Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003–05

Abstract

Objective To describe a system for learning from cases of major obstetric haemorrhage.Design Prospective critical incident audit.Setting All consultant-led maternity units in Scotland, between 1 January 2003 and 31 December 2005.Population Women suffering from major obstetric haemorrhage (estimated blood loss ‡2500 ml or transfused ‡5 units of blood or received treatment for coagulopathy during the acute event).Methods Hospital clinical risk management teams reviewed local cases using a standard, national assessment pro forma.Main outcome measures Standard of care provided and learning points identified.Results Rate of major haemorrhage was 3.7 (3.4-4.0) per 1000 births. Pro formas returned for 517 of 581 reported cases (89%); 41% were delivered by emergency caesarean section (compared with 15% of all Scottish births). Uterine atony was the most common cause (250 women, 48%); 32% had multiple causes. A consultant obstetrician gave hands-on care to 368 (71%) and a consultant anaesthetist to 262 (50%). Placenta praevia as a cause was independently associated with consultant presence. Central venous pressure monitoring was used in 164 (31%) women, and 108 (21%) women were admitted to intensive care. Parity, blood loss, and placenta praevia as a cause were independently associated with peripartum hysterectomy (performed in 62 women, 12%). Balloon tamponade and haemostatic uterine suturing were successful in 92 of 116 women (79%). Most cases were assessed as well managed, with 'major suboptimal' care identified in only 14 cases (3%).Conclusions It is feasible to identify and assess cases of major obstetric haemorrhage prospectively on a national basis. Most women received appropriate care, but many learning points and action plans were identified.

Retrospective study of massive obstetric haemorrhage and its materno fetal outcomes in a tertiary care centre

“…12,16 Kodla CS et al identified a hysterectomy rate of 10.31% which was similar to findings of Drief et al 19,22 Regarding maternal outcomes, 25.6% had DIVC, 8.5% developed septicaemia and 6% developed acute renal The most common cause was placenta previa with bