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Hospital Harm: Obstetric Hemorrhage

Postpartum hemorrhage is the leading cause of maternal death worldwide, with an estimated mortality rate of 140 000 per year, or one maternal death every four minutes. PPH occurs in five per cent of all deliveries and is responsible for a major part of maternal mortality. The majority of these deaths occur within four hours of delivery, which indicates that they are a consequence of the third stage of labour. Nonfatal PPH results in further interventions, such as uterine exploration, evacuation or surgical procedures. Other implications include: iron deficiency anemia, exposure to blood products, coagulopathy, and organ damage with associated hypotension and shock which has the potential to jeopardize future fertility (Leduc et al. 2018).

Topics
  • Patient safety
  • Hospital harm
Audience

  • Point of care provider

  • Quality or safety improvement lead

  • Policy advisor or analyst

Goal

To prevent obstetrical hemorrhage from the pelvic area, genital tract, or perineum following vaginal delivery and from surgical incision after an instrument-assisted delivery or Caesarean section.

Overview

Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.

Despite the use of uterotonics and active management of third stage of labour to prevent PPH, increases in PPH rates have been reported from high income countries, including Canada, the United States, the United Kingdom and Australia. Rates of severe PPH and of transfusion for treatment also appear to be rising. Rates of postpartum hemorrhage and severe postpartum hemorrhage continued to increase in Canada between 2003 and 2010 [from 3.9 per cent in 2003 to 5.0 per cent in 2010] and occurred in most provinces and territories. The increase could not be explained by maternal, fetal, or obstetric factors. Routine audits of severe postpartum hemorrhage are recommended for ensuring optimal management and patient safety (Mehrabadi et al. 2014).

Primary Postpartum Hemorrhage (PPH) is defined as excessive bleeding that occurs within the first 24 hours after delivery. Traditionally the definition of PPH has been blood loss in excess of 500 mL after vaginal delivery and in excess of 1000 mL after abdominal delivery. For clinical purposes, any blood loss that has the potential to produce hemodynamic instability should be considered PPH. The amount of blood loss required to cause hemodynamic instability will depend on the pre-existing condition of the woman. Hemodynamic compromise is more likely to occur when conditions such as anemia (e.g., iron deficiency, thalassemia) or volume-contracted states (e.g., dehydration, gestational hypertension with proteinuria) (Leduc et al. 2018) are present.

PPH is one of the few obstetric complications with an effective preventive intervention and it is generally assumed that by preventing and treating PPH, most PPH-associated deaths could be avoided (Mathai et al. 2007; WHO 2012). Specifically, 54-93% of maternal deaths due to obstetric hemorrhage may be prevented. Imprecise healthcare provider estimation of actual blood loss during birth and the immediate postpartum period is the leading cause of delayed response to hemorrhage (The American College of Obstetricians and Gynecologists 2019). Blood loss is difficult to estimate and is frequently underestimated when volumes are high and overestimated when volumes are low (The American College of Obstetricians and Gynecologists 2019; Lyndon et al. 2015).

There are several possible reasons for severe bleeding during and after the third stage of labour, often referred to as the four T's:

  • Tone or uterine atony: abnormalities of uterine contraction;

  • Tissue: retained placenta, products of conception;

  • Trauma of the genital tract: lacerations of the cervix, vagina or perineum; uterine rupture; uterine inversion; and

  • Thrombin: abnormalities of coagulation due to pre-existing states such as haemophilia A and von Willebrand's Disease, or acquired in pregnancy such as Immune Thrombocytopenic Purpura (ITP) or Disseminated Intravascular Coagulation (DIC) (Leduc, et al. 2018).

Secondary PPH is defined as excessive vaginal bleeding from 24 hours after delivery, to up to six weeks postpartum. Most cases of secondary PPH are due to retained products of conception, infection, subinvolution of the placental site and inherited coagulation defects such as von Willebrand (The American College of Obstetricians and Gynecologist 2017).

Instrumentation and Caesarean Section: Some obstetrical interventions are found to consistently be associated with higher rates of blood loss at the time of delivery thus predisposing patients to developing PPH. Included interventions are instrumental deliveries, episiotomy and caesarean sections, with emergency caesarean sections associated with higher rates of blood loss. It is important to note that more recent studies suggest that some obstetrical interventions increase the likelihood of PPH in a subsequent pregnancy, and that the recent increase in PPH in developed countries, which cannot seem to be wholly explained by factors related to the current pregnancy and delivery, may be due to more distal contributory factors (Roberts et al. 2009; Briley et al. 2014).

Importance to Patients and Families

By following the recommended strategies for active management of the third stage of labour, a hospital team can reduce the incidence of harm and/or death from obstetrical hemorrhage.

Patient Story

Melissa Price, the patient representative on the hemorrhage task force, had a late postpartum hemorrhage. Melissa ended up with a hysterectomy and about 12 units of blood transfused. While in the Emergency Department, Melissa recalls asking the nurses how they could tell how much blood she was losing – the nurses never weighed the blood, and dumped it from a bed pan into a portable toilet. After Melissa's obstetrician got the bleeding to stop, she was left alone behind a curtain and checked on infrequently. Melissa recalls the feeling sheer panic when the bleeding started up again with 'enormous clots'… "I screamed and I will never forget the look on the nurse's face when she lifted up that blanket. After that, ER staff was running around everywhere. Rushing to call my OB, rushing to get an OR suite, rushing to figure out how to get my insulin pump turned off. I just kept thinking, God give them more time. They need more time to save me." (Lyndon et al. 2015).

Clinical and System Reviews, Incident Analyses

Given the broad range of potential causes of obstetrical hemorrhage, in addition to recommendations listed above, we recommend conducting clinical and system reviews to identify latent causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

  1. Measure and monitor the types and frequency of these occurrences.

  2. Use appropriate analytical methods to understand the contributing factors.

  3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.

  4. Have mechanisms in place to mitigate consequences of harm when it occurs.

Measures

Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:

You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.

Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.

Whenever possible, use measures you are already collecting for other programs.

Try to include both process and outcome measures in your measurement scheme.

Discharge Abstract Database

Success Stories

Grand Rounds: Ob Team Stat: Developing a better L&D rapid response team

The recommended 30 minute "decision to incision" response time to obstetric emergency is not adequate to prevent adverse outcomes in certain scenarios. Improving on the current sequential team activation response to emergency, Allan Bombard, M.D., along with Karyn Almyrde, BSN and Val Catanzarite, MD Phd, developed the "Ob Team Stat" rapid response team. They utilized the Lockheed Martin "Skunk Works" approach to team project development, often employed in the business world. "Ob Team Stat" employs a simultaneous team activation approach to obstetric emergency. The system is activated by any team member, who simultaneously overhead pages and beeps the L&D charge nurse, in-house obstetrician, anesthesiologist, OR surgical team, neonatalogist, and NICU team.

After approval for a new hospital procedure, the team concept was discussed and refined through the Hospital Committees of all the team members and those they would interact with, and then put into operation within a week. Review of six months of data after "Ob Stat Team" introduction revealed the time from team activation to delivery had a mean of 10.9+/- 4.0 minutes, with a range of four to 19 minutes. In a team activation for uterine rupture during a VBAC, delivery was within six minutes and 30 seconds from onset of bradycardia. A different approach to problem solving by a small team, followed by continual monitoring and adaptation of the "Ob Stat Team" dramatically improved response times to obstetric emergencies compared with other institutions (Catanzarite, Almryde, Bombard 2007).

References

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