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Makwe CC, Okunade KS. Conservative approaches to postpartum haemorrhage. Best Pract Res Clin Obstet Gynaecol 2024; 95:102516. [PMID: 38902107 DOI: 10.1016/j.bpobgyn.2024.102516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024]
Abstract
Postpartum haemorrhage (PPH) and PPH-related deaths are disproportionately higher in low-income countries, with sub-Saharan Africa and Southern Asia accounting for approximately 85% of the global burden of PPH-related maternal deaths. Although PPH-related mortality is directly related to the amount and duration of bleeding, the high maternal death burden in resource-limited countries suggests that a great majority of these deaths would be avoidable with the appropriate resources and effective use of evidence-based interventions. Non-surgical management is often the first-line approach for PPH, but conservative surgical interventions may be required if bleeding persists or if the underlying cause is not responsive to the initial conservative measures. The appropriate interventions should be selected based on the individual's specific circumstances and clinical condition.
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Affiliation(s)
- Christian Chigozie Makwe
- Department of Obstetrics & Gynaecology, College of Medicine University of Lagos, Nigeria; Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Nigeria.
| | - Kehinde Sharafadeen Okunade
- Department of Obstetrics & Gynaecology, College of Medicine University of Lagos, Nigeria; Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Nigeria
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2
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Vogel JP, Nguyen PY, Ramson J, De Silva MS, Pham MD, Sultana S, McDonald S, Adu-Bonsaffoh K, McDougall ARA. Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review. Am J Obstet Gynecol 2024; 231:67-91. [PMID: 38336124 DOI: 10.1016/j.ajog.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/13/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE 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. DATA SOURCES 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. STUDY ELIGIBILITY CRITERIA 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Phi-Yen Nguyen
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jen Ramson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
| | - Manarangi S De Silva
- Department of Obstetrics, Gynaecology and Newborn Health, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Minh D Pham
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Saima Sultana
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Steve McDonald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Accra, Ghana
| | - Annie R A McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Australia
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3
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Bruce KE, Desai S, Reilly K, Keil A, Swanson M, Cobb B, Zahn K, McKenzie C, Coviello E, Mallampati D, Tully KP, Kolarczyk L, Maaske S, Quist-Nelson J. Use of Postpartum Hemorrhage Checklist during Vaginal Deliveries: A Quality Improvement Study. Am J Perinatol 2024. [PMID: 38452794 DOI: 10.1055/a-2282-8923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) protocols improve patient safety and reduce utilization of blood products; however, few data exist on sustainability of PPH checklist use, how use affects care delivery, and variation of use among patient subgroups. This study aimed to (1) examine compliance with PPH checklist use during vaginal deliveries, (2) evaluate whether checklist use varied by patient and/or care team characteristics, and (3) evaluate whether checklist use was associated with increased use of recommended medications/interventions. STUDY DESIGN This was a quality improvement study performed from April 2021 through June 2023. A multidisciplinary team developed a revised PPH checklist and used quality improvement methodology to increase checklist use following vaginal birth. Data were collected from medical records and clinician survey. Control charts were generated to track checklist use and evaluate special cause variation. Chi-square tests and logistic regression were used to evaluate variation in medications/interventions and across subgroups. RESULTS During the study period, there were 342 cases of PPH at the time of vaginal birth. The checklist was used in 67% of PPH cases during the 20-month period after implementation in a setting where no checklist was previously being used. We found no statistically significant differences in checklist use by patient or health care team characteristics. Use of tranexamic acid, carboprost, and misoprostol were significantly associated with checklist use. CONCLUSION This study demonstrated successful implementation of a checklist protocol where no checklist was previously being used, with sustained use in an average of 67% of PPH cases over 20 months. Checklist use was consistent across subgroups and was associated with higher use of interventions shown to lower blood loss. KEY POINTS · Our study showed sustainability of PPH checklist use over a 20-month period.. · PPH checklist use was associated with increased use of interventions known to reduce blood loss.. · Checklist was used consistently across patient subgroups; may help address inequities in obstetric outcomes..
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Affiliation(s)
- Katharine E Bruce
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC
| | - Shivani Desai
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Kelly Reilly
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Arianna Keil
- Institute for Healthcare Quality Improvement, University of North Carolina Health, Chapel Hill, NC
| | - Michelle Swanson
- Department of Women's Services, University of North Carolina Health, Chapel Hill, NC
| | - Benjamin Cobb
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Katelin Zahn
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Christine McKenzie
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Elizabeth Coviello
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Divya Mallampati
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA
| | - Kristin P Tully
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Shannon Maaske
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
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Agrawal S, Smith M, Berg R, Hoskins IA. Serum Lactate Level as a Predictor for Blood Transfusion in Postpartum Hemorrhage. Am J Perinatol 2023; 40:1798-1802. [PMID: 34808683 DOI: 10.1055/s-0041-1740009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality. At present, there are no reliable clinical or laboratory indicators to identify which patients might require blood transfusions during a PPH. Serum lactate has long been used as an early biomarker of tissue hypoperfusion in trauma settings. The aim of this study is to understand serum lactate's role in the management of obstetric hemorrhage. STUDY DESIGN A retrospective chart review was performed of women who delivered between 2016 and 2019 at our institution and experienced a PPH. The patients were divided into two groups: those with a normal serum lactate level, defined as ≤2 mmol/L, and those with an abnormal serum lactate level, defined as >2 mmol/L. Need for packed red blood cell transfusion, as part of the resuscitation, was assessed for both groups. RESULTS During the study period, 938 women experienced PPH. Of these, 108 (11.5%) had a normal serum lactate, ≤2 mmol/L, and 830 (88.5%) had an abnormal lactate, >2 mmol/L. Women with elevated lactate levels were more likely to receive a blood transfusion versus those with a normal lactate level (57.0 vs. 46.3%, p = 0.035, respectively). Additionally, the average number of blood transfusions administered was significantly higher in the abnormal lactate group versus in the normal lactate group (1.34 vs. 0.97, respectively, p = 0.004). In a multivariable linear regression model, increasing serum lactate levels were found to be predictive of requiring more than 1 unit of blood (p < 0.001). CONCLUSION Women with elevated serum lactate levels were more likely to require blood transfusions during a PPH versus those with a normal serum lactate level. Thus, serum lactate levels are useful as an early indicator of requirement for blood transfusion in the management of obstetric hemorrhage. KEY POINTS · Lactate is a biomarker for blood transfusion in trauma.. · Lactate's role in PPH is unknown.. · Elevated lactate predicts receiving more blood transfusions..
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Affiliation(s)
- Surbhi Agrawal
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Maria Smith
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Robert Berg
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
| | - Iffath A Hoskins
- Department of Obstetrics and Gynecology, New York University Langone Medical Center, New York, New York
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5
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Haering D, Meador H, Lynch E, Lauria M, Garchar E, Braude D. Management of Postpartum Hemorrhage in Critical Care Transport. Air Med J 2023; 42:488-495. [PMID: 37996188 DOI: 10.1016/j.amj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 11/25/2023]
Abstract
Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.
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Affiliation(s)
- Donald Haering
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM.
| | - Hallie Meador
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Lynch
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Michael Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Garchar
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Darren Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
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Song KH, Choi ES, Kim HY, Ahn KH, Kim HJ. Patient blood management to minimize transfusions during the postpartum period. Obstet Gynecol Sci 2023; 66:484-497. [PMID: 37551109 PMCID: PMC10663398 DOI: 10.5468/ogs.22288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/11/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023] Open
Abstract
Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.
