Quality Improvement Opportunities Identified Through Case Review of Pregnancy-Related Deaths From Obstetric Hemorrhage

Development and Validation of an Automated, Real-Time Predictive Model for Postpartum Hemorrhage

OBJECTIVE

To develop and validate a predictive model for postpartum hemorrhage that can be deployed in clinical care using automated, real-time electronic health record (EHR) data and to compare performance of the model with a nationally published risk prediction tool.

METHODS

A multivariable logistic regression model was developed from retrospective EHR data from 21,108 patients delivering at a quaternary medical center between January 1, 2018, and April 30, 2022. Deliveries were divided into derivation and validation sets based on an 80/20 split by date of delivery. Postpartum hemorrhage was defined as blood loss of 1,000 mL or more in addition to postpartum transfusion of 1 or more units of packed red blood cells. Model performance was evaluated by the area under the receiver operating characteristic curve (AUC) and was compared with a postpartum hemorrhage risk assessment tool published by the CMQCC (California Maternal Quality Care Collaborative). The model was then programmed into the EHR and again validated with prospectively collected data from 928 patients between November 7, 2023, and January 31, 2024.

RESULTS

Postpartum hemorrhage occurred in 235 of 16,862 patients (1.4%) in the derivation cohort. The predictive model included 21 risk factors and demonstrated an AUC of 0.81 (95% CI, 0.79-0.84) and calibration slope of 1.0 (Brier score 0.013). During external temporal validation, the model maintained discrimination (AUC 0.80, 95% CI, 0.72-0.84) and calibration (calibration slope 0.95, Brier score 0.014). This was superior to the CMQCC tool (AUC 0.69 [95% CI, 0.67-0.70], P <.001). The model maintained performance in prospective, automated data collected with the predictive model in real time (AUC 0.82 [95% CI, 0.73-0.91]).

CONCLUSION

We created and temporally validated a postpartum hemorrhage prediction model, demonstrated its superior performance over a commonly used risk prediction tool, successfully coded the model into the EHR, and prospectively validated the model using risk factor data collected in real time. Future work should evaluate external generalizability and effects on patient outcomes; to facilitate this work, we have included the model coefficients and examples of EHR integration in the article.

Postpartum bleeding visual underestimation: A persistent problem

Postpartum bleeding volume calculated by the visual method is lower than the bleeding volume that is objectively quantified.

Perceptions and experiences of the prevention, detection, and management of postpartum haemorrhage: a qualitative evidence synthesis

BACKGROUND

Postpartum haemorrhage (PPH), defined as blood loss of 500 mL or more after childbirth, is the leading cause of maternal mortality worldwide. It is possible to prevent complications of PPH with timely and appropriate detection and management. However, implementing the best methods of PPH prevention, detection and management can be challenging, particularly in low- and middle-income countries.

OBJECTIVES

Our overall objective was to explore the perceptions and experiences of women, community members, lay health workers, and skilled healthcare providers who have experience with PPH or with preventing, detecting, and managing PPH, in community or health facility settings.

SEARCH METHODS

We searched MEDLINE, CINAHL, Scopus, and grey literature on 13 November 2022 with no language restrictions. We then performed reference checking and forward citation searching of the included studies.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored perceptions and experiences of PPH prevention, detection, and management among women, community members, traditional birth attendants, healthcare providers, and managers.

DATA COLLECTION AND ANALYSIS

We used three-stage maximum variation sampling to ensure diversity in terms of relevance of the study to the review objectives, richness of data, and coverage of critical contextual elements: setting (region, country income level), perspective (type of participant), and topic (prevention, detection, management). We extracted data using a data extraction form designed for this review. We used thematic synthesis to analyse and synthesise the evidence, and we used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. To identify factors that may influence intervention implementation, we mapped each review finding to the Theoretical Domains Framework (TDF) and the Capability, Motivation, and Opportunity model of Behaviour change (COM-B). We used the Behaviour Change Wheel to explore implications for practice.

