along
the management pathway, in the order of up-to-date systematic review
(with meta-analyses), up-to-date systematic review (without
meta-analyses), any available systematic review, validated decision
rules, randomized controlled trials, non-randomized controlled trials,
observations studies, and consensus documents.
Population and Setting The algorithms were developed to cover
the assessment and management of pregnant women with singleton, term
pregnancies considered to be low risk, who developed third stage
abnormalities after vaginal delivery. Health facilities in low-and
middle-income countries were the priority. However, the algorithms are
applicable to any health care setting, and possible adaptations that may
be required were acknowledged. The target users for these algorithms are
skilled health personnel providing care during childbirth working alone
or as part of teams, particularly midwives, clinical officers or
equivalent, non-specialized clinicians (i.e. clinicians without
specialist training in obstetrics but who also provide care for women in
labour), and specialists.
Development of the Algorithms After collating the evidence, a
selection process for inclusion of the evidence in the algorithm took
place. Selection was based on relevance of the evidence to the key
decision points and severity of the condition targeted by an
intervention. The selection also accounted for the strength of evidence
and applicability and feasibility in a LMIC context. If there were
inconsistencies among guidelines, the most up-to-date guidelines and
evidence were reviewed and used to inform consultation with experts. A
list of inconsistencies was discussed at the WHO Technical Working Group
meeting and a consensus reached on evidence for the algorithm.
Algorithms were structured to cover criteria that should be used to
suspect a deviation from normal third stage of labour, initial
assessment, probable causes and potential differential diagnosis,
further assessments to reach the most probable diagnosis, and management
of the condition. Draw.io, an open source diagramming software, was used
to construct the algorithm in a flowchart format. The online software
facilitated remote working on SELMA by the WHO Technical Working Group.
The algorithm was composed of standardised but variable shaped boxes,
representing either a clinical state, decision point, action task, or
link to a different algorithm. Each box was numbered and joined to other
boxes via arrows, to orientate the reader to the direction of flow. The
numbers also corresponded to a table of evidence, showing the evidence
source for the action and decision points. They algorithms underwent
internal peer review by the WHO Technical Working Group and revisions
where needed.