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Affiliation(s)
- Kwan Heup Song
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Eun Saem Choi
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Hai Joong Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
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7
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Foessleitner P, Budil MC, Mayer S, Kraft F, Zeilberger MS, Deinsberger J, Farr A. Peripartum Maternal Admission to the Intensive Care Unit: An Observational Study over a 15-Year Period at a Tertiary Center in Austria. J Clin Med 2023; 12:5386. [PMID: 37629428 PMCID: PMC10455968 DOI: 10.3390/jcm12165386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
Peripartum maternal admission to the intensive care unit is challenging for anesthesiologists, obstetricians, and all personnel involved. An understanding of altered maternal physiology, fetal considerations, and acute peripartum emergencies is required to ensure adequate maternal and neonatal outcomes. In this study, we analyzed data of peripartum maternal admissions to the intensive care unit at our large tertiary referral center in order to define trends and changes over time. This study retrospectively analyzed maternal morbidity, admission diagnoses, treatments, and outcomes of women with peripartum admission to the intensive care unit at our tertiary care center over a 15-year period. We found that patient characteristics and admission diagnoses remained remarkably consistent over the observational period; however, there was a significant increase in postpartum hemorrhage (r = 0.200, p < 0.001) and cesarean hysterectomy (r = 0.117, p = 0.027) over time. Moreover, we found a reduction in preterm births (r = -0.154, p = 0.004) and a decreased peripartum neonatal intensive care unit admission rate (r = -0.153, p = 0.006) among women who were transferred to the intensive care unit. Based on our long-term observational data, there is consistent need for intensive care in obstetrics due to a small number of different etiologies. Specialized training for the predominant diagnoses involved as well as multidisciplinary care of the affected patients are both warranted.
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Affiliation(s)
- Philipp Foessleitner
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.F.)
| | - Marie-Christin Budil
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.F.)
| | - Stefanie Mayer
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.F.)
| | - Felix Kraft
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Mira Stephanie Zeilberger
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Julia Deinsberger
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Alex Farr
- Department of Obstetrics and Gynecology, Division of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, 1090 Vienna, Austria; (P.F.)
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8
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Turkoglu O, Friedman P. Evaluation During Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:357-366. [PMID: 37130377 DOI: 10.1097/grf.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Postpartum hemorrhage is an obstetric emergency that is the leading and the most preventable cause of maternal death that occurs on the day of birth. The treatment of postpartum hemorrhage in a timely fashion is crucial to prevent morbidity and mortality. The accurate assessment of blood loss during delivery and the postpartum period remains a major challenge. Hence, it is imperative to have a standardized evaluation strategy for accurate assessment of blood loss, adequate classification of hemorrhage, and timely initiated interventions. The multidisciplinary evaluation strategy should be in place regardless of the delivery route.
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Affiliation(s)
- Onur Turkoglu
- Beaumont Hospital, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Perry Friedman
- Beaumont Hospital, Royal Oak, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
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9
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Eid J, Stahl D. Blood Product Replacement for Postpartum Hemorrhage. Clin Obstet Gynecol 2023; 66:408-414. [PMID: 36730283 DOI: 10.1097/grf.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Consideration for blood products replacement in postpartum hemorrhage should be given when blood loss exceeds 1.5 L or when an estimated 25% of blood has been lost. In cases of massive hemorrhage, standardized transfusion protocols have been shown to improve maternal morbidity and mortality. Most protocols recommend a balanced transfusion involving a 1:1:1 ratio of packed red blood cells, platelets, and fresh frozen plasma. Alternatives such as cryoprecipitate, fibrinogen concentrate, and prothrombin complex concentrates can be used in select clinical situations. Although transfusion of blood products can be lifesaving, it does have associated risks.
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Affiliation(s)
- Joe Eid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center
| | - David Stahl
- Division of Critical Care Medicine, Department of Anesthesiology, The Ohio State University, Columbus, Ohio
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10
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Liu LY, Nathan L, Sheen JJ, Goffman D. Review of Current Insights and Therapeutic Approaches for the Treatment of Refractory Postpartum Hemorrhage. Int J Womens Health 2023; 15:905-926. [PMID: 37283995 PMCID: PMC10241213 DOI: 10.2147/ijwh.s366675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/03/2023] [Indexed: 06/08/2023] Open
Abstract
Refractory postpartum hemorrhage (PPH) affects 10-20% of patients with PPH when they do not respond adequately to first-line treatments. These patients require second-line interventions, including three or more uterotonics, additional medications, transfusions, non-surgical treatments, and/or surgical intervention. Multiple studies have suggested that patients with refractory PPH have different clinical characteristics and causes of PPH when compared to patients who respond to first-line agents. This review highlights current insights into therapeutic approaches for the management of refractory PPH. Early management of refractory PPH relies on both hypovolemic resuscitation and achievement of hemostasis, with an emphasis on early blood product replacement and massive transfusion protocols. Transfusion needs can be more rapidly and accurately identified through point-of-care tests such as thromboelastography. Medical therapies for the treatment of refractory PPH involve treatment of both uterine atony as well as the underlying coagulopathy, with the use of tranexamic acid and adjunct therapies such as factor replacement. The principles guiding the management of refractory PPH include restoring normal uterine and pelvic anatomy, through the evaluation and management of retained products of conception, uterine inversion, and obstetric lacerations. Intrauterine vacuum-induced hemorrhage control devices are novel methods for the treatment of refractory PPH secondary to uterine atony, in addition to other uterine-sparing surgical procedures that are under investigation. Resuscitative endovascular balloon occlusion of the aorta can be considered for cases of critical refractory PPH, to prevent or decrease ongoing blood loss while definitive surgical interventions are performed. Finally, for patients with critical hemorrhage resulting in hemorrhagic shock, damage control resuscitation (a staged surgical approach focused on restoring normal physiologic recovery and maximizing tissue oxygenation prior to proceeding with definitive surgical management) has been shown to successfully control refractory PPH, with an overall mortality decrease for obstetric patients.
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Affiliation(s)
- Lilly Y Liu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Lisa Nathan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Jean-Ju Sheen
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Dena Goffman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
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11
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Gulersen M, Gerber RP, Rochelson B, Nimaroff M, Jones MDF. Vacuum-induced hemorrhage control versus uterine balloon tamponade for postpartum hemorrhage. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:267-272. [PMID: 36924993 DOI: 10.1016/j.jogc.2023.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To compare maternal outcomes of uterine balloon tamponade (UBT) versus an intrauterine vacuum-induced hemorrhage-control device (VHD) for the management of primary postpartum hemorrhage (PPH). METHODS Retrospective cohort of all patients with PPH due to uterine atony treated with an intrauterine device within a university health system from January 2019 to June 2021. The primary outcome of massive transfusion, defined as PPH requiring transfusion of ≥ 4 units of packed red blood cells (PRBC), was compared between 2 groups: UBT (n = 78) versus VHD (n = 36). Statistical analysis included use of Chi-squared and Wilcoxon rank sum tests with statistical significance set at P < 0.05. RESULTS Baseline characteristics were similar between the 2 groups. The proportion of patients who received ≥ 4 units of PRBC was significantly lower in the VHD group compared to the UBT group (2.8% vs. 20.5%, P = <0.01). The proportion of patients who were transfused ≥ 2 units of PRBC and median estimated blood loss (EBL) were also both significantly lower in the VHD group compared to the UBT group (36.1% vs. 57.7%, P = <0.01, and 1 500 mL vs. 1 875 mL, P = 0.02, respectively). Rates of other secondary outcomes were similar between the 2 groups. CONCLUSION Our data suggest that the use of intrauterine VHD in the management of PPH is associated with a lower number of massive transfusions and EBL compared to UBT. Randomized controlled trials are needed before drawing definitive conclusions on which device is more effective in this setting.
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Affiliation(s)
- Moti Gulersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; Division of Maternal- Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
| | - Rachel P Gerber
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Burton Rochelson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Michael Nimaroff
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, North Shore University Hospital - Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Monique D F Jones
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center - Zucker School of Medicine at Hofstra/Northwell, Queens, NY
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12
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Postpartum Hemorrhage Trends and Outcomes in the United States, 2000-2019. Obstet Gynecol 2023; 141:152-161. [PMID: 36701615 DOI: 10.1097/aog.0000000000004972] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/19/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy. METHODS This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association. RESULTS Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption. CONCLUSION Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.
