Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort

Abstract

Background: Visual estimation of blood loss following delivery often under-reports actual bleed volume. To improve accuracy, quantitative blood loss measurement was introduced for all births in the 12 hospitals providing maternity care in Wales. This intervention was incorporated into a quality improvement programme (Obstetric Bleeding Strategy for Wales, OBS Cymru). We report the incidence of postpartum haemorrhage in Wales over a 1year period using quantitative measurement. Methods: This prospective, consecutive cohort included all 31,341 women giving birth in Wales in 2017. Standardised training was cascaded to maternity staff in all 12 hospitals in Wales. The training comprised mockscenarios, a video and team drills. Uptake of quantitative blood loss measurement was audited at each centre. Data on postpartum haemorrhage of > 1000 mL were collected and analysed according to mode of delivery. Data on blood loss for all maternities was from the NHS Wales Informatics Service. Results: Biannual audit data demonstrated an increase in quantitative measurement from 52.1 to 87.8% (P < 0.001). The incidence (95% confidence intervals, CI) of postpartum haemorrhage of > 1000 mL, > 1500 mL and > 2000 mL was 8.6% (8.3 to 8.9), 3.3% (3.1 to 3.5) and 1.3% (1.2 to 1.4), respectively compared to 5%, 2% and 0.8% in the year before OBS Cymru. The incidence (95% CI) of bleeds of > 1000 mL was similar across the 12 hospitals despite widely varied size, staffing levels and case mix, median (25th to 75th centile) 8.6% (7.8-9.6). The incidence of PPH varied with mode of delivery and was mean (95% CI) 4.9% (4.6-5.2) for unassisted vaginal deliveries, 18.4 (17.1-19.8) for instrumental vaginal deliveries, 8.5 (7.7-9.4) for elective caesarean section and 19.8 (18.6-21.0) for non-elective caesarean sections. Conclusions: Quantitative measurement of blood loss is feasible in all hospitals providing maternity care and is associated with detection of higher rates of postpartum haemorrhage. These results have implications for the definition of abnormal blood loss after childbirth and for management and research of postpartum haemorrhage.

Intramuscular oxytocin versus Syntometrine® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double‐blinded clinical trial of effectiveness, side effects and quality of life

“…It is possible that our weighed blood loss might be increased by inadvertent liquor contamination. It is also possible that previously accepted incidence of 5–10% may underestimate the true burden of PPH, particularly now that weighed estimation is more common in routine clinical practice; the incidence of PPH ≥500 ml for all maternities in Wales in 2017 was 34.0%, 26 and was 57.7% after vaginal birth in one Chinese centre in 2018 27 …”

“…It is possible that our weighed blood loss might be increased by inadvertent liquor contamination. It is also possible that previously accepted incidence of 5-10% may underestimate the true burden of PPH, particularly now that weighed estimation is more common in routine clinical practice; the incidence of PPH ≥500 ml for all maternities in Wales in 2017 was 34.0%, 26 and was 57.7% after vaginal birth in one Chinese centre in 2018. 27 There could have been under-reporting in other studies: despite a three-fold difference in PPH rate between this study and CHAMPION, 7 the rate of blood transfusion in IMox was only twice that of the CHAMPION study (mean 2.9% versus 1.45%).…”

A comprehensive digital phenotype for postpartum hemorrhage

“…Though mortality rates due to PPH have remained stable over the past 15 years[7,8], the prevalence has increased considerably[9], as well as the need for critical interventions to treat severe cases[1,9–12]. Even in developed countries where rates are significantly lower than in developing countries[13], prevalence estimates range from 3% to 9% depending on the definition[7,11,14–17]. There is a critical need for optimization of preventative care (e.g., earlier identification of risk factors and prompt recognition of PPH) and treatment modalities to reduce morbidity and mortality[18].…”

“…However, blood loss is still most commonly estimated visually and this measure is central to diagnosis and initiation of treatment[4,6], as well as the primary metric used retrospectively for hospital quality outcomes and research aimed at improving prevention and treatment of PPH[15]. Overreliance on estimated blood loss (EBL) alone has contributed to underestimation of hemorrhage[17,19,20,22,23,25]; this is a key area for improvement in PPH prevention efforts.…”

Reduction in Massive Postpartum Haemorrhage and Red Blood Cell Transfusion During a National Quality Improvement Project, Obstetric Bleeding Strategy for Wales, OBS Cymru: An Observational Study

“…Bleeding after childbirth (postpartum haemorrhage, PPH) is the leading cause of maternal death worldwide. 1 In resource rich countries PPH causes 80% of severe maternal morbidity and its incidence is increasing in many regions, 2 3 including Wales, 4 despite international guidance. [5][6][7] In the UK PPH is described as moderate at 1000 mL blood loss and severe at 2000 mL.…”