Reduction in Massive Postpartum Haemorrhage and Red Blood Cell Transfusion During a National Quality Improvement Project, Obstetric Bleeding Strategy for Wales, OBS Cymru: An Observational Study

Abstract

Background: Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite comprehensive 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 reduced moderate bleeds (1000 mL) progressing to massive haemorrhage (2500 mL or more) and the need for red blood cell transfusion. Methods: A PPH care bundle was introduced into all 12 obstetric units in Wales and included all women giving birth in 2017 and 2018 (n=61094). The care bundle consisting of: 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 collected at each obstetric unit and submitted to a national database. The main outcome measures were incidence of massive PPH, defined as bleeds of 2500 mL or more and red blood cell transfusion. Results: There was good uptake of the intervention with use of quantitative blood loss measurement increasing to 98.1% of all maternities. Massive haemorrhage decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P=0.011). Fewer women progressed from moderate bleeds to massive haemorrhage 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 blood cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P=0.015). Red blood 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. Conclusions: The 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.