MAIN RESULTS

We included 67 studies and sampled 43 studies for our analysis. Most were from low- or middle-income countries (33 studies), and most included the perspectives of women and health workers. We downgraded our confidence in several findings from high confidence to moderate, low, or very-low confidence, mainly due to concerns about how the studies were conducted (methodological limitations) or concerns about missing important perspectives from some types of participants or in some settings (relevance). In many communities, bleeding during and after childbirth is considered "normal" and necessary to expel "impurities" and restore and cleanse the woman's body after pregnancy and birth (moderate confidence). In some communities, people have misconceptions about causes of PPH or believe that PPH is caused by supernatural powers or evil spirits that punish women for ignoring or disobeying social rules or for past mistakes (high confidence). For women who give birth at home or in the community, female family members or traditional birth attendants are the first to recognise excess bleeding after birth (high confidence). Family members typically take the decision of whether and when to seek care if PPH is suspected, and these family members are often influenced by trusted traditional birth attendants or community midwives (high confidence). If PPH is identified for women birthing at home or in the community, decision-making about the subsequent referral and care pathway can be multifaceted and complex (high confidence). First responders to PPH are not always skilled or trained healthcare providers (high confidence). In health facilities, midwives may consider it easy to implement visual estimation of blood loss with a kidney dish or under-pad, but difficult to accurately interpret the amount of blood loss (very low confidence). Quantifying (rather than estimating) blood loss may be a complex and contentious change of practice for health workers (low confidence). Women who gave birth in health facilities and experienced PPH described it as painful, embarrassing, and traumatic. Partners or other family members also found the experience stressful. While some women were dissatisfied with their level of involvement in decision-making for PPH management, others felt health workers were best placed to make decisions (moderate confidence). Inconsistent availability of resources (drugs, medical supplies, blood) causes delays in the timely management of PPH (high confidence). There is limited availability of misoprostol in the community owing to stockouts, poor supply systems, and the difficulty of navigating misoprostol procurement for community health workers (moderate confidence). Health workers described working on the maternity ward as stressful and intense due to short staffing, long shifts, and the unpredictability of emergencies. Exhausted and overwhelmed staff may be unable to appropriately monitor all women, particularly when multiple women are giving birth simultaneously or on the floor of the health facility; this could lead to delays in detecting PPH (moderate confidence). Inadequate staffing, high turnover of skilled health workers, and appointment of lower-level cadres of health workers are key challenges to the provision of quality PPH care (high confidence). Through team-based simulation training, health workers of different cadres (doctors, midwives, lay health workers) can develop a shared mental model to help them work quickly, efficiently, and amicably as a team when managing women with PPH (moderate confidence).

AUTHORS' CONCLUSIONS

Our findings highlight how improving PPH prevention, detection, and management is underpinned by a complex system of interacting roles and behaviours (community, women, health workers of different types and with different experiences). Multiple individual, sociocultural, and environmental factors influence the decisions and behaviours of women, families, communities, health workers, and managers. It is crucial to consider the broader health and social systems when designing and implementing PPH interventions to change or influence these behaviours. We have developed a set of prompts that may help programme managers, policymakers, researchers, and other key stakeholders to identify and address factors that affect implementation and scale-up of interventions to improve PPH prevention, detection, and management.

Incidence of postpartum hemorrhage based on the improved combined method in evaluating blood loss: A retrospective cohort study

OBJECTIVE

In view of the current clinical inaccuracies and underestimations of postpartum hemorrhage amount, this study aims to investigate the incidence, etiology, clinical characteristics of postpartum hemorrhage in different modes of delivery based on the combination of volumetric method, gravimetric method and area method in evaluating blood loss.

DESIGN

This retrospective cohort study was conducted in Hangzhou Women's Hospital from January 2020 to June 2021, including 725 cases of postpartum hemorrhage among 18,977 parturients. Based on different modes of delivery, the participants were divided into three groups: vaginal delivery, forceps delivery, and cesarean section, for comparison.