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Mendez-Figueroa H, Bell CS, Wagner SM, Pedroza C, Gupta M, Mulder I, Lee K, Blackwell SC, Bartal MF, Chauhan SP. Postpartum hemorrhage drills or simulations and adverse outcomes: a systematic review and Bayesian meta-analysis. J Matern Fetal Neonatal Med 2022; 35:10416-10427. [PMID: 36220264 DOI: 10.1080/14767058.2022.2128659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare the rates of adverse outcomes with postpartum hemorrhage (PPH) before and after implementation of drills or simulation exercises. STUDY ELIGIBILITY CRITERIA We included all English studies that reported on rates of PPH and associated complications during the pre- and post-implementation of interventional exercises. STUDY APPRASIAL AND SYNTHESIS METHODS Two investigators independently reviewed the abstracts, and full articles for eligibility of all studies. Inconsistencies related to study evaluation or data extraction were resolved by a third author. The co-primary outcomes were the rate of PPH and of any transfusion; the secondary outcomes included admission to the intensive care unit (ICU), transfusion ≥ 4 units of packed red blood cells, hysterectomy, or maternal death. Study effects were combined by Bayesian meta-analysis and reported as risk ratios (RR) and 95% credible intervals (Cr). RESULTS We reviewed 142 full length articles. Of these, 18 publications, with 355,060 deliveries-150,562 (42%) deliveries during the pre-intervention and 204,498 (57.6%) deliveries in the post-interventional period-were included in the meta-analysis. Using the Newcastle-Ottawa Scale, only three studies were considered good quality, and none of them were done in the US. The rate of PPH prior to intervention was 5.06% and 5.46% afterwards (RR 1.09, 95% CI 0.87-1.36; probability of reduction in the diagnosis being 21%). The likelihood of transfusion decreased from 1.68% in the pre-intervention to 1.27% in the post-intervention period (RR 0.80, 95% Cr 0.57-1.09). The overall probability of reduction in transfusion was 93%, albeit it varied among studies done in non-US countries (96%) versus in the US (23%). Transfusion of 4 units or more of blood occurred in 0.44% of deliveries before intervention and 0.37% afterwards (RR of 0.85, 95% CI 0.50-1.52), with the overall probability of reduction being 72% (76% probability of reduction in studies from non-US countries and 49% reduction with reports from the US). Surgical interventions to manage PPH, which was not reported in any US studies, occurred in 0.14% before intervention and 0.28% afterwards (RR 1.29; 95% CI 0.56-3.06; probability of reduction 27%). Admission to the ICU occurred in 0.10% before intervention and 0.08% subsequently (RR 0.92, 95% CI 0.58-1.43), with the overall probability of reduction being 65% (81% in studies from non-US countries and 27% from the study done in the US). Maternal death occurred in 0.17% in the pre-intervention period and 0.09% during the post-intervention (RR 0.62, 95% CI 0.33-1.05; probability of reduction 93% in studies from non-US countries and 82% in one study from the US). CONCLUSIONS Interventions to reduce the sequelae of PPH are associated with decrease in adverse outcomes. The conclusion, however, ought not to be accepted reflexively for the US population. All of the studies on the topic done in the US are of poor quality and the associated probability of reduction in sequelae are consistently lower than those done in other countries. SYNOPSIS Since the putative benefits of PPH drills or simulation exercises are based on poor quality pre- and post-intervention trials, policies recommending them ought to be revisited.
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Affiliation(s)
- Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Cynthia S Bell
- Department of Center for Clinical Research & Evidence-Based Medicine in the Department of Pediatrics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Steve M Wagner
- Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI, USA
| | - Claudia Pedroza
- Department of Center for Clinical Research & Evidence-Based Medicine in the Department of Pediatrics, The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Megha Gupta
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Isabelle Mulder
- Department of Obstetrics and Gynecology, University of Texas Southwestern, Dallas, TX, USA
| | - Keya Lee
- The Texas Medical Center Library, Houston, TX, USA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Michal F Bartal
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
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Ende HB. Risk assessment tools to predict postpartum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:341-348. [PMID: 36513429 DOI: 10.1016/j.bpa.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 07/08/2022] [Accepted: 08/09/2022] [Indexed: 12/15/2022]
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality, and accurate risk assessments may allow providers to anticipate and prevent serious hemorrhage-related adverse events. Multiple category-based tools have been developed by national societies through expert consensus, and these tools assign low, medium, or high risk of hemorrhage based on a review of each patient's risk factors. Validation studies of these tools show varying performance, with a wide range of positive and negative predictive values. Risk prediction models for PPH have been developed and studied, and these models offer the advantage of more nuanced and individualized prediction. However, there are no published studies demonstrating external validation or successful clinical use of such models. Future work should include refinement of these models, study of best practices for implementation, and ultimately linkage of prediction to improved patient outcomes.
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Affiliation(s)
- Holly B Ende
- Department of Anesthesiology, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA.
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15
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Point-of-care coagulation testing for postpartum haemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:383-398. [PMID: 36513433 DOI: 10.1016/j.bpa.2022.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/03/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Abstract
The use of viscoelastic haemostatic assays (VHAs) to guide blood product replacement during postpartum haemorrhage is expanding. Rotem and TEG devices can be used to detect and treat clinically significant hypofibrinogenaemia, although evidence to support the role of VHAs for guiding fresh frozen plasma and platelet transfusion is less clear. If Rotem/TEG traces are normal, clinicians should investigate for another cause of bleeding, and haemostatic support is not required. Guidelines support the use of VHAs during postpartum haemorrhage as part of locally agreed algorithms. There is a wide consensus that fibrinogen replacement is needed if the Fibtem A5 is <12 mm and if there is ongoing bleeding. Guidelines recommend against using VHAs to guide tranexamic acid infusion, and this drug should be given as soon as bleeding is recognised, irrespective of the Rotem/TEG traces. The cost-effectiveness of VHAs during postpartum haemorrhage needs to be addressed.
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Postpartum Hemorrhage: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2022; 77:665-682. [DOI: 10.1097/ogx.0000000000001061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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17
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Jigyasa S, Agrawal S, Pandey U, Sachan S, Rajan M, Singh TB, Sapna S. Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India. Cureus 2022; 14:e26819. [PMID: 35847163 PMCID: PMC9279140 DOI: 10.7759/cureus.26819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 12/03/2022] Open
Abstract
Background The major cause of maternal death globally is postpartum hemorrhage (PPH). When PPH develops, early detection of bleeding and rapid treatment with evidence-based guidelines can prevent most PPH-related severe morbidity and mortality. The bundle care approach for PPH management could be a potential solution to inefficient and uneven evidence-based practice implementation worldwide. Bundle care is a collection of discrete, evidence-based interventions given to every eligible person simultaneously or in quick succession and requires teamwork, communication, and cooperation. The primary objective of this study was to analyze whether implementing a PPH bundle of care may reduce maternal morbidity and mortality in our institution. Methods This was a single-center retrospective pre-post case-control study was carried out at a tertiary care center and teaching hospital in Varanasi, eastern Uttar Pradesh state, India. From January 2021 to June 2021, pretraining data (PRE) were collected retrospectively on all births from the department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University. Subsequently, medical and paramedical personnel of our hospital were trained in Postpartum Hemorrhage Emergency Care Using a Bundle Approach (PPH EmC) as per the guidelines laid down by the World Health Organization (WHO) for PPH management and implemented in July 2021. Post-training data (POST) were then collected retrospectively on all deliveries at our hospital from August 2021 to January 2022. All the data within two periods were computed and analyzed. The results were then compared for any significant changes in the incidences of maternal mortality and morbidity in terms of the rates of blood transfusion required and the type of management used (medical or medical-surgical), use of tranexamic acid, and additional uterotonics. The results were expressed as proportions, and p≤0.05 was considered statistically significant using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). Results A total of 1304 women gave birth from January 2021 to January 2022, of whom 107 patients (61 in the PRE and 57 in the POST group) were diagnosed and treated for PPH. There was no significant difference in the incidence of PPH in the PRE and POST groups (p=0.581). There was a significant increase in the use of tranexamic acid (p=0.041) and a significant reduction in blood transfusion rates (p=0.032) after the implementation of bundled care in the POST group. The odds of PPH non-occurrence after pre- and post-test was 1.103 (95% CI=0.747 to 1.635). No significant difference was observed in maternal mortality in the PRE and POST groups (p=0.96). The requirement for radical surgical treatment of PPH, which included hysterectomies, was also significantly reduced, from 27.27% in the PRE group to 11.54% in the POST group (p=0.032). Conclusions PPH care bundles might improve the morbidity of PPH with the use of fewer resources and fewer interventions required. While these data are promising, further studies are needed to analyze bundle care's long-term effects.
