Leçons et impact de deux audits sur les hémorragies du postpartum dans les 24 maternités du réseau « Sécurité Naissance – Naître Ensemble » des Pays-de-la-Loire

Abstract

The aim of the study is to assess the compliance rate of treatment of postpartum hemorrhage (PPH) according to guidelines developed by the CNGOF within our network by a first audit, and evaluate the impact of this first audit by conducting a second audit. An initial audit of resources and management of postpartum hemorrhage (PPH) was conducted in 2006-2008 in 24 maternity hospitals of the Pays-de-la-Loire. The audit had identified six areas for improvement. A second audit was implemented in 2009-2010 to evaluate the actions of prevention and measure changes in the management of PPH. Two interns have distributed the 24 maternity homes and moved in each hospital to see 10 cases of vaginal delivery (VD) (section "Prevention"), and the last cases of PPH following a VD. The results are in compliance rate compared to the repository of the HAS in 2004. The first audit was conducted on 101 PPH in total. It has allowed us to propose corrective actions to the 24 maternity hospitals: leaf specific monitoring, reporting amounts of blood loss, transfusion on these clinical criteria without waiting for the blood cell counts, indicating more frequent and rapid sulprostone, set for maternity hospitals without surgical skill an agreement with a visceral surgery department, and avoid maternal transfers for PPH. For the second audit, the compliance rate of the preventive aspect was 73% (95: 71-75%) of 239 cases of BA with variations according to maternity from 48 to 93%. Compliance rates according to the criteria were: 99% obstetric consultations, 98% for anesthesia, 92% for hemoglobin, 77% for the group card available in the record, 89% agglutinins, 35% for the notification of the installation of bag, 36% for the notification of the amount of blood lost, 69% for the supervisor within two hours, and 64% for the directed delivery. For component "Support", the overall compliance rate was 81% (95: 79-83%) of 118 PPH AVB, and 85% in the 71 uterine atonies in 21 pregnancies (3 had no HPP during the period) with variations according to maternity from 51 to 93%. Conformities compared with the first audit were: improvement of time noted PPH (66 and 85%), initiation of a leaf-specific monitoring (0% and 87%), equivalence of appeals responders (86 and 88%), improving the amount of blood noted (51 and 67%), equivalent to the practice of evacuation of retained placenta (88 and 91%), decreased prescription of antibiotics (83 and 71%). For only uterine atony (n=71), there was a slight improvement in the prescription of sulprostone within 30 minutes (53 and 58%), and improved decision within 2 hours (47 and 69%). Finally, there was no connection rates in the two components (r=0.32, p=0.15). Criteria associated with good compliance were calculated. There is a general improvement in prevention and care, with critical points and persistent disparities between pregnancies. In the aftermath of the completion of the audit, the overall results were sent to officials with the rank of each maternity, inviting each responsible to analyze weaknesses and implement corrective actions. Further action is planned within the network.