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Maternal-fetal medicine fellow Frank I. Jackson discusses his article “Affordable postpartum hemorrhage solutions every OB/GYN should know.” Frank explains how postpartum hemorrhage remains a leading cause of maternal mortality, especially in low-resource settings where advanced devices like the JADA® System are inaccessible. He introduces two innovative, low-cost techniques—FOCUS (Foley catheter for uterine suction) and STUT (suction tube uterine tamponade)—that replicate the life-saving mechanism of expensive devices but with tools found in nearly every labor ward. Frank shares evidence from recent clinical trials, describes practical steps for implementation, and emphasizes why every obstetric provider should learn these methods. Listeners will gain actionable knowledge on how to apply simple, affordable interventions that can save lives globally.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Frank Jackson. He is a maternal-fetal medicine fellow. Today’s KevinMD article is “Affordable postpartum hemorrhage solutions every OB/GYN should know.” Frank, welcome to the show.

Frank Jackson: Hi Kevin. Thank you for having me.

Kevin Pho: All right, let us start by briefly sharing your story and then jump into the KevinMD article and tell us what it is about.

Frank Jackson: All right, so I am a maternal-fetal medicine fellow. I trained originally in Connecticut during the pandemic when we were going through a lot of supply shortages and figuring out how to take care of patients on less than we used to have traditionally. And then I moved on to fellowship here on Long Island and got very passionate about the topic of care of our postpartum hemorrhage patients.

Kevin Pho: All right, so tell us what your article is about for those who did not get a chance to read it yet.

Frank Jackson: Sure. So it is about a technique for vacuum-induced uterine tamponade for postpartum hemorrhage. Essentially back in 2020, the new way of treating postpartum hemorrhage came out. We started using this device called the Jada, which is essentially a suction tube that goes inside the uterus and helps control hemorrhage very, very quickly, and it was completely transformative for us as OB/GYNs in the United States.

Many labor and delivery units transitioned to using this. However, as supply shortages were hitting all of us across the United States, part of my mindset came to how would I live? How would I take care of my patients if I did not have this device? Looking around our labor and delivery unit, thinking about what people had done in the past, thinking about what would be available in any situation. My thought was, “Well, the Foley catheter is something that we are all familiar with as OB/GYNs. It is something that we have seen used time and time again for hemorrhage or in labor.” And so if I could hook that up to suction that would potentially do the trick.

And a case came by probably about a year ago where a patient had a hemorrhage and they were not eligible for the Jada. Their cervix was not dilated enough for the Jada to fit. And so I tried out the technique and it worked like the Jada would have worked. So I published that case report and I started thinking this worked very well for my patient. However, there are many patients who die of postpartum hemorrhage worldwide.

So approximately 70,000 to 90,000 women a year die of postpartum hemorrhage. And it is not generally because we do not have the know-how. It is not because the technology does not exist to save their lives. It is because the technology is not available to save their lives in every setting. And using a Foley, which is available in pretty much every labor and delivery, every ED, worldwide was something that could actually transform that.

And so I started thinking, how do I spread the word for OB/GYNs to know that these techniques are available? I came across STUT, which is similar to FocUS, where we use a gastric tube instead of a Foley to do uterine tamponade. And I thought, “Well, both of these things could be inserted in the uterus, hooked up to low wall suction when a patient is hemorrhaging and could control the hemorrhage very quickly.” There are some good studies that show that STUT works very well. There are a few studies that we are working on that show that FocUS works very well, and I figured, “I would write to KevinMD and make sure that your readership knew that this is an option if they do not have anything else available to provide this care.”

Kevin Pho: All right, so before talking about some of these techniques, just give us a little bit of context in terms of how common postpartum hemorrhage is. You did mention some data in terms of how many women died from it. What are some of the risk factors? How much should it worry OB/GYNs in the delivery room?

Frank Jackson: Sure. I mean, every OB/GYN is very familiar with postpartum hemorrhage. So in the United States, about 3 to 5 percent of patients receive blood transfusions after their delivery. There is a multitude of risk factors for postpartum hemorrhage, so patients who it is their first baby are at risk for postpartum hemorrhage. Patients who have cesarean deliveries are at risk for postpartum hemorrhage. Patients who had many pregnancies in the past are at risk for postpartum hemorrhage. So people who have had more than five deliveries, people with clotting disorders at high risk, higher BMI puts patients at higher risk.

And then there are some conditions that put patients at exceedingly high risk. Certain conditions, for example, like having a placenta accreta where the placenta is morbidly adherent to the uterus puts patients at very, very high risk for postpartum hemorrhage. Preeclampsia, which is a common condition of high blood pressures in pregnancy, increases risk of postpartum hemorrhage as well.

In terms of how we manage postpartum hemorrhage, as OB/GYNs will know, and maybe a new development since some of us have gone to medical school, now we have taken steps prophylactically to prevent postpartum hemorrhage. So it is routine in the United States now for every patient to receive oxytocin to prevent postpartum hemorrhage, but it does not work all the time. So when that does not work, sometimes we have to turn to devices like the Jada that I spoke about or we have a different device called the Bakri that also works by putting pressure outwards instead of pulling it inwards. And then in some cases people lose their fertility. They have to have hysterectomies in order to stop the hemorrhage.

Kevin Pho: So tell us a little bit more about the Jada system. It sounds like that is standard of care. How often is that used, or how recent is that development?

Frank Jackson: Sure. So the Jada was first described in 2016 in a small study of 16 patients in Indonesia. And essentially the way that the Jada system works is instead of applying pressure outwards, like some of the prior techniques had been doing with uterine balloon tamponade, we are sucking the walls of the uterus in, which is much more physiologic. And so that was followed up with a larger study, the PEARL trial, which came out in 2019 or 2020, which in 100 patients showed that the Jada was very effective at controlling hemorrhage. So within five minutes, the majority of hemorrhages were controlled. Over 90 percent of patients who were having significant hemorrhage stopped having a significant hemorrhage.

And so at that point, the device became marketed across the United States to different labor and delivery units. And for many of us, it became transformative. Just from clinical experience, we could see that patients were doing better faster with the Jada than they were with the Bakri. So when I started as a medical student, when I started as an intern, we did not have the Jada and we would place the Bakri. And the Bakri is a good device, but we saw that when the Jada came along our success rate of controlling hemorrhage appeared to be significantly better.

And so, at least in the units that I have worked in, we have switched predominantly to the Jada for postpartum hemorrhage control just because it seems to work better in our experience. There are a couple studies that have looked at efficacy of these two approaches. The balloon where we push outwards versus the Jada where you draw inwards. Some have shown that the Jada works better. Some have shown equivocal results. But I think in the United States, I would suspect that it is about 50 percent of OB/GYNs are using Jada as their first device nowadays, which is pretty astounding for something that came out just five years ago.

Kevin Pho: So before Jada, were obstetricians using things like the Foley catheter or the suction tube?

Frank Jackson: So, sure. So before the Jada came out, what people were using for the most part was something called the Bakri balloon, which is essentially a large Foley catheter that goes inside the uterus that gets blown up to push out the uterus. And then the alternative in lower resourced areas is people would do what is called a condom catheter, where they would take a Foley catheter, they would wrap a condom over it, tie up the bottom, and then they would backfill it to essentially create a large balloon. And so essentially what they would do is create a balloon that was about 500 ccs of fluid, and they would push the uterus outwards.

Now, when you are trying to control hemorrhage in obstetrics, what you are trying to do is actually shrink the uterus. So all the medications that we give, the uterotonics, so oxytocin, misoprostol, methylergometrine, hemabate, they are all meant to shrink the uterus down. When we do surgical interventions before we move on to a hysterectomy, when we do a B-Lynch suture, that is to contract the uterus or help bring it down. And so the only intervention that we are doing that makes the uterus bigger is this uterine balloon tamponade. And so that is what we were generally doing as devices up until the Jada came out.

And the Jada is really what switched us to thinking about suction. And so when the Jada study came out, that is when people started investigating these other devices. So the suction, the gastric tube, there is a group out of South Africa, Dr. Hofmeyr, that published on this. They just published the first randomized controlled trial actually looking at vacuum-induced tamponade versus uterine balloon tamponade. And they showed that it is very promising to do a vacuum-induced tamponade over a balloon tamponade. And that is the first study that actually compares the two head-to-head. They found that they achieved the desirable outcome of hemorrhage control much faster with vacuum tamponade. They found that we had lower blood loss with vacuum tamponade, less blood transfusions with vacuum tamponade. And the results are so promising that the WHO is pursuing a large randomized control trial right now called the E-MOTIVE trial to establish once and for all, whether vacuum tamponade should really be the one first-line standard of care before we go to balloon tamponade. But it is really a recent development for the past five years.

Kevin Pho: So now that we are in a post-pandemic era and presumably we do not have a shortage of resources, where do you see the role of the Foley catheter or the suction tube techniques?