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Does the Quality of Postpartum Hemorrhage Local Protocols Improve the Identification and Management of Blood Loss after Vaginal Deliveries? A Multicenter Cohort Study. Healthcare (Basel) 2022; 10:healthcare10060992. [PMID: 35742043 PMCID: PMC9222306 DOI: 10.3390/healthcare10060992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/19/2022] [Accepted: 05/24/2022] [Indexed: 11/16/2022] Open
Abstract
Substandard care, which can result from a delayed recognition of the severity of blood loss, can increase maternal morbidity. Our objectives were to assess the incidence of postpartum hemorrhage (PPH) and of second-line procedures in maternity units according to the quality of their PPH protocol. We used a mixed design, a prospective cohort (3442 women with PPH after vaginal delivery; February−July 2011), and an audit of the written protocols (177 French maternity units; September 2010−June 2011). A quality score was calculated for the protocol of each unit. Maternity units were classified into three categories according to this score: category 1 (total score: 0−8), category 2 (9−12.5), and category 3 (>12.5). The PPH incidence (>500 mL) was 3.2%, 3.3% and 4.6% among maternity units in categories 1, 2 and 3, respectively (p < 0.0001). The incidence of severe maternal morbidity (surgery and/or artery embolization and/or blood transfusion) was higher among maternity units in category 1 (54.8%; 95% CI: 51.9, 57.7) than in either category 2 (50.1%; 95% CI: 47.8, 52.5) or 3 (38.0%; 95% CI: 33.8, 42.4]) (p < 0.0001). The risks of severe maternal morbidity were lower for category 3 than category 1 and 2 (respectively, adjusted RR 0.68, 95% CI 0.60−0.86 and 0.77, 95% CI 0.68−0.87). Finally, maternity units with higher scores identified PPH better and used fewer curative second-line procedures.
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The prevalence of blood product transfusion after the implementation of a postpartum hemorrhage bundle: a retrospective cohort at a single safety net academic institution. Am J Obstet Gynecol MFM 2022; 4:100662. [PMID: 35577315 DOI: 10.1016/j.ajogmf.2022.100662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postpartum hemorrhage, defined as blood loss of ≥1000 mL within 24 hours after birth, is a leading cause of maternal morbidity and is associated with substantial financial and emotional burden. Based on societal and regulatory guidelines, in 2019, our institution adopted a postpartum hemorrhage prevention and management bundle based on the California Maternal Quality Care Collaborative initiatives. OBJECTIVE The study aimed to compare the prevalence of maternal blood product transfusion before and after the implementation of the bundle. STUDY DESIGN This was a retrospective cohort study comparing the prevalence of blood product transfusion before and after the implementation of a California Maternal Quality Care Collaborative-based postpartum hemorrhage management bundle at a single safety net teaching hospital between October 2017 and December 2019 excluding a 4-month rollout period between September 2018 and December 2018. The study included all patients ≥18 years of age and at >20 weeks' gestation. Exclusion criteria were out-born deliveries, delivery at time of significant nonobstetrical trauma, and refusal of blood transfusion. The primary outcome was the frequency of any blood product transfusion in the pre- and postbundle implementation cohorts. Secondary outcomes included blood product transfusion type and amount, maternal death, intrauterine balloon placement, uterine artery embolization, unplanned peripartum hysterectomy, intensive care admission, and length of stay among all deliveries complicated by postpartum hemorrhage. We further evaluated compliance with bundle measures for all postpartum hemorrhage cases. Cohort characteristics were compared using chi-square tests or Fisher exact tests for categorical data and Satterthwaite or Wilcoxon 2-sample tests for continuous variables based on data distributions. The proportion of blood product transfusion were evaluated using a chi-square test. RESULTS A total of 6744 deliveries were included with 3310 in the pre- and 3425 in the postbundle cohort. The prevalence of any blood product transfusion was similar between the pre- and postbundle cohorts (3.41%; 113/3310 vs 3.47%; 119/3425; P=.892). The prevalence of postpartum hemorrhage was 7.05% (233/3310) in the prebundle cohort and 10.34% (354/3434) in the postbundle cohort (P<.001). Among women with postpartum hemorrhage, those in the prebundle cohort had a higher rate of blood product transfusion than those in the postbundle cohort (36.05%; 84/233 vs 26.84%; 95/354; P=.018). Compared with the prebundle counterparts, patients with postpartum hemorrhage in the postbundle cohort had higher rates of utilization of intrauterine balloon placement (10.30%; 24/233 vs 16.95%; 60/354; P=.024). There were no significant differences among other secondary outcomes. The overall compliance with the bundle among those with blood loss ≥1000 mL was 92.1%. CONCLUSION The implementation of the postpartum hemorrhage bundle did not decrease the overall prevalence of blood product transfusion and may have led to higher rates of utilization of resources.
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Kjaer K. Quality Assurance and Quality Improvement in the Labor and Delivery Setting. Anesthesiol Clin 2021; 39:613-630. [PMID: 34776100 DOI: 10.1016/j.anclin.2021.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Quality assurance (QA) is the maintenance of a desired level of quality, whereas quality improvement (QI) is the continuous process of creating systems to make things better. Implementation science promotes the systematic uptake of best practices. Bundles are a structured list of best practices whereas toolkits provide the necessary details, rationale, and implementation materials, such as sample policies and protocols. Metrics that can guide care on the labor and delivery (L&D) floor may be related to team structure (obstetric, multidisciplinary, anesthetic), processes (patient monitoring, team effects), and outcomes (postpartum hemorrhage, venous thromboembolism). Multiple anesthetic quality metrics have been proposed, including the mode of anesthesia for cesarean delivery.
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Affiliation(s)
- Klaus Kjaer
- Weill Cornell Medical College, 525 East 68th Street, New York, NY 10065, USA.
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21
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Saucedo López A, García Briones A, Velázquez Merino A, Corona Alvarado E, Gómez Fernández A. Morbimortalidad en pacientes sometidas a ligadura de arterias hipogástricas con riesgo de hemorragia obstétrica. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2021.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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The Postpartum Hemorrhage Patient Safety Bundle Implementation at a Single Institution: Successes, Failures, and Lessons Learned. Am J Perinatol 2021; 38:1281-1288. [PMID: 32455466 DOI: 10.1055/s-0040-1712452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE In 2015, a multidisciplinary consensus bundle of recommendations for the anticipation and management of postpartum hemorrhage was published. Our goal was to evaluate the successes and failures of our institutional bundle implementation process. STUDY DESIGN An interdisciplinary committee was created to facilitate bundle implementation. All components of the bundle were addressed with cross-disciplinary teaching between stakeholders on the obstetrics units. Tools were built in the electronic medical record to facilitate bundle components of risk stratification, quantitative blood loss calculation, and stage-based hemorrhage management. Bundle components were individually evaluated for acceptability and sustainability. Overall rates of hemorrhage and transfusion from the periods 1 year before and after bundle implementation were also evaluated. RESULTS Readiness bundle components were successfully implemented, although simulation drills demonstrated limited sustainability. Recognition components were mixed: risk stratification was successfully and sustainably implemented while quantitative blood loss met resistance and was ultimately discontinued as it did not clinically perform superiorly to estimated blood loss. Among response and reporting elements, patient level support and team debriefing were noted as particular deficiencies in our program. CONCLUSION The postpartum hemorrhage patient safety bundle provided concrete individual elements, which overall improved the success of a stratified program implementation. Multiple deficiencies in acceptability and sustainability were uncovered during our process, particularly concerns about quantitative blood loss implementation and team communication skills. KEY POINTS · Supply readiness and protocol development were "quick wins.". · Culture change elements included recognition, response, and communication.. · Dedicated champions and electronic medical record tools improved sustainability.. · Poor acceptability and lack of improved outcomes led to element failure..
