Investigation of an increase in postpartum hemorrhage in Canada

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
BJOG An International Journal of Obstetrics & Gynaecology (Impact Factor: 3.86). 05/2007; 114(6):751 - 759. DOI: 10.1111/j.1471-0528.2007.01316.x

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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    • "Firstly, although low, the risk clearly exists, leaving midwives and obstetricians knowing that perinatal death will occur at some point, but not knowing which woman will be affected. Secondly, induction of labour itself has been associated with increased risk of caesarean section and haemorrhage (Joseph et al., 2007; Grivell et al., 2011; Rossen et al., 2011; Burgos et al., 2012), and there is evidence that it is associated with longer, more painful labours and reduced satisfaction for women compared to spontaneous labour (Shetty et al., 2005). "
    Midwifery 07/2012; 28(4):352-5. DOI:10.1016/j.midw.2012.06.009 · 1.71 Impact Factor
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    • "Different countries report variations in postpartum haemorrhage rates, however there appears to be an increasing trend in the postpartum haemorrhage rate (Lu et al., 2005; Cameron et al., 2006; Joseph et al., 2007). When providing care during the third stage of labour there are two widely accepted options or care pathways provided for women although these processes are managed in different ways around the world (Bais et al., 2004; NZCOM, 2006; NICE, 2007; Winter et al., 2007; Fahy, 2009). "
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    ABSTRACT: BACKGROUND: during the third stage of labour there are two approaches for care provision - active management or physiological (expectant) care. The aim of this research was to describe, analyse and compare the midwifery care pathway and outcomes provided to a selected cohort of New Zealand women during the third stage of labour between the years 2004 and 2008. These women received continuity of care from a midwife Lead Maternity Carer and gave birth in a variety of birth settings (home, primary, secondary and tertiary maternity units). METHODS: retrospective aggregated clinical information was extracted from the New Zealand College of Midwives research database. Factors such as type of third stage labour care provided; estimated blood loss; rate of treatment (separate to prophylaxis) with a uterotonic; and placental condition were compared amongst women who had a spontaneous onset of labour and no further assistance during the labour and birth. The results were adjusted for age, ethnicity, parity, place of birth, length of labour and weight of the baby. FINDINGS: the rates of physiological third stage care (expectant) and active management within the cohort were similar (48.1% vs. 51.9%). Women who had active management had a higher risk of a blood loss of more than 500mL, the risk was 2.761 when a woman was actively managed (95% CI: 2.441-3.122) when compared to physiological management. Women giving birth at home and in a primary unit were more likely to have physiological management. A longer labour and higher parity increased the odds of having active management. Manual removal of the placenta was more likely with active management (0.7% active management - 0.2% physiological p<0.0001). For women who were given a uterotonic drug as a treatment rather than prophylaxis a postpartum haemorrhage of more than 500mL was twice as likely in the actively managed group compared to the physiological managed group (6.9% vs. 3.7%, RR 0.54, CI: 0.5, 0.6). CONCLUSIONS: the use of physiological care during the third stage of labour should be considered and supported for women who are healthy and have had a spontaneous labour and birth regardless of birth place setting. Further research should determine whether the use of a uterotonic as a treatment in the first instance may be more effective than as a treatment following initial exposure prophylactically.
    Midwifery 12/2011; 29(1). DOI:10.1016/j.midw.2011.11.003 · 1.71 Impact Factor
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    ABSTRACT: This paper proposes a traffic control scheme to support real-time traffic over the IEEE 802.11 wireless LAN systems that do not have QoS support functionality. The main features of the proposed scheme are bandwidth control for each flow and load balancing between access points by using information of data link, network and transport layers. The proposed scheme was implemented on a Linux machine which is called traffic controller. The traffic controller connects a high capacity backbone network and an access network and the access points of wireless LAN are attached to the access network. We evaluated the performance of the proposed traffic controller and confirmed that the communication quality of real-time traffic would be greatly improved by using this technique.
    Wireless Communication Systems, 2004. 1st International Symposium on; 10/2004
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