Dataset Information

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

ABSTRACT: OBJECTIVES:To assess variations in management of severe postpartum hemorrhage: 1) between obstetricians in the same situation 2) by the same obstetrician in different situations. STUDY DESIGN:A 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. RESULTS:Analysis 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. CONCLUSION:Case 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.

SUBMITTER: Rousseau A

PROVIDER: S-EPMC6292622 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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

Rousseau Anne A Rozenberg Patrick P Perrodeau Elodie E Ravaud Philippe P

PloS one 20181213 12

<h4>Objectives</h4>To assess variations in management of severe postpartum hemorrhage: 1) between obstetricians in the same situation 2) by the same obstetrician in different situations.<h4>Study design</h4>A 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 ...[more]

PMID: 30543683

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Project description:BackgroundPostpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction.MethodsA nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline.ResultsIn 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3-3.3], Creole aOR 1.8[95%CI 1.1-3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7-7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7-3.4]), cesarean section (aOR 3.9[95%CI 2.9-5.3]), stillbirth (aOR 6.4 [95%CI 3.4-12.2]), preterm birth (aOR 2.1[95%CI 1.3-3.2]), and macrosomia (aOR 2.8 [95%CI 1.5-5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]).ConclusionsPPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.

Project description:Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype.To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ?1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models.For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI], 4.9-99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI, 4.2-15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI, 3.4-11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI, 1.7-17.1), multiple pregnancies (aOR = 3.2; 95% CI, 1.7-6.3), and a predelivery hemoglobin ? 9.9 g/dL (aOR = 3.0; 95% CI, 1.3-6.9; reference group = predelivery hemoglobin ? 11 g/dL).Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.

Dataset Information

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

Publications

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

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