Impact of nursing team performance on the effectiveness of the red key protocol for obstetric hemorrhage in Ecuadorian hospitals: a systematic review
DOI:
https://doi.org/10.71112/swp9fr96Keywords:
obstetric hemorrhage, Red Code, nursing performance, maternal safetyAbstract
Obstetric hemorrhage continues to be one of the leading causes of maternal death worldwide and a priority challenge for public health in Ecuador. In response to this problem, the Clave Roja protocol seeks to standardize clinical response through the rapid activation of multidisciplinary teams. The objective of this study was to analyze the impact of nursing team performance on the effectiveness of the Clave Roja protocol in Ecuadorian hospitals. A systematic review was conducted according to the 2020 PRISMA guidelines, covering publications from 2020 to 2025 in international and regional databases. From 612 initial records, 20 studies that met the inclusion criteria were selected. The results show that early detection, effective communication, and ongoing training of nursing staff are associated with a significant reduction in maternal morbidity and improved response times. Evidence indicates that nursing leadership and interprofessional simulation are determining factors for adherence to the protocol and quality of care. It is concluded that strengthening the technical and organizational skills of the nursing team improves the effectiveness of the Red Code protocol and contributes to maternal safety in the Ecuadorian hospital setting.
Downloads
References
Almutairi, W. M., Almutaraiy, S., Al-Zahrani, A., Alsharif, F., Faheem, W., Abunar, A., & Thabet, H. (2025). Transforming postpartum care: The efficacy of simulation training in hemorrhage management among nurses. Healthcare, 13(5), 549. https://doi.org/10.3390/healthcare13050549
Aromataris, E., & Munn, Z. (Eds.). (2020). JBI manual for evidence synthesis. Joanna Briggs Institute. https://doi.org/10.46658/JBIMES-20-01
Bohren, M. A., et al. (2025). Early detection and a treatment bundle strategy for postpartum haemorrhage: Formative implementation research (E-MOTIVE). The Lancet Global Health, 13(1), e1–e12. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(24)00454-6/fulltext
Cevallos, M., Herrera, P., & Toapanta, G. (2023). Implementación del protocolo Clave Roja en hospitales de Quito: Evaluación de desempeño de enfermería. Revista Ecuatoriana de Obstetricia y Ginecología, 29(2), 87–99.
Cikwanine, A., et al. (2025). An assessment of the effects of simulation training on knowledge retention and skills in managing postpartum hemorrhage. BMC Medical Education, 25(1), 7393. https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-025-07393-3
Clark, S. L., Christmas, J. T., & Hankins, G. D. V. (2024). Managing postpartum hemorrhage: Clinical innovations and evolving evidence. Obstetrics & Gynecology Clinics of North America, 51(1), 85–102. https://doi.org/10.1016/j.ogc.2023.11.004
Dunlop, S., et al. (2024). The virtual reality classroom: A randomized control trial for postpartum hemorrhage emergency management. Frontiers in Medicine, 11, 1371075. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2024.1371075/pdf
Gallos, I. D., Williams, H. M., Kamphuis, E. I., et al. (2023). Randomized trial of early detection and treatment of postpartum hemorrhage (E-MOTIVE). The New England Journal of Medicine, 388(21), 1957–1967. https://doi.org/10.1056/NEJMoa2303966
Grant, C., et al. (2025). Massive hemorrhage protocol adoption and standardization with a provincial toolkit: A follow-up survey of Ontario hospitals. BMC Health Services Research, 25, 80861. https://pmc.ncbi.nlm.nih.gov/articles/PMC12380861/
Harrison, G., Fitzgerald, K., & O’Leary, P. (2024). Promoting men-inclusive maternity services: Exploring the expectations, experiences and needs of men as fathers. BMC Pregnancy and Childbirth, 24, 477. https://doi.org/10.1186/s12884-024-06644-3
Instituto Nacional de Estadística y Censos (INEC). (2024). Registro estadístico de defunciones generales 2023: Principales resultados. Quito: INEC. https://www.ecuadorencifras.gob.ec/documentos/web-inec/Poblacion_y_Demografia/Defunciones_Generales/2023/Principales_resultados_EDG_2023.pdf
Lapo-Talledo, G. J., et al. (2024). Nationwide study of in-hospital maternal mortality associated with deliveries in Ecuador. BMC Pregnancy and Childbirth, 24, 1062. https://doi.org/10.1186/s12884-024-06644-3
Lawrence, A., Kendall, C., & Kayem, G. (2023). Stage-based management of postpartum hemorrhage: Evidence and clinical outcomes. American Journal of Obstetrics and Gynecology, 229(3), 233–241. https://doi.org/10.1016/j.ajog.2023.05.004
Lutgendorf, M. A., Magann, E. F., & Martin, J. N. (2024). Interprofessional obstetric simulation training improves postpartum haemorrhage management and decreases maternal morbidity. BJOG: An International Journal of Obstetrics & Gynaecology, 131(9), 1572–1581. https://doi.org/10.1111/1471-0528.17640