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Development and validation of a prediction model for postpartum hemorrhage at a single safety net tertiary care center. Am J Obstet Gynecol MFM 2021; 3:100404. [PMID: 34048966 DOI: 10.1016/j.ajogmf.2021.100404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postpartum hemorrhage is a leading cause of pregnancy-related morbidity and mortality; however, there is limited ability to identify women at risk of this obstetrical complication. OBJECTIVE This study aimed to develop and validate a prediction model for postpartum hemorrhage based on antenatal and intrapartum risk factors. STUDY DESIGN This was a retrospective cohort study of women who delivered between April 2016 and March 2019 at a single safety net hospital. The prevalence of postpartum hemorrhage, defined as blood loss of ≥1000 mL at the time of delivery, was determined, and characteristics were compared between women with and without postpartum hemorrhage. Women were randomly assigned to a prediction or a validation cohort. The selection of predictors to be included in the model was based on known antenatal and intrapartum risk factors for postpartum hemorrhage. A multivariable logistic regression with a backward stepwise approach was used to create a prediction model. Area under the receiver operating characteristic curve and 95% bootstrap confidence intervals were calculated. Using the final model, a single threshold for classifying postpartum hemorrhage was chosen, and the resulting sensitivity, specificity, and false-negative and false-positive rates were explored. RESULTS The prevalence rates of postpartum hemorrhage in the prediction and validation cohorts were 6.3% (377 of 6000 cases) and 6.4% (241 of 3774 cases), respectively (P=.83). The following predictors were selected for the final model: maternal body mass index (kg/m2), number of fetuses, history of postpartum hemorrhage, admission platelets of <100,000/µL, chorioamnionitis, arrest of descent, placental abruption, and active labor duration. The predictive model had an area under the receiver operating characteristic curve of 0.82 (95% confidence interval, 0.81-0.84). When applied to the validation cohort, the model had an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.78-0.83), a sensitivity of 86.9%, a specificity of 74.2%, a positive predictive value of 18.6%, a negative predictive value of 98.8%, a false-negative rate of 13.1%, and a false-positive rate of 25.9%. CONCLUSION The model performed reasonably well in identifying women at risk of postpartum hemorrhage. Further studies are necessary to evaluate the model in clinical practice and its effect on decreasing the prevalence of postpartum hemorrhage and associated maternal morbidity.
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Bell SF, Collis RE, Pallmann P, Bailey C, James K, John M, Kelly K, Kitchen T, Scarr C, Watkins A, Edey T, Macgillivray E, Greaves K, Volikas I, Tozer J, Sengupta N, Roberts I, Francis C, Collins PW. Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study. BMC Pregnancy Childbirth 2021; 21:377. [PMID: 33992094 PMCID: PMC8126150 DOI: 10.1186/s12884-021-03853-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/05/2021] [Indexed: 12/22/2022] Open
Abstract
Background Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. A national quality improvement programme called the Obstetric Bleeding Strategy for Wales (OBS Cymru) was introduced in all obstetric units in Wales. The aim was to reduce moderate PPH (1000 mL) progressing to massive PPH (> 2500 mL) and the need for red cell transfusion. Methods A PPH care bundle was introduced into all 12 obstetric units in Wales included all women giving birth in 2017 and 2018 (n = 61,094). The care bundle prompted: universal risk assessment, quantitative measurement of blood loss after all deliveries (as opposed to visual estimation), structured escalation to senior clinicians and point-of-care viscoelastometric-guided early fibrinogen replacement. Data were submitted by each obstetric unit to a national database. Outcome measures were incidence of massive PPH (> 2500 mL) and red cell transfusion. Analysis was performed using linear regression of the all Wales monthly data. Results Uptake of the intervention was good: quantitative blood loss measurement and risk assessment increased to 98.1 and 64.5% of all PPH > 1000 mL, whilst ROTEM use for PPH > 1500 mL increased to 68.2%. Massive PPH decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P = 0.011). Fewer women progressed from moderate to massive PPH in the last 6 months, 74/1490 (5.0%), than in the first 6 months, 97/1386 (7.0%), (P = 0.021). Units of red cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P = 0.015). Red cells were transfused to 350/15204 (2.3%) and 268/15150 (1.8%) (P = 0.001) in the first and last 6 months, respectively. There was no increase in the number of women with lowest haemoglobin below 80 g/L during this time period. Infusions of fresh frozen plasma fell and there was no increase in the number of women with haemostatic impairment. Conclusions The OBS Cymru care bundle was feasible to implement and associated with progressive, clinically significant improvements in outcomes for PPH across Wales. It is applicable across obstetric units of widely varying size, complexity and staff mixes. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03853-y.
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Affiliation(s)
- Sarah F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Rachel E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Philip Pallmann
- Deputy Director Research Design and Conduct Centre, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Christopher Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Kathryn James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Miriam John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Kevin Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Thomas Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Cerys Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Adam Watkins
- Improvement Cymru, Public Health Wales, Cardiff, UK
| | - Tracey Edey
- Department of Midwifery, Singleton Hospital, Swansea, UK
| | | | - Kathryn Greaves
- Department of Obstetrics and Gynaecology, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK
| | - Ingrid Volikas
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - James Tozer
- Department of Anaesthetics and Intensive Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladri Sengupta
- Department of Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Iolo Roberts
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Claire Francis
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Peter W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK.
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Eppes CS, Han SB, Haddock AJ, Buckler AG, Davidson CM, Hollier LM. Enhancing Obstetric Safety Through Best Practices. J Womens Health (Larchmt) 2020; 30:265-269. [PMID: 33227226 PMCID: PMC8020520 DOI: 10.1089/jwh.2020.8878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.
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Affiliation(s)
- Catherine Squire Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Sacha B Han
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alison J Haddock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - A Gretchen Buckler
- Office of Research on Women's Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Christina M Davidson
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Lisa M Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Bell SF, Watkins A, John M, Macgillivray E, Kitchen TL, James D, Scarr C, Bailey CM, Kelly KP, James K, Stevens JL, Edey T, Collis RE, Collins PW. Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort. BMC Pregnancy Childbirth 2020; 20:271. [PMID: 32375687 PMCID: PMC7201938 DOI: 10.1186/s12884-020-02971-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Visual estimation of blood loss following delivery often under-reports actual bleed volume. To improve accuracy, quantitative blood loss measurement was introduced for all births in the 12 hospitals providing maternity care in Wales. This intervention was incorporated into a quality improvement programme (Obstetric Bleeding Strategy for Wales, OBS Cymru). We report the incidence of postpartum haemorrhage in Wales over a 1-year period using quantitative measurement. METHODS This prospective, consecutive cohort included all 31,341 women giving birth in Wales in 2017. Standardised training was cascaded to maternity staff in all 12 hospitals in Wales. The training comprised mock-scenarios, a video and team drills. Uptake of quantitative blood loss measurement was audited at each centre. Data on postpartum haemorrhage of > 1000 mL were collected and analysed according to mode of delivery. Data on blood loss for all maternities was from the NHS Wales Informatics Service. RESULTS Biannual audit data demonstrated an increase in quantitative measurement from 52.1 to 87.8% (P < 0.001). The incidence (95% confidence intervals, CI) of postpartum haemorrhage of > 1000 mL, > 1500 mL and > 2000 mL was 8.6% (8.3 to 8.9), 3.3% (3.1 to 3.5) and 1.3% (1.2 to 1.4), respectively compared to 5%, 2% and 0.8% in the year before OBS Cymru. The incidence (95% CI) of bleeds of > 1000 mL was similar across the 12 hospitals despite widely varied size, staffing levels and case mix, median (25th to 75th centile) 8.6% (7.8-9.6). The incidence of PPH varied with mode of delivery and was mean (95% CI) 4.9% (4.6-5.2) for unassisted vaginal deliveries, 18.4 (17.1-19.8) for instrumental vaginal deliveries, 8.5 (7.7-9.4) for elective caesarean section and 19.8 (18.6-21.0) for non-elective caesarean sections. CONCLUSIONS Quantitative measurement of blood loss is feasible in all hospitals providing maternity care and is associated with detection of higher rates of postpartum haemorrhage. These results have implications for the definition of abnormal blood loss after childbirth and for management and research of postpartum haemorrhage.
