Investigation of an increase in postpartum haemorrhage in Canada
ABSTRACT Objective To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada.Design Retrospective cohort study.Setting Canada between 1991 and 2004.Population All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia).Methods Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models.Main outcome measures Postpartum haemorrhage, postpartum haemorrhage with hysterectomy, postpartum haemorrhage with blood transfusion and postpartum haemorrhage by subtype.Results Rates of postpartum haemorrhage increased from 4.1% in 1991 to 5.1% in 2004 (23% increase, 95% CI 20–26%), while rates of postpartum haemorrhage with hysterectomy increased from 24.0 in 1991 to 41.7 per 100 000 deliveries in 2004 (73% increase, 95% CI 27–137%). These increases were because of an increase in atonic postpartum haemorrhage, from 29.4 per 1000 deliveries in 1991 to 39.5 per 1000 deliveries in 2004 (34% increase, 95% CI 31–38%). Adjustment for temporal changes in risk factors did not explain the increase in atonic postpartum haemorrhage but attenuated the increase in atonic postpartum haemorrhage with hysterectomy.Conclusions There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.
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ABSTRACT: Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement OBJECTIVE: To use statistical process control charts to describe trends in the prevalence of severe postpartum haemorrhage after vaginal delivery. This assessment was performed 7 years after we initiated a continuous quality improvement programme that began with regular criteria-based audits STUDY DESIGN: Observational descriptive study, in a French maternity unit in the Rhône-Alpes region. Intervention: Quarterly clinical audit meetings to analyse all cases of severe postpartum haemorrhage after vaginal delivery and provide feedback on quality of care with statistical process control tools. Main outcome measures: The primary outcomes were the prevalence of severe PPH after vaginal delivery and its quarterly monitoring with a control chart. The secondary outcomes included the global quality of care for women with severe postpartum haemorrhage, including the performance rate of each recommended procedure. Differences in these variables between 2005 and 2012 were tested. From 2005 to 2012, the prevalence of severe postpartum haemorrhage declined significantly, from 1.2% to 0.6% of vaginal deliveries (p<0.001). Since 2010, the quarterly rate of severe PPH has not exceeded the upper control limits, that is, been out of statistical control. The proportion of cases that were managed consistently with the guidelines increased for all of their main components. Implementation of continuous quality improvement efforts began seven years ago and used, among other tools, statistical process control charts. During this period, the prevalence of severe postpartum haemorrhage after vaginal delivery has been reduced by 50%.European journal of obstetrics, gynecology, and reproductive biology 04/2014; · 1.97 Impact Factor
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ABSTRACT: Little is known of the experience and perceptions of care for survivors of emergency peripartum hysterectomy (EPH), an obstetric event that is increasing in incidence. We sought to explore women's experiences of EPH to make recommendations for care. This qualitative study utilized purposive sampling through an online support group of women who experienced EPH. Eligible participants were at least 18 years old, had their hysterectomy at least 6 months but no more than 3 years before the interview, had a surviving infant associated with the delivery, and did not report suicidal ideation. In-depth, semi-structured telephone interviews were conducted and analyzed using Constant Comparative Analysis. Kappa statistics assessed interrater reliability for two independent coders. Fifteen women participated with a mean age of 32.5 years. Most had a cesarean section, with uterine atony as the most common indication for EPH. Kappa statistics indicated near-perfect interrater agreement between two coders, ranging from .82 to .89. Seven major themes were identified: fear; pain; death and dying; numbness or delay in emotional reaction; bonding with baby; communication; and the need for information. Psychological upset occurred postpartum and was often delayed. A major finding is the need for additional follow-up visits to address the emotional after-effects and to fill in gaps in women's understanding and memory of what had occurred. Understanding women's experiences with EPH can help practitioners address not only women's initial complications but provide needed long-term support.Birth 12/2013; 40(4):256-263. · 2.93 Impact Factor
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ABSTRACT: To quantify reporting errors, measure incidence of postpartum haemorrhage (PPH) and define risk factors for PPH (≥500 ml) and progression to severe PPH (≥1500 ml). Prospective observational study. Two UK maternity services. Women giving birth between 1 August 2008 and 31 July 2009 (n = 10 213). Weighted sampling with sequential adjustment by multivariate analysis. Incidence and risk factors for PPH and progression to severe PPH. Errors in transcribing blood volume were frequent (14%) with evidence of threshold preference and avoidance. The incidences of PPH ≥500, ≥1500 and ≥2500 ml were 33.7% (95% CI 31.2-36.2), 3.9% (95% CI 3.3-4.6) and 0.8% (95% CI 0.6-1.0). New independent risk factors predicting PPH ≥ 500 ml included Black African ethnicity (adjusted odds ratio [aOR] 1.77, 95% CI 1.31-2.39) and assisted conception (aOR 2.93, 95% CI 1.30-6.59). Modelling demonstrated how prepregnancy- and pregnancy-acquired factors may be mediated through intrapartum events, including caesarean section, elective (aOR 24.4, 95% CI 5.53-108.00) or emergency (aOR 40.5, 95% CI 16.30-101.00), and retained placenta (aOR 21.3, 95% CI 8.31-54.7). New risk factors were identified for progression to severe PPH, including index of multiple deprivation (education, skills and training) (aOR 1.75, 95% CI 1.11-2.74), multiparity without caesarean section (aOR 1.65, 95% CI 1.20-2.28) and administration of steroids for fetal reasons (aOR 2.00, 95% CI 1.24-3.22). Sequential, interacting, traditional and new risk factors explain the highest rates of PPH and severe PPH reported to date.BJOG An International Journal of Obstetrics & Gynaecology 02/2014; · 3.76 Impact Factor