Variation in severe postpartum hemorrhage management: A national vignette-based study.

Anne Rousseau,Elodie Perrodeau,Philippe Ravaud,Patrick Rozenberg,Jane B Ford

doi:10.1371/journal.pone.0209074

Abstract

ObjectivesTo assess variations in management of severe postpartum hemorrhage: 1) between obstetricians in the same situation 2) by the same obstetrician in different situations.Study designA link to a vignette-based survey was emailed to obstetricians of 215 maternity units; the questionnaire asked them to report how they would manage the PPH described in 2 previously validated case-vignettes of different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH. They were constructed in 3 successive steps and included multiple-choice questions proposing several types of clinical practice options at each step. Variations in PPH were assessed in a descriptive analysis; agreement about management and its timing between vignette 1 and vignette 2 was assessed with the Kappa coefficient.ResultsAnalysis of complete responses from 119 (43.4%) obstetricians from 53 (24.6%) maternity units showed delayed or inadequate management in both vignettes. While 82.3% and 83.2% of obstetricians (in vignettes 1 and 2, respectively) would administer oxytocin 15 minutes after PPH diagnosis, only 52.9% and 29.4% would alert other team members. Management by obstetricians of the two vignette situations was inconsistent in terms of choice of treatment and timing of almost all treatments.ConclusionCase vignettes demonstrated inadequate management as well as variations in management between obstetricians and in different PPH situations. Protocols or procedures are necessary in all maternity units to reduce the variations in practices that may explain a part of the delay in management that leads to PPH-related maternal mortality and morbidity.

Highlights

IntroductionThe initial treatment of severe PPH involves medical management, uterine massage, and uterotonic drugs such as oxytocin and prostaglandin
Severe postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide [1,2,3,4] and occurs in around 1% to 2% of deliveries [3,4].The initial treatment of severe PPH involves medical management, uterine massage, and uterotonic drugs such as oxytocin and prostaglandin
Protocols or procedures are necessary in all maternity units to reduce the variations in practices that may explain a part of the delay in management that leads to PPH-related maternal mortality and morbidity

Summary

Introduction

The initial treatment of severe PPH involves medical management, uterine massage, and uterotonic drugs such as oxytocin and prostaglandin When these first-line treatments fail to control a hemorrhage, intrauterine balloon and/or invasive therapy for postpartum hemorrhage is usually recommended, as shown by similar national guidelines from several countries [5,6,7,8]. Intrauterine tamponade is considered the leading second-line therapy, for it avoids the need for further interventional surgery in most cases [9,10] Surgical procedures, such as uterine compressive sutures, vascular ligation, and arterial embolization, can be attempted to avoid hysterectomy and have similar effectiveness rates—around 60–80% [11,12,13,14,15,16,17,18]. Reports from confidential enquiries have shown that as many as 67% of the deaths in the United States and 85% of those in France are avoidable, resulting as they have from either delayed or inadequate treatment [21,22,23]

Objectives

Methods

Discussion

Conclusion