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Affiliation(s)
- Sarah F Bell
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Adam Watkins
- 1000 Lives Improvement, Public Health Wales, Tyndall Street, Cardiff, UK
| | - Miriam John
- Department of Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | | | - Thomas L Kitchen
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Donna James
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Cerys Scarr
- Department of Obstetrics and Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Christopher M Bailey
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Bangor, UK
| | - Kevin P Kelly
- Department of Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Glan Clwyd Hospital, Bodelwyddan, UK
| | - Kathryn James
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jenna L Stevens
- Department of Anaesthetics, Aneurin Bevan University Health Board, Newport, UK
| | - Tracey Edey
- Department of Obstetrics and Gynaecology, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Rachel E Collis
- Department of Anaesthetics, Intensive Care and Pain Medicine, Cardiff and Vale University Health Board, Cardiff, UK
| | - Peter W Collins
- Institute of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. .,Departmentt of Haematology, University Hospital of Wales Heath Park, Cardiff, UK.
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Reale SC, Easter SR, Xu X, Bateman BT, Farber MK. Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesth Analg 2020; 130:e119-e122. [DOI: 10.1213/ane.0000000000004424] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bell SF, Kitchen T, John M, Scarr C, Kelly K, Bailey C, James K, Watkins A, Macgillivray E, Edey T, Greaves K, Volikas I, Tozer J, Sengupta N, Francis C, Collis R, Collins P. Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales). BMJ Open Qual 2020; 9:e000854. [PMID: 32273281 PMCID: PMC7326295 DOI: 10.1136/bmjoq-2019-000854] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/06/2020] [Accepted: 03/20/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales. INTERVENTION A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures. RESULTS Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%-76%), objective measurement of blood loss (52%-88%) and POC testing for coagulation for PPH ≥1500 mL (38%-59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit's management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23-6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively. CONCLUSIONS A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.
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Affiliation(s)
- Sarah Frances Bell
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Thomas Kitchen
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Miriam John
- Emergency Medicine, Aneurin Bevan University Health Board, Newport, UK
| | - Cerys Scarr
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Kevin Kelly
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Christopher Bailey
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Kathryn James
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | | | | | - Tracey Edey
- Midwifery, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | | | - Ingrid Volikas
- Anaesthetics, Intensive Care and Pain Medicine, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - James Tozer
- Anaesthesia and Critical Care, Aneurin Bevan University Health Board, Newport, UK
| | - Niladril Sengupta
- Obstetrics and Gynaecology, Betsi Cadwaladr University Health Board, Rhyl, UK
| | - Claire Francis
- Obstetrics and Gynaecology, University Hospital of Wales, Cardiff, UK
| | - Rachel Collis
- Anaesthesia and Critical Care, University Hospital of Wales, Cardiff, UK
| | - Peter Collins
- Haematology, University Hospital of Wales, Cardiff, UK
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Chang OH, Levy B, Lytle H, Pope R, Phiri H, Gellhaus T, Eckhardt C, Sclafani J. Implementation of the Alliance for Innovation on Maternal Health Program to Reduce Maternal Mortality in Malawi. Obstet Gynecol 2019; 133:507-514. [PMID: 30741809 DOI: 10.1097/aog.0000000000003108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate maternal mortality and changes in the culture of safety before and after the implementation of the Alliance for Innovation on Maternal Health (AIM) Malawi program. METHODS This was a prospective cohort study at a central hospital and a district health center in Malawi from March 2016 to November 2017. The AIM Malawi program included classroom didactics on obstetric hemorrhage, teamwork protocols, skills laboratory activities, and simulation training. The time periods of comparison were preintervention, education period, and postintervention. Hospital birth paper records were used to collect data on patient demographics and obstetric and neonatal information. The Hospital Survey of Patient Safety was used to measure the culture of safety before and after the program. RESULTS We trained 128 participants. In the postintervention period, 16 procedural interventions were performed to manage postpartum hemorrhage, including B-lynch sutures (n=7), condom balloon catheter (n=5), nonpneumatic antishock garment (n=3), and uterine artery ligation (n=1). There was a significant increase in the use of B-lynch sutures for the management of uterine atony in the postintervention compared with preintervention period (P=.014). In the postintervention period, the rate of maternal mortality from obstetric hemorrhage decreased significantly from 1.2% to 0.2% (P=.02), a relative decrease of 82.1% from the preintervention rate. Hospital safety culture scores improved significantly from baseline in four out of five domains after the AIM Malawi training. CONCLUSION After implementation of the AIM Malawi program, we found an increased use of postpartum hemorrhage procedural interventions, a decreased rate of maternal mortality and an increase in Hospital Survey of Patient Safety composite safety scores. The AIM Malawi program may be an effective framework for adaptation to improve maternal mortality in a low-resource setting.
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Affiliation(s)
- Olivia H Chang
- Division of Global Women's Health, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; the American College of Obstetricians and Gynecologists, Washington, DC; and Kamuzu Central Hospital, Lilongwe, Malawi
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Henriquez DDCA, Caram-Deelder C, le Cessie S, Zwart JJ, van Roosmalen JJM, Eikenboom JCJ, So-Osman C, van de Watering LMG, Zwaginga JJ, Koopman-van Gemert AWMM, Bloemenkamp KWM, van der Bom JG. Association of Timing of Plasma Transfusion With Adverse Maternal Outcomes in Women With Persistent Postpartum Hemorrhage. JAMA Netw Open 2019; 2:e1915628. [PMID: 31730187 PMCID: PMC6902812 DOI: 10.1001/jamanetworkopen.2019.15628] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Early plasma transfusion for women with severe postpartum hemorrhage (PPH) is recommended to prevent coagulopathy. However, there is no comparative, quantitative evidence on the association of early plasma transfusion with maternal outcomes. OBJECTIVE To compare the incidence of adverse maternal outcomes among women who received plasma during the first 60 minutes of persistent PPH vs women who did not receive plasma for similarly severe persistent PPH. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study used a consecutive sample of women with persistent PPH, defined as PPH refractory to first-line measures to control bleeding, between January 1, 2011, and January 1, 2013. Time-dependent propensity score matching was used to select women who received plasma during the first 60 minutes of persistent PPH and match each of them with a woman who had shown the same severity and received the same treatment of PPH but who had not received plasma at the moment of matching. Transfusions were not guided by coagulation tests. Statistical analysis was performed from June 2018 to June 2019. EXPOSURES Transfusion of plasma during the first 60 minutes of persistent PPH vs no or later plasma transfusion. MAIN OUTCOMES AND MEASURES Incidence of adverse maternal outcomes, defined as a composite of death, hysterectomy, or arterial embolization. RESULTS This study included 1216 women (mean [SD] age, 31.6 [5.0] years) with persistent PPH, of whom 932 (76.6%) delivered vaginally and 780 (64.1%) had PPH caused by uterine atony. Seven women (0.6%) died because of PPH, 62 women (5.1%) had a hysterectomy, and 159 women (13.1%) had arterial embolizations. Among women who received plasma during the first 60 minutes of persistent PPH, 114 women could be matched with a comparable woman who had not received plasma at the moment of matching. The incidence of adverse maternal outcomes was similar between the women, with adverse outcomes recorded in 24 women (21.2%) who received early plasma transfusion and 23 women (19.9%) who did not receive early plasma transfusion (odds ratio, 1.09; 95% CI, 0.57-2.09). Results of sensitivity analyses were comparable to the primary results. CONCLUSIONS AND RELEVANCE In this cohort study, initiation of plasma transfusion during the first 60 minutes of persistent PPH was not associated with adverse maternal outcomes compared with no or later plasma transfusion, independent of severity of PPH.
