Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France

Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study)

Changes between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study's principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries.

Safety and Quality in Maternal and Neonatal Care: Any Progress since Ignaz Semmelweis?

James Lind (1716–1794) is considered the pioneer of medical technology assessments [...]

Does the Quality of Postpartum Hemorrhage Local Protocols Improve the Identification and Management of Blood Loss after Vaginal Deliveries? A Multicenter Cohort Study

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.

A study of the healthcare resource use for the management of postpartum haemorrhage in France, Italy, the Netherlands, and the UK

OBJECTIVE

Postpartum haemorrhage (PPH) complicates approximately 5% of births worldwide and is a leading direct cause of maternal death. Rates of PPH are increasing in many developed countries, particularly PPH related to uterine atony. There is a lack of published up-to-date information about healthcare resource use associated with management of PPH following vaginal birth. The objective of this study was to describe healthcare resource use for the management of minor PPH (blood loss 500-1,000 ml) and major PPH (blood loss > 1,000 ml) compared to uncomplicated birth (no PPH) following hospital vaginal birth in France, Italy, the Netherlands, and the UK.

STUDY DESIGN

In-depth interviews with two midwives from each participating country were conducted to establish differences in resource use for the management of minor PPH, major PPH, and uncomplicated birth. A web-survey was then developed and one obstetrician per participating country reviewed the survey. In total, 100 midwives (25 per country) completed the survey. Results were discussed at a multi-professional consensus meeting of midwives and obstetricians/gynaecologists (n = 6).

RESULTS AND CONCLUSIONS

Midwives participating in the survey estimated that 80% of women receive Active Management of the Third Stage of Labour (AMTSL) and 93% of participants specified that uterotonics would routinely be used during AMTSL. Most participants (84%) reported that blood loss is routinely measured in their hospital, using a combination of methods. PPH is associated with increased healthcare resource use, including administration of additional uterotonics and use of additional medical interventions, such as urinary catheter, intravenous fluids, and possible requirement for surgery. The number of nurses, obstetricians/gynaecologists, and anaesthetists involved in the management of PPH increases with the occurrence and severity of PPH, as well as the proportion of healthcare personnel providing continuous care. Women may spend an additional 24 h in hospital following major PPH compared to uncomplicated birth. The results of this study highlight the burden of PPH management on healthcare resources. To reduce costs associated with PPH, prevention is the most effective strategy and can be enhanced with the use of an effective uterotonic as part of the active management of the third stage of labour.

A French audit of maternity unit protocols for immediate postpartum hemorrhage: A cross-sectional study (HERA)

OBJECTIVES

The principal objective of this work was to assess how well the written protocols of maternity units used for the prevention and management of postpartum hemorrhage (PPH) corresponded to the 2004 French guidelines on this topic. The second objective was to assess whether or not this correspondence with the national guidelines varied according to hospital level (basic, specialized, and subspecialized) and status (teaching, public, and private).

METHODS

This observational multicenter cross-sectional study took place in September 2010 and included French perinatal networks that volunteered to participate. We asked 300 French maternity units belonging to these networks to participate by emailing a copy of their department's protocol for PPH to the study team. This team designed and performed a clinical audit of these protocols, defining 16 criteria that incorporated the 2004 French guidelines for prevention and management of PPH. The main outcome measure was the percentage of units reporting protocols meeting these criteria.

RESULTS

Of the 244 maternity units responding, 97.1 % had a written protocol but only 67.0 % had a local protocol. Protocol correspondence with the 2004 French guidelines was good for the criteria involving quantitative assessment of the quantity of blood loss (83.5 %) and secondary management of PPH (>80 %). Correspondence with the guidelines was poor in terms of defining PPH in the protocol (25.3 %) and of requiring the recording of the time of PPH diagnosis (53.2 %) and of the volume of blood loss (55.7 %). These results differed only slightly according to maternity unit status or level.

CONCLUSION

In all, 67.0 % (159/237) of maternity units had a local protocol for PPH. The contents of these protocols should be improved to be closer to the national guidelines.