Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan

Abstract

BackgroundMassive postpartum hemorrhage is a life threatening obstetric emergency. In order to prevent the complications associated with this condition, an organized and step-wise management protocol should be immediately initiated.MethodsAn evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment.ResultsDuring 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500 - 9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases.ConclusionThis report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order to further ameliorate patient outcomes in emergency obstetrical practice. More audits like the one we performed are important to recognize and rectify any deficiencies in obstetrical practice in developing countries. Dissemination of the same is pivotal to enable an open discourse on the improvement of existing obstetrical strategies.

The impact of the implementation of the postpartum haemorrhage management guidelines at the first regional perinatal centre in Southern Kazakhstan

“…This outcome corresponds to the findings by Shields et al [10], but contradicts the results of studies performed in France, Pakistan or New York [8, 12, 15]. Some studies associate this increase with the growing caesarean section rate and its impact on future pregnancies [12, 15]. Although the number of women with a previous caesarean section was higher in the post-intervention period, this did not have any impact on the PPH or severe PPH rate or on the increase in the number of hysterectomies in our study.…”

Clinical study of post partum haemorrhage from a teaching hospital in Maharashtra, India

“…7,10 While it varies between 0.5-9.5% in different studies done in Pakistan. [9][10][11][12] Amongst these majority of the cases were due to atonicity i.e. 1147 cases were of atonic PPH accounting to 86% of the total cases.…”

“…These findings were evident by the studies conducted in America and Pakistan. 9,10,13,14 ( Table 1). Among these majority of the cases were treated with uterotonics alone i.e.…”

“…7 Anticipation of risk factors and active management of the third stage of labor, including the prophylactic application of uterotonics, are Many national and international studies show that uterine atony is the commonest cause of PPH followed by trauma to genital tract, adherent placenta, uterine angle extension and retained placenta. 9 Generally, PPH requires early recognition of its cause, immediate control of the bleeding source by medical, mechanical, invasive-nonsurgical and surgical procedures, rapid stabilization of the mother's condition, and a multidisciplinary approach. 8 Second-line treatment of PPH remains challenging, since there is a lack of univocal recommendations from current guidelines and sufficient data from randomized controlled trials.…”

“Post partum hemorrhage: causes and management”

“…It is axiomatic that Post partum hemorrhage occur unpredictably and no patient is immune from it, it simply states that it is an equal opportunity killer. Blood loss of 500 ml following a delivery is generally considered as physiologically normal and anything above this limit is known as Post partum hemorrhage [3]. For vaginal delivery blood loss of above 500 ml and in C-section blood loss of above 1500 ml.…”