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Affiliation(s)
- Dacia D. C. A. Henriquez
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin-Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Camila Caram-Deelder
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin-Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia le Cessie
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin-Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost J. Zwart
- Department of Obstetrics and Gynecology, Deventer Hospital, Deventer, the Netherlands
| | - Jos J. M. van Roosmalen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Athena Institute, Vrije Universiteit, Amsterdam, the Netherlands
| | - Jeroen C. J. Eikenboom
- Division of Thrombosis and Hemostasis, Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Cynthia So-Osman
- Sanquin Blood Bank, Unit Transfusion Medicine, Leiden, the Netherlands
| | | | - Jaap Jan Zwaginga
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Kitty W. M. Bloemenkamp
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Obstetrics, Birth Center Wilhelmina’s Children Hospital, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Johanna G. van der Bom
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin-Leiden University Medical Center, Leiden, the Netherlands
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Non-clinical interventions to prevent postpartum haemorrhage and improve its management: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 240:300-309. [DOI: 10.1016/j.ejogrb.2019.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
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Bundles for Maternal Safety: Promises and Challenges of Bundle Implementation: The Case of Obstetric Hemorrhage. Clin Obstet Gynecol 2019; 62:539-549. [DOI: 10.1097/grf.0000000000000470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality in the United States, and worldwide. Recognition of PPH is challenging, but once hemorrhage is recognized, management needs to focus on achieving adequate uterine tone and maintaining maternal hemodynamic stability. There have been several advances in the management of postpartum hemorrhage, many of which can be implemented at the labor and delivery unit level. RECENT FINDINGS There have been many advances in the understanding of at-risk parturients, and the use of hemorrhage protocols and safety bundles have been shown to improve patient outcomes. There are many new advances in transfusion management (e.g. fibrinogen concentrate, prothrombin complex concentrate, tranexamic acid) that can compliment traditional component therapy. Consideration should be given to transferring women at high risk for complications (e.g. invasive placentation) to a higher level facility for delivery. SUMMARY Although postpartum hemorrhage itself may not be preventable, early identification of blood loss, and mobilization of resources may prevent adverse outcomes. Multidisciplinary planning at the system level, ensuring that hemorrhage protocols exist, as well as for management of high-risk patients is important for improving patient outcomes.
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Heesen M, Carvalho B, Carvalho JCA, Duvekot JJ, Dyer RA, Lucas DN, McDonnell N, Orbach‐Zinger S, Kinsella SM. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia 2019; 74:1305-1319. [DOI: 10.1111/anae.14757] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2019] [Indexed: 01/21/2023]
Affiliation(s)
- M. Heesen
- Department of Anaesthesia Kantonsspital Baden Switzerland
| | - B. Carvalho
- Department of Anesthesiology Stanford University School of Medicine Stanford CAUSA
| | - J. C. A. Carvalho
- Department of Anaesthesia and Department of Obstetrics and Gynaecology University of Toronto ONCanada
| | - J. J. Duvekot
- Department of Obstetrics and Gynecology Erasmus Medical Centre Rotterdam Rotterdamthe Netherlands
| | - R. A. Dyer
- Department of Anaesthesia and Peri‐operative Medicine University of Cape Town Cape TownSouth Africa
| | - D. N. Lucas
- Department of Anaesthesia Northwick Park Hospital Harrow UK
| | - N. McDonnell
- Department of Anaesthesia and Pain Medicine King Edward Memorial Hospital for Women Subiaco WA Australia
| | - S. Orbach‐Zinger
- Department of Anaesthesia Beilinson Hospital, Petach Tikvah, and Sackler Medical School Tel Aviv University Tel Aviv Israel
| | - S. M. Kinsella
- Department of Anaesthesia St Michael's Hospital Bristol UK
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Katz D, Beilin Y. Management of post-partum hemorrhage and the role of the obstetric anesthesiologist. J Matern Fetal Neonatal Med 2019; 34:1487-1493. [PMID: 31257973 DOI: 10.1080/14767058.2019.1638360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW The landscape of post-partum hemorrhage management is rapidly changing. Modifications to definitions, bundles, and care plans occur frequently with management strategies becoming more complex. It has become apparent that the management of these patients requires a multidisciplinary approach with the involvement of obstetricians, anesthesiologists, gynecologist/oncologists, nursing, and care associates. This review article is meant to be an evidence-based review of post-partum hemorrhage with practical recommendations and a look at future directions of the management of post-partum hemorrhage from the vantage point of the obstetric anesthesiologist in an effort to enhance the collaborative treatment of this at risk population.
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Affiliation(s)
- Daniel Katz
- Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yaakov Beilin
- Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Management of postpartum haemorrhage: from research into practice, a narrative review of the literature and the Cardiff experience. Int J Obstet Anesth 2019; 37:106-117. [DOI: 10.1016/j.ijoa.2018.08.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/16/2018] [Accepted: 08/19/2018] [Indexed: 01/02/2023]
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Abstract
Reporting and systems learning provide the backbone for a sustainable comprehensive response to maternal hemorrhage. Reporting back to the institution requires capturing various elements such as compliance, results of debriefs, and comprehensive reviews of cases where there has been severe maternal morbidity. The system then learns from these reviews, and modifies as necessary any areas not performing as desired. Compliance monitoring, aside from review of an adverse event, is also an essential element of the reporting process by assessing for drift, returning to pre-implementation practices.
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Affiliation(s)
- Laurence E Shields
- Marian Regional Medical Center, 1400 E Church St, Santa Maria, CA 93454, USA; Dignity Health Patient Safety, 185 Berry St #300, San Francisco, CA 94107, USA
| | - Suzanne Wiesner
- Dignity Health Patient Safety, 185 Berry St #300, San Francisco, CA 94107, USA
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Abstract
Postpartum hemorrhage is an important contributor to maternal morbidity, and is one of the most common worldwide causes of preventable maternal mortality. Preventing significant morbidity and mortality from postpartum hemorrhage necessitates preparedness on both a unit and patient level. Our objectives are to define a bundle, to review the elements of the Council on Patient Safety in Women's Healthcare Obstetric Hemorrhage Bundle and to highlight simulation-based training opportunities, focusing on readiness for this significant obstetric emergency.
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Affiliation(s)
- Jessica Spiegelman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, United States.
| | - Jean-Ju Sheen
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, United States
| | - Dena Goffman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, United States
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Seacrist M, Bingham D, Scheich B, Byfield R. Barriers and Facilitators to Implementation of a Multistate Collaborative to Reduce Maternal Mortality From Postpartum Hemorrhage. J Obstet Gynecol Neonatal Nurs 2018; 47:688-697. [DOI: 10.1016/j.jogn.2017.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 10/18/2022] Open
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Bingham D, Scheich B, Bateman BT. Structure, Process, and Outcome Data of AWHONN’s Postpartum Hemorrhage Quality Improvement Project. J Obstet Gynecol Neonatal Nurs 2018; 47:707-718. [DOI: 10.1016/j.jogn.2018.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 10/28/2022] Open
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Schlembach D, Helmer H, Henrich W, von Heymann C, Kainer F, Korte W, Kühnert M, Lier H, Maul H, Rath W, Steppat S, Surbek D, Wacker J. Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016). Geburtshilfe Frauenheilkd 2018; 78:382-399. [PMID: 29720744 PMCID: PMC5925693 DOI: 10.1055/a-0582-0122] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 02/08/2018] [Accepted: 02/26/2018] [Indexed: 12/12/2022] Open
Abstract
Purpose
This is an official interdisciplinary guideline, published and coordinated by the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (OEGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline was developed for use in German-speaking countries and is backed by the German Society of Anaesthesiology and Intensive Medicine (DGAI), the Society of Thrombosis and Haemostasis Research (GTH) and the German Association of Midwives. The aim is to provide a consensus-based overview of the diagnosis and management of peripartum bleeding obtained from an evaluation of the relevant literature.
