The Toolkit: Improving Health Care Response to Obstetric Hemorrhage

A new toolkit developed by the California Maternal Quality Care Collaborative (CMQCC) is making an impact on one of the biggest contributors to maternal morbidity and mortality — obstetric hemorrhage. 
The toolkit, titled, Improving Health Care Response to Obstetric Hemorrhage, was created by a statewide task force of doctors, midwives, nurses, researchers and healthcare providers in response to alarming trends in post partum hemorrhage (PPH). It addresses a pervasive lack of up-to-date, effective guidelines and techniques for identifying and treating the leading cause of postpartum death.

Unpacking the toolkit requires a specific technical and medical knowledge base, but essentially, it’s a comprehensive, how-to guide for all healthcare providers and hospital departments whose participation is required to save a bleeding mother’s life. It provides a range of articles on what to do in cases of PPH from the most basic intervention — identifying the hemorrhaging patient — to advanced challenges like, what to do for women who decline blood transfusions. It contains care guidelines, checklists, flowcharts and step-by-step guides to assist hospitals leaders in creating and implementing hospital wide, coordinated teams.

CMQCC’s toolkit also includes the most recent statistics, which confirm nationwide increases in PPH over approximately 10-year periods: 26% increase between 1994 and 2006 and 27.5% increase between 1995 and 2004. Concurrently, blood transfusions increased 92% during delivery hospitalizations nationwide between 1997 and 2005. That leads us to what we consider the two most important questions related to PPH:

  • Why are so many mothers hemorrhaging after birth?
  • Are we saving more mothers lives during hemorrhages?

We asked Hemorrhage Task Force co-chairs, Audrey Lyndon PhD, RNC, CNS at the University of California, San Francisco and David Lagrew, MD a maternal-fetal medicine specialist at Saddleback Memorial Hospital to address these questions. Lyndon says, “We’re definitely seeing an increase in hemorrhage cases but studies aren’t clear about why. It’s important to remember even though we’re seeing more of it, hemorrhage is still rare and death from hemorrhage is even more rare. Other complications are more common. In fact, serious complications from hemorrhage are 50 times more common than death.”

And that’s where the toolkit comes in. Lyndon says, “The taskforce’s goal is to identify hemorrhage cases earlier, do a better job treating them and dramatically reduce the number of women suffering complications like hysterectomy, blood clotting problems, respiratory problems, damage to vital organs and long ICU stays. Birth is supposed to be a normal physiologic process in most cases and we know that PPH is overwhelmingly preventable.” Lyndon says that with aggressive and coordinated intervention, many complications can be avoided.

Lagrew thinks there’s strong clinical and anecdotal evidence as to why more women are experiencing PPH. He says, “We’re definitely seeing more women experiencing massive bleeds and we know, at least anecdotally, that along with other issues like obesity and hypertension, it’s related to many of the interventions we’re now working hard to reduce — excessive use of inductions and C-sections.” Lagrew explained that uterine atony (when the uterus is unable to contract and reduce bleeding after deliver), can cause PPH. Additionally, Lagrew says, “PPH is caused by placental issues related to C-section scars including placenta acreta and placenta previa, and the risks for those conditions increase with every subsequent pregnancy a woman has.”

Lagrew says providers recognized an urgent need to do something about PPH back in 2008/2009. He says, “We had all these women going to the ICU with massive bleeds. We were pouring in countless units of blood and seeing more mothers who should have had normal births suffering serious complications and even death.” That’s when the taskforce introduced their first hemorrhage toolkit and Lagrew says, “Since then, we’ve seen quite a turnaround. We’re still seeing too many cases of hemorrhage, but now, we’re seeing far fewer mothers who suffer terrible outcomes.” He and Lyndon credit changes made to the new toolkit for making instructions more straightforward for all hospital units involved– from the operating room to the blood bank to hospital administration to every person involved in preventing and treating PPH.

The state of California has made the new Hemorrhage toolkit available for free download so that every hospital in the country can access it. Dr. Lagrew says, “We released this on March 24 and so far we’ve seen more than 1000 downloads. I’m confident this is going to make a huge difference to women all over the country.” 

To download a copy of the toolkit, click here.

*Photo by Josh Estey at Bumi Sehat, Bali, Indonesia.

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