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Audit on management of massive PPH

Wednesday, 28 September, 2011 - 13:30
Stream 1 - Board 3

Audit on Management of Massive Postpartum Haemorrhage Miss S Banu Miss S Kalla   Introduction •          Postpartum haemorrhage (PPH) is an obstetrical emergency that can follow vaginal or caesarean delivery. It is a leading cause of admission to intensive care unit and the most preventable cause of maternal mortality and severe maternal morbidity.   •          Globally, PPH accounts for 11% of all maternal deaths.      WHO estimates 1% case fatality rate for the 14 million annual cases of PPH.   •          Massive PPH refers to the loss of 30-40%(generally >2L) of the patient’s blood volume.   •          In the UK, the incidence of massive PPH occurs in 3.7 per 1000 maternities ( 95% CI 3.4 - 4.0), but the mortality has fallen to 0.39/100,000 maternities (95% CI 0.17-0.70)   Consequences of massive PPH     - sudden and rapid cardiovascular de-compensation and     coagulopathy     - iatrogenic complications of fluid replacement and multiple blood     transfusion (pulmonary oedema, transfusion reactions and ARDS)     - surgical complications (intra-peritoneal bleeding,     haematoma formation, wound complication)     - postnatal depression   Background   In 2007, total no of deliveries in HWPH –  5371 No of cases of postpartum haemorrhage (>500ml) – 651(12.1%) No of cases of postpartum haemorrhage (>2000ml) - 29 (0.54%)                                               In 2008, total no of deliveries in HWPH –  5312 No of cases of postpartum haemorrhage (>500ml) – 807 (15.2%) No of cases of postpartum haemorrhage (>2000ml)- 20 (0.38%)                                                                                (In 2006, no. of del -5119    no. of cases of pph >500ml – 632(12.3%)    no. of cases of pph>2000ml –23(0.45%)   Purpose AIM      To evaluate whether management of massive post-partum haemorrhage (pph) is in compliance with the ‘best practice’     (HWPH labour-ward guideline based on RCOG Green-top guideline)   OBJECTIVES To undertake a retrospective audit of patients who underwent massive pph in 2007 and 2008   To identify areas of good practice along with areas where improvement may be required   To generate recommendations from the audit findings and       formulate an action-plan based on these recommendations   Standard ■ ‘Massive PPH Management Protocol’ in      HWPH obstetric clinical guideline-    (Following presentation and discussion of ‘Massive PPH audit for 2007’ in      March 2008 at Multi-disciplinary Audit Meeting, the protocol for     ‘Management of Massive PPH’ was evaluated and updated)   Methodology Audit Period: January 2007 – December 2008 (24 months)     ■ ‘Quick Query’ menu from the drop-down list was used to extract     cases from CMiS (Ciconia Maternity Information System)   ■ Total no of cases – 49 (29+20)   ■ In 2007, notes available for  data collection – (n=23)         (6 notes were booked out to risk management and other          specialities)   ■ In 2008, all the notes were available for data collection – (n=20) ■ Exclusion criteria – PPH <2000ml                                   secondary PPH                      ■ An audit proforma  was designed and used as a tool for data    collection   ■ A retrospective case-note review was undertaken     ■ Data were entered into a database and analysed using Microsoft    Access by the Clinical Audit Team   Conclusion •          PPH is more prevalent in older women (78%07, 60%08 ), parous women (63%07, 70%08), and in term pregnancies (63%07, 85%08).   •          Less common in White British women (40%08).   •          Low placenta, caesarean section, uterine fibroid, prolonged rupture of membranes remain significant risk factors.   •          >50% of women (57%07, 52%08)  did not have any risk factors during labour.   •          Majority of women (74%07, 55%08) delivered in theatre and significant number by caesarean section (73%07, 50%08).   •          Oxytocics  were used more effectively in 2008 to control haemorrhage and less women required invasive procedures. ■ In 2008, fewer women required ITU admissions (30%07, 20%08).   ■ In 2008, more women had PPH due to genital tract trauma   (30%07, 55%08), and retained placental tissue (4%07, 25%08).   ■ Majority of women (59%07, 73%08 ) required up to 5 units of blood.   ■ Majority of women (78%07, 90%08) had EBL of 4 litres.   ■ Multidisciplinary team-working  improved in 2008.   ■ Documentation on ‘Massive PPH Proforma’ in labour-notes improved    record-keeping significantly in 2008.     Recommendations Raising awareness of the occurrence of massive pph is needed and all clinical staff must learn from critical events and SUIs (serious untoward incidents) occuring in the unit.   Women must be advised that caesarean section is not a risk-free procedure and can cause problems in current and future pregnancies.   ‘Massive PPH protocol’ should be followed effectively.   Oxytocics should be used promptly and appropriately.   Senior staff must be involved as early as possible.   ■  Pre-designed proforma can be used to aid documentation     contemporaneously and for prospective audit.     ■  Risk-events should be anticipated antenatally or in early labour and     a clear plan of management involving multi-disciplinary team should     be laid out to prevent and manage massive pph.     ■  Lean thinking, good communication, collective effort and skilled     teamwork may reduce morbidity and mortality due to the     phenomenon of ‘too little too late’ as quoted in CEMACE.   Action Plan ■  Regular training of staff in the identification and management of      haemorrhage by attending multi-disciplinary programme e.g. practice development workshop/ ALSO course for midwives, ALSO/ MOET/PROMT courses for obstetricians.     ■  Modified early obstetric warning system (MEOWS) chart should be used to help in timely recognition, treatment and referral of women who are developing critical illness.     ■  Regular emergency ‘PPH drills’ should be organised in the labour ward to improve and maintain skill of staff. ■  The management of women with placenta percreta requires careful multidisciplinary planning in the antenatal period and consultant-led multi-disciplinary team must be involved at delivery.   ■   Women who have had a previous CS must have their placental site determined. In doubtful cases, MRI can be used along with US scanning to identify placenta accreta or percreta.   ■   Reviews of cases  and regular feedback from risk-management team with learning points must be welcomed.   ■   A blame-free culture should be promoted.   Future ■   A large multi-centric double-blinded placebo-controlled  RCT is required to assess safety and efficacy of pharmacological, surgical and radiological interventions used for the treatment of primary pph   ■   EUPHRATES – European Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System   ■   Follow-up of the ‘Study Group Meeting’ at the RCOG on maternal mortality towards achieving  the Millenium Development Goals: Management of third stage of labour and postpartum haemorrhage   ■   Further research in the use of uterine tamponade baloon and/or      uterine compression sutures            - efficacy, morbidity and outcome in subsequent pregnancies ■  Further research in the use of anti-shock garment, logethotopulos pack for resuscitation and haemostasis for uncontrollable pph   ■  Local policy         - use of recombinant activated factor VII in obstetric haemorrhage         - use of uterine artery embolisation in elective as well as in           emergency cases   ■  Local audit         - efficacy of intrauterine baloon +/- uterine compression sutures   ■  Re-visit and update the ‘Massive PPH Guideline’ and re-audit  

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