Méndez-Figueroa, H., et al. (2022). Postpartum hemorrhage drills or simulations and adverse outcomes before vs after implementation. The Journal of Maternal-Fetal & Neonatal Medicine, 35(25), 4857–4865. https://doi.org/10.1080/14767058.2022.2128659
Ministerio de Salud Pública del Ecuador (MSP). (2022). Protocolo nacional para la atención de la hemorragia obstétrica (Clave Roja). Quito: MSP. https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://enlace.17d07.mspz9.gob.ec/biblioteca/prov/guias/guias/Score%2520mam%25C3%25A1,%2520claves%2520y%2520D.E.R.%2520Obst%25C3%25A9tricos.pdf&ved=2ahUKEwjAxfzh_72QAxUrgmoFHQNrNKkQFnoECBsQAQ&usg=AOvVaw2p4o8eAukXwuYd05BRD0Dg
Minor, S., et al. (2024). Virtual simulation training for postpartum hemorrhage in low-volume hospitals: Feasibility study. Contemporary OB/GYN. https://www.sciencedirect.com/science/article/pii/S2666577824000510
Organización Panamericana de la Salud (OPS). (2025, abril 7). PAHO highlights progress in reducing maternal mortality in the Americas but warns of persistent challenges. https://www.paho.org/en/news/7-4-2025-paho-highlights-progress-reducing-maternal-mortality-americas-warns-persistent
Ordoñez, S., Muñoz, C., & Rojas, M. (2023). Evaluación de la adherencia al bundle obstétrico en emergencias por hemorragia posparto. Revista Colombiana de Enfermería, 22(1), 51–63.
Page, M. J., McKenzie, J. E., Bossuyt, P. M., et al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71
Papageorgiou, A., et al. (2025). Practical Obstetric Multi-Professional Training (PROMPT): Scope and modules including major obstetric haemorrhage. Archives of Gynecology and Obstetrics, 311(2), 513–521. https://link.springer.com/article/10.1007/s00404-025-08213-1
Peng, Y., et al. (2025). Evaluating the implementation of maternal safety bundles for obstetrical hemorrhage and severe hypertension: A statewide assessment. BMC Pregnancy and Childbirth, 25(1), 7896. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-025-07896-3
Pezdirc, N., et al. (2025). Obstetric-specific compared to general early warning system for predicting severe postpartum maternal morbidity. Biomolecules and Biomedicine, 25(2), 11679. https://doi.org/10.17305/bb.2024.11679
Riascos, L., et al. (2023). Effect of the postpartum hemorrhage intervention package implementation in a fourth-level hospital in Latin America. International Journal of Gynaecology & Obstetrics, 162(1), 112–120. https://doi.org/10.1002/ijgo.14886
Sirisomboon, R., et al. (2024). Enhancing the competencies of obstetrical nurses and midwives through simulation-based training in a low-resource setting: A pilot study. Midwifery, 130, 103780. https://pubmed.ncbi.nlm.nih.gov/39111124/
Srivastava, A., et al. (2025). Time to hemorrhage response after implementation of obstetric hemorrhage bundle. American Journal of Perinatology, 42(3), 331–339. https://pubmed.ncbi.nlm.nih.gov/40097171/
Stierman, B., et al. (2023). Statewide perinatal quality improvement, teamwork and respectful care. Journal of Perinatology, 43(6), 875–883. https://pmc.ncbi.nlm.nih.gov/articles/PMC10290572/
Vogel, J. P., et al. (2024). Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: A systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 230(2), 203–215. https://www.ajog.org/article/S0002-9378(24)00042-5/fulltext
World Medical Association (WMA). (2013). Declaration of Helsinki: Ethical principles for medical research involving human subjects. https://www.wma.net/policies-post/wma-declaration-of-helsinki-ethical-principles-for-medical-research-involving-human-subjects/
Wu, N., et al. (2024). Effect of simulation-based training workshop on obstetric emergency team collaboration and communication: A mixed-methods study. Frontiers in Medicine, 11, 1282421. https://doi.org/10.3389/fmed.2024.1282421
Yang, X., et al. (2025). Enhancing postpartum hemorrhage training by integrating case-problem-based learning with simulation: A quasi-experimental study. Journal of Obstetrics & Gynaecology, 45(2), 361–369. https://doi.org/10.1080/01443615.2024.2443617
Zenani, N., Tulelo, P., Netshisaulu, K., Sepeng, N., Musie, M., Gundo, R., & Mulaudzi, F. (2025). A scoping review on the contribution of interprofessional collaboration to the management of postpartum haemorrhage. BMC Nursing, 24, 455. https://doi.org/10.1186/s12912-025-02988-z
Zhang, L., et al. (2025). Implementation and evaluation of STEPS program to reduce postpartum hemorrhage. AJOG-MFM, 7(4), 3070. https://www.sciencedirect.com/science/article/pii/S2589933324003070
Downloads
Published
Issue
Section
License
Copyright (c) 2025 Multidisciplinary Journal Epistemology of the Sciences
This work is licensed under a Creative Commons Attribution 4.0 International License.
