Abstract
BackgroundPostpartum 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.MethodsA 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.ResultsUptake 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.ConclusionsThe 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.
Highlights
Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines
Massive PPH decreased by 1.10 per 1000 maternities per year (P = 0.011)
A care bundle for the management of PPH, that included point-of-care tests of coagulation to guide the treatment of coagulopathy, was introduced as a national quality improvement project involving more than 30,000 maternities annually
Summary
Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. Bleeding after childbirth (postpartum haemorrhage, PPH) is the leading cause of maternal death worldwide [1]. In resource rich countries PPH causes 80% of severe maternal morbidity and its incidence is increasing in many regions [2, 3], including Wales [4], despite international guidance [5,6,7]. In the UK PPH is described as moderate at 1000 mL blood loss and severe at 2000 mL [6]. Massive PPH is defined as > 2500 mL and, in resource rich countries, is associated with a hysterectomy rate of 6% and intensive care admission in 11.8% of cases [3]. A recent confidential enquiry identified deficiencies in care, compared to guidelines, in 90% of cases [11]
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