Methods
This S2k guideline was developed from the structured consensus of representative members of the various professional associations and professions commissioned by the Guideline Commission of the DGGG.
Recommendations
The guideline encompasses recommendations on definitions, risk stratification, prevention and management.
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Affiliation(s)
| | - Hanns Helmer
- Universitätsklinik für Frauenheilkunde, Klinische Abteilung für Geburtshilfe und feto-maternale Medizin, Medizinische Universität Wien, Wien, Austria
| | - Wolfgang Henrich
- Klinik für Geburtsmedizin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Franz Kainer
- Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg, Germany
| | | | - Maritta Kühnert
- Klinik für Frauenheilkunde und Geburtshilfe, Universitätsklinikum Gießen-Marburg, Marburg, Germany
| | - Heiko Lier
- Klinik für Anästhesie und operative Intensivmedizin, Universitätsklinik Köln, Köln, Germany
| | - Holger Maul
- Geburtshilfe & Pränatalmedizin, Asklepios Klinik Barmbek, Hamburg, Germany
| | - Werner Rath
- Gynäkologie und Geburtshilfe, Universitätsklinikum RWTH Aachen, Aachen, Germany
| | | | - Daniel Surbek
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und feto-maternale Medizin, Bern, Switzerland
| | - Jürgen Wacker
- Klinik für Gynäkologie und Geburtshilfe, Fürst-Stirum-Klinik Bruchsal, Bruchsal, Germany
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Colucci G, Helsing K, Biasiutti FD, Raio L, Schmid P, Tsakiris DA, Eberle B, Surbek D, Lämmle B, Alberio L. Standardized Management Protocol in Severe Postpartum Hemorrhage: A Single-Center Study. Clin Appl Thromb Hemost 2018; 24:884-893. [PMID: 29669438 PMCID: PMC6714733 DOI: 10.1177/1076029618758956] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Severe postpartum hemorrhage (sPPH) is an obstetric emergency that needs prompt and effective therapy to reduce the risk of complications. In this study, women who developed sPPH (study cohort, n = 27) were treated according to a standardized management protocol prescribing sequential administration of uterotonic drugs, crystalloids, tranexamic acid, labile blood products, low-dose fibrinogen, and recombinant activated factor VII (rFVIIa). This group was compared to patients treated with different strategies during 2 preceding periods: an in-house guideline regulating the administration of rFVIIa (historical cohort 1, n = 20) and no specific guideline (historical cohort 2, n = 27). The management protocol was used over 33 months. The study cohort had a lower estimated blood loss (P = .004) and required less red blood cell concentrates (P = .007), fresh frozen plasma units (P = .004), and platelet concentrates (P = .020) compared to historical cohort 1 and historical cohort 2, respectively. The necessity of emergency postpartum hysterectomy was lower in the study group (P = .012). In conclusion, in patients with sPPH treated with this standardized management protocol, we observed a decreased requirement of labile blood products and lower need to proceed to emergency postpartum hysterectomy.
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Affiliation(s)
- Giuseppe Colucci
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,2 Service of Hematology, Clinica Luganese Moncucco, Lugano, Switzerland
| | - Karin Helsing
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Franziska Demarmels Biasiutti
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | - Luigi Raio
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Pirmin Schmid
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland
| | | | - Balthasar Eberle
- 5 Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Daniel Surbek
- 3 Department of Obstetrics and Gynecology, University Hospital and University of Bern, Bern, Switzerland
| | - Bernhard Lämmle
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,6 Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
| | - Lorenzo Alberio
- 1 Department of Hematology and Central Hematology Laboratory, University Hospital and University of Bern, Bern, Switzerland.,7 Service et laboratoire central d'hématologie, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
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44
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Yazer MH, Dunbar NM, Cohn C, Dillon J, Eldib H, Jackson B, Kaufman R, Murphy MF, O'Brien K, Raval JS, Seheult J, Staves J, Waters JH. Blood product transfusion and wastage rates in obstetric hemorrhage. Transfusion 2018. [DOI: 10.1111/trf.14571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mark H. Yazer
- Department of Pathology; Pittsburgh Pennsylvania
- The Institute for Transfusion Medicine; Pittsburgh Pennsylvania
| | - Nancy M. Dunbar
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Jessica Dillon
- Department of Pathology and Laboratory Medicine; Dartmouth-Hitchcock Medical Center; Lebanon New Hampshire
| | - Howida Eldib
- Department of Laboratory Medicine and Pathology; University of Minnesota; Minneapolis Minnesota
| | - Bryon Jackson
- Department of Pathology and Laboratory Medicine; Emory University School of Medicine; Atlanta Georgia
| | - Richard Kaufman
- Brigham and Women's Hospital Adult Transfusion Service; Boston Massachusetts
| | - Michael F. Murphy
- NHS Blood & Transplant, Oxford University Hospitals, and University of Oxford; Oxford UK
| | - Kerry O'Brien
- Department of Pathology; Beth Israel Deaconess Medical Center; Boston Massachusetts
| | - Jay S. Raval
- Department of Pathology and Laboratory Medicine; University of North Carolina, Chapel Hill, North Carolina; the McGowan Institute for Regenerative Medicine; Pittsburgh Pennsylvania
| | | | | | - Jonathan H. Waters
- Departments of Anesthesiology and Bioengineering; University of Pittsburgh; Pittsburgh Pennsylvania
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Quality measures in high-risk pregnancies: Executive Summary of a Cooperative Workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2017; 217:B2-B25. [PMID: 28735702 DOI: 10.1016/j.ajog.2017.07.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 07/14/2017] [Indexed: 01/07/2023]
Abstract
Providers perceive current obstetric quality measures as imperfect and insufficient. Our organizations convened a "Quality Measures in High-Risk Pregnancies Workshop." The goals were to (1) review the current landscape regarding quality measures in obstetric conditions with increased risk for adverse maternal or fetal outcomes, (2) evaluate the available evidence for management of common obstetric conditions to identify those that may drive the highest impact on outcomes, quality, and value, (3) propose measures for high-risk obstetric conditions that reflect enhanced quality and efficiency, and (4) identify current research gaps, improve methods of data collection, and recommend means of change.
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46
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Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomized controlled trial. Br J Anaesth 2017; 119:411-421. [DOI: 10.1093/bja/aex181] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 12/25/2022] Open
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Collins P, Cannings-John R, Bruynseels D, Mallaiah S, Dick J, Elton C, Weeks A, Sanders J, Aawar N, Townson J, Hood K, Hall J, Harding K, Gauntlett R, Collis R. Viscoelastometry guided fresh frozen plasma infusion for postpartum haemorrhage: OBS2, an observational study. Br J Anaesth 2017; 119:422-434. [DOI: 10.1093/bja/aex245] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2017] [Indexed: 12/22/2022] Open
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49
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Schneider PD, Sabol BA, Lee King PA, Caughey AB, Borders AEB. The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels. Clin Perinatol 2017; 44:511-528. [PMID: 28802336 DOI: 10.1016/j.clp.2017.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.
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Affiliation(s)
- Patrick D Schneider
- Maternal-Fetal Medicine, NorthShore University HealthSystem, University of Chicago, 2650 Ridge Avenue, Walgreen Building Suite 1506, Evanston, IL 60201, USA
| | - Bethany A Sabol
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Patricia Ann Lee King
- Feinberg School of Medicine, Northwestern University, 633 North St. Clair Street, Chicago, IL 60611, USA
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098, USA
| | - Ann E B Borders
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem Evanston Hospital, Pritzker School of Medicine, University of Chicago, Walgreen Building, Suite 1507, Evanston, IL 60201, USA.
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50
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National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. Anesth Analg 2017; 125:540-547. [PMID: 28696959 DOI: 10.1213/ane.0000000000002304] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.
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