METHODS

Using an improved combined assessment method for blood loss, we retrospectively analyzed a cohort of parturients with postpartum hemorrhage who underwent vaginal delivery, forceps delivery, or cesarean section and were hospitalized in Hangzhou Women's Hospital from January 2020 to June 2021.

RESULTS

(1) Among the 18,977 parturients, 725 cases of postpartum hemorrhage occurred, with an incidence rate of 3.8%, and severe postpartum hemorrhage accounted for 0.4% of the cases. (2) The incidence of postpartum hemorrhage was significantly higher in the forceps delivery group than in the vaginal delivery group (χ2 = 19.27, P<0.001), while the incidence of severe postpartum hemorrhage was significantly higher in the cesarean section group than in the vaginal delivery group (χ2 = 8.71, P = 0.003). (3) The causes of postpartum hemorrhage were statistically different among the different delivery modes, with varying underlying factors (P<0.001). (4) Patients with postpartum hemorrhage in different delivery modes showed statistically significant differences in age, body mass index (BMI), birth weight, gestational age, gravidity, parity, the decline of postpartum peripheral blood hemoglobin concentration, and estimated blood loss (P<0.05). (5) The proportion of blood transfusion was significantly higher in the cesarean section group than in the vaginal delivery and forceps delivery groups (χ2 = 231.03, P<0.001).

LIMITATIONS

This study is a single-center retrospective study, which may have led to selection bias in case selection. Additionally, the implementation of the combined three blood loss assessment methods may not have been strictly followed in all cases. Moreover, due to the mixing of bleeding with amniotic and irrigation fluids, the accuracy of evaluation may have been affected, leading to the possibility of inaccuracy of blood loss.

CONCLUSIONS

Forceps delivery and cesarean section increase the risk of postpartum hemorrhage, but forceps delivery does not significantly increase the incidence of severe postpartum hemorrhage. Uterine atony remains the leading cause of postpartum hemorrhage, while birth canal laceration and placental factors are the second most common causes of postpartum hemorrhage in forceps delivery and cesarean section, respectively. In this study, the volumetric method, gravimetric method and area method were combined to quantitatively assess postpartum hemorrhage amount. The combined method has strong clinical practicability and is less affected by subjective factors, although it also has limitations. In the future, we still need to focus on the early prediction and identification of postpartum hemorrhage, and further improve the quantitative assessment of postpartum blood loss.

Evaluation During Postpartum Hemorrhage

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.

Optimizing systems to manage postpartum hemorrhage

Systems to optimize the management of postpartum hemorrhage must ensure timely diagnosis, rapid hemodynamic and hemostatic resuscitation, and prompt interventions to control the source of bleeding. None of these objectives can be effectively completed by a single clinician, and the management of postpartum hemorrhage requires a carefully coordinated interprofessional team. This article reviews systems designed to standardize hemorrhage diagnosis and response.

Guideline No. 431: Postpartum Hemorrhage and Hemorrhagic Shock

OBJECTIVE

This guideline aims to provide evidence for prevention, recognition, and treatment of postpartum hemorrhage including severe hemorrhage leading to hemorrhagic shock.

TARGET POPULATION

All pregnant patients.

BENEFITS, HARMS, AND COSTS

Appropriate recognition and treatment of postpartum hemorrhage can prevent serious morbidity while reducing costs to the health care system by minimizing more costly interventions and length of hospital stays.

EVIDENCE

Medical literature, PubMed, ClinicalTrials.gov, the Cochrane Database, and grey literature were searched for articles, published between 2012 and 2021, on postpartum hemorrhage, uterotonics, obstetrical hemorrhage, and massive hemorrhage protocols.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All members of the health care team who care for labouring or postpartum women, including, but not restricted to, nurses, midwives, family physicians, obstetricians, and anesthesiologists.

