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PICOT Question: Postpartum Hemorrhage as a Care Issue


Bleeding during pregnancy and childbirth remains one of the leading causes of maternal death in the world. Pregnancy-related blood loss can occur in women in all trimesters of pregnancy, in the first and postpartum periods of childbirth, as well as in the early and late postpartum periods. Often, postpartum hemorrhage (PPH) is caused by iatrogenic factors associated with “obstetric aggression” during childbirth. To these factors belong unmotivated induction and stimulation of labor; the use of the Christelle method, which promotes trauma; amniotomy with an “immature” cervix, which increases the frequency of cesarean section. Many of these cases are often associated with a lack of specific education among the nurses.

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PICOT Question

The quality of healthcare is comprised of clinical safety, which is considered a crucial component that identifies and reduces the risks faced by patients. According to Nishimwe et al. (2021), “nurses and midwives are the key clinicians in birth care” (p. 1). Does the provision of education to nurses on preventing postpartum hemorrhage in healthcare facilities help reduce the instances of it?

The population that is targeted by this intervention is comprised of pregnant women in the second and third trimesters. Anca et al. (2020) claim that “incorporation of a standard Hemorrhage Risk Assessment (HRA) has shown improvements in identification of all women at risk for complications and a reduction in the incidence of PPH” (p. 1). The educational interventions must support policies and guidelines to create a safe environment and reduce risk factors. Ghosh et al.’s (2019) research explores how “in the state of Bihar, India, a multi-faceted quality improvement nurse-mentoring program was implemented to improve provider skills in normal and complicated deliveries” (p. 1). The studies show that the prevention strategies explained in the process of education should stimulate engagement in technical aspects to eliminate potential hemorrhage hazards. Ulfa et al.’s (2021) study results show that “the intervention group which received team-based learning showed a higher knowledge of PPH at 2 weeks, 6 weeks, and 12 weeks post-tests than the control group” (p. 6). Finally, the last point of nurses’ education should elaborate on raising awareness among patients and communities on the risk factors and prevention measures of postpartum hemorrhage.

Among the other interventions that have to be considered is the implementation of digital technologies that would help assess the patient’s condition in real-time. However, it must be noted that in order for the nurses to properly use such technologies, educational programs should also be used. The desired outcome for the intervention proposed in this PICOT question is the reduction of PPH incidents in the Labor and Delivery department, as well as a decrease in maternal mortality rates. The estimated time frame for the first results of the intervention implementation – 6 months, as this period is optimal for completing at least one educational program.

Literature Search Strategy

Relevant articles were retrieved from various sources through search engines, including the GCU library, CINAHL, Google Scholar, Web of Science, and PubMed. The search of these articles involved words related to the topic of the project, such as postpartum hemorrhage prevention, nurses’ education, patient safety, nursing knowledge and skills, and nurses’ learning. The search only considered articles that have been published over the past five years.

Literature Analysis

The first article that was chosen for this research is the study by Anca et al. (2020). The authors briefly discuss the problem of postpartum hemorrhage and the role of nursing intervention in it. Anca et al. (2020) state that the issue lies in the “inconsistencies in communication practices of the nurse who led interprofessional perioperative huddles” (p. 1). They emphasize the fact that even when the nurse used a hemorrhage risk assessment on the patient, the information was communicated to the patient in the labor only when the risk of postpartum hemorrhage was high.

According to the authors, as a method of addressing the problem, a clinical specialist in Labor and Delivery department conducted literature research in collaboration with nursing staff and graduate students. After completing the research, the specialist then performed lectures on the best perioperative tactics for the members of the L&D Shared Governance Council and students. According to Anca et al. (2020), “the results of that educational intervention show 100% compliance for HRA scores communication during perioperative huddles, while activation of massive transfusion protocols was decreased by 20%” (p. 1). This research directly shows how important nursing intervention is in preventing postpartum hemorrhage and decreasing maternal mortality risks.

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The second article also studies the opportunities the nursing intervention brings in preventing postpartum hemorrhage. Gnosh et al. (2019) explain how a multi-faceted nursing mentoring program influenced the issue. According to the authors (2019), “facilities received one week of mentoring monthly for 7–9 consecutive months; the mentors engaged in a variety of activities including skill demonstrations and bedside mentoring during actual patient care” (p. 3). Moreover, the training program was culturally tailored, which further helped in addressing local contextual needs related to childbirth.

Additionally, the authors (2019) stated that they used “two data sources, which were collected and maintained by CARE India – the Facility Information System (FIS) and direct observation of deliveries (DOD)” (p. 4). This proves that the research is evidence-based and reliable. The study showed overall positive outcomes: culturally specific educational practices helped nursing staff in identifying and addressing postpartum hemorrhage. Gnosh et al. (2019) state that “the nurse-mentoring program appears to have built provider’s capacity to identify PPH; moreover, providers seem to be relatively well poised to manage these complications” (p. 12). This study also proves the acute need for proper educational programs for nurses in order to successfully address the issue of postpartum hemorrhage and the maternal mortality associated with it.


Anca, R., Mahoney, M., & Lucarini, E. (2020). Nurse-driven initiative to increase awareness during perioperative interprofessional huddles of women at risk for postpartum hemorrhage. Journal of Obstetric, Gynecologic & Neonatal Nursing, 49(6).

Ghosh, R., Spindler, H., Morgan, M. C., Cohen, S. R., Begum, N., Gore, A.,… Walker, D. M. (2019). Diagnosis and management of postpartum hemorrhage and intrapartum asphyxia in a Quality Improvement Initiative using nurse-mentoring and simulation in Bihar, India. PLOS ONE, 14(7).

Nishimwe, A., Ibisomi, L., Nyssen, M., & Conco, D. N. (2021). The effect of a learning application on nurses’ and midwives’ knowledge and skills for the management of postpartum hemorrhage and neonatal resuscitation: Pre–post-intervention study. Human Resources for Health, 19(1).

Ulfa, Y., Igarashi, Y., Takahata, K., Shishido, E., & Horiuchi, S. (2021). Effectiveness of team-based learning on postpartum hemorrhage in midwifery students in Indonesia: A quasi-experimental study. Nurse Education Today, 105, 105015.

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