Frank Jackson: So, when we think about FocUS, which is a Foley catheter hooked up to suction, or STUT, which is a gastric tube hooked up suction, we are really talking about one in high resource settings when patients are not dilated enough and they have a contraindication to the Jada. And then when we are in low resource settings, there are plenty of settings where we cannot access the Jada. So information on the cost of the Jada is individualized to the hospital, is not necessarily publicly available. There is one article that quotes the cost at about 1,000 dollars, which for high resource settings like Long Island, New York, or Nashua, New Hampshire, the Jada is available and affordable to save women’s lives. But in many settings, they do not have 1,000 dollars for a device that sits on the shelf and might expire. So I have actually heard from many midwives who deliver in the United States and do home births, where right now they do not have a good device to do vacuum induced tamponade or from OB/GYNs in Africa, but even OB/GYNs in countries like France or Switzerland where they do not have the Jada because it is cost prohibitive. And so even in what we would consider high resourced areas, there is a need for an affordable option to help manage hemorrhage.

Kevin Pho: So talking about the rest of the world, you said the kind of lower resource settings is FocUS and STUT. The Foley catheter, G-tube, is that standard of care there?

Frank Jackson: So, they are not standard of care yet. So what is happening in the United States, vacuum tamponade has become standard of care. That is not the case in other countries. I have spoken to OB/GYNs, for example, in France who say when they come to the United States, everybody talks about the Jada like it is God’s gift to obstetrics. But it is too expensive for France. And so in France, they do not use it. They still do uterine balloon tamponade. I think what is going to happen in the next couple years is when that WHO E-MOTIVE trial comes out. I think they will confirm the study results that Dr. Hofmeyr had in his initial STUT trial and show that vacuum induced tamponade is actually superior to uterine balloon tamponade. Once that happens, I think that it will become standard of care for anywhere that has suction that is readily available.

Kevin Pho: And what do you see going forward in the United States? Do you still see Jada type systems or Jada still becoming standard of care? Or do you still see these lower cost techniques still being used in rural areas or lower resource settings?

Frank Jackson: I think what is going to happen in the U.S. is at least in the short, medium term, and at least in my practice, what is happening is that when a patient is appropriate for the Jada, people are going to use the Jada and I think it is going to happen more and more. So ACOG, the American College of Obstetricians and Gynecologists, just came out about a month ago or so, after the article I wrote, actually was published, that now having vacuum-induced tamponade devices should be standard on every labor and delivery unit. So they should have, now there is a recommendation we should have both types of devices available, which was not the case up until very recently. So I think every labor and delivery unit is going to start having these supplies.

And I think when the patient is a candidate, we are going to go to Jada because it is the on-label device. That is the device that has the most efficacy and safety data around it. And that is what we are going to reach for first. But there are plenty of cases where patients cannot have Jada and where we will still need to reach for the Foley. So for example, there are cases where people have second trimester pregnancy losses, or even first trimester pregnancy losses where we have used FocUS. There are patients who have cesarean deliveries where they are not dilated yet. The Jada cannot go into a patient unless they are at least 3 centimeters dilated. Right now, those patients have no option for vacuum-induced tamponade unless they reach for a Foley or gastric tube. And I think in well-resourced American hospitals, that is where FocUS and STUT fill a gap is these places where you are looking at the list of contraindications to Jada, you say, “Well, Jada is contraindicated in this situation; let me reach out for a Foley and use it the exact same way as we use the Jada, put it in the uterus, hook up to suction, and it works the exact same way.”

Kevin Pho: And how about in academic medical centers? Like you are a maternal-fetal medicine fellow. Are these fellows and residents being trained in all of these techniques?

Frank Jackson: Yeah, so residents and fellows are starting to be trained in these techniques. And then the other development is, AWHONN, which is the overseeing body of OB/GYN and neonatal nurses has expressed interest in FocUS because they are on the field. They are on the ground talking to nurses all over the country. And they are training nurses in postpartum hemorrhage management all over the country. And they see the value in having a device that is low-cost and that can be used on any labor and delivery or even ED setting nationwide, especially for these patients where we know, for example, c-sections are a risk factor for hemorrhage, but we cannot put the Jada in every c-section patient.

Kevin Pho: We are talking to Frank Jackson. He is a maternal-fetal medicine fellow. Today’s KevinMD article is “Affordable postpartum hemorrhage solutions every OB/GYN should know.” Frank, let us end with some take home messages that you want to leave with the KevinMD audience.

Frank Jackson: Sure. I mean, I think the first thing is when you have a woman who has postpartum hemorrhage, stop and think. You want to be calm and composed, and once you have taken that time, use the same principles you would use to save the patient, even if the tool that is available to you is not right. So if the Jada is not going to work for you, think about the other tools that can fill that gap. I think that FocUS and STUT are two tools that make it a lot easier to manage postpartum hemorrhages in these situations where we could not have used the Jada in the past. And the other piece I think is if you are a physician who has some idea on how to help people out, do not keep it for yourself and make sure that it is something that is available for all.

Kevin Pho: Frank, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Frank Jackson: Thank you, Kevin.