RECOMMENDATIONS

Evaluating the quality of care for postpartum hemorrhage with a new quantitative tool: a population-based study

To develop a new tool to assess the global quality of care for post-partum hemorrhage (PPH)-the leading preventable cause of maternal mortality worldwide-and to identify characteristics of maternity units associated with inadequate PPH management. This is a secondary analysis of the EPIMOMS population-based study conducted in 2012-2013 in 119 french maternity units (182,309 women who gave birth). We included women with severe PPH. We first developed a score to quantify the quality of care for PPH. Then, we identified characteristics of the maternity units associated with "inadequate care" defined by a score below the 25th percentile, with multi-level logistic regression adjusted for individual characteristics. The score combined 8 key components of care and took into account delivery mode and PPH cause. For PPH after vaginal delivery, the risk of inadequate care was increased in low versus high-volume maternity units (< 1000 deliveries/year: aOR-2.20 [1.12-4.32], [1000-2000 [deliveries/year: aOR-1.90 [1.02-3.56] compared to ≥ 3500 deliveries/year), in private versus public units (aOR-1.72 [1.00-2.97]), and in low versus high-level of care units (aOR-2.04 [1.24-3.35]). For PPH after cesarean, the only characteristic associated with an increased risk of inadequate care was the absence of 24/24-onsite anesthesiologist (aOR-4.34 [1.41-13.31]). These results indicate where opportunities for improvement are the greatest.

Hospital-level variation in rates of postpartum hemorrhage in California

BACKGROUND

To examine the extent of hospital-level variation in risk-adjusted rates of postpartum hemorrhage (PPH).

STUDY DESIGN AND METHODS

We performed a cross-sectional study examining live births in 257 California hospitals between 2011 and 2015 using linked birth certificate and maternal discharge data. PPH was measured using International Classification of Diseases Codes version 9. Mixed-effects logistic regression models were used to examine the presence and extent of hospital-level variation in PPH before and after adjustment for patient-level risk factors and select hospital characteristics (teaching status and annual delivery volume). Risk-adjusted rates of PPH were estimated for each hospital. The extent of hospital variation was evaluated using the median odds ratio (MOR) and intraclass correlation coefficient (ICC).

RESULTS

Our study cohort comprised 1,904,479 women who had a live birth delivery hospitalization at 247 hospitals. The median, lowest, and highest hospital-specific rates of PPH were 3.48%, 0.54%, and 12.0%, respectively. Similar rates were observed after adjustment for patient and hospital factors (3.44%, 0.60%, and 11.48%). After adjustment, the proportion of the total variation in PPH rates attributable to the hospital was low, with a MOR of 2.02 (95% confidence interval [CI]: 1.89-2.15) and ICC of 14.3% (95% CI: 11.9%-16.3%).

DISCUSSION

Wide variability exists in the rate of PPH across hospitals in California, not attributable to patient factors, hospital teaching status, and hospital annual delivery volume. Determining whether differences in hospital quality of care explain the unaccounted-for variation in hospital-level PPH rates should be a public health priority.

Prevention of Failure to Rescue in Obstetric Patients: A Realist Review

BACKGROUND

At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue.

AIMS

To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events.

METHODS

A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety.

RESULTS

Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork.

LINKING EVIDENCE TO ACTION

Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.

Goals for Collaborative Management of Obstetric Hemorrhage

Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.

Perinatal Quality and Equity-Indicators That Address Disparities

There is tremendous attention in maternal and neonatal disparities, particularly disparities of race and ethnicity and subsequent outcomes that continue despite calls to action. The literature has offered potential opportunities for exploring data related to racial and ethnic disparities, including the utilization of a race and ethnicity reporting dashboard. This article reviews definitions of perinatal quality and disparity and provides insight into the development of a nationally targeted race and ethnicity dashboard. This quarterly dashboard provides hospitals with specific key metric outcomes through the lens of race and ethnicity, provides a national benchmark for comparison, and creates a data platform for team exploration and comprehensive review of findings. An overview of the development of the dashboard is provided, and the selection of key maternal and neonatal metrics is reviewed. In addition, recommendations for data science strategic planning and nursing's role in metric development, analysis, and utilization are offered and key steps in accelerating disparity data into everyday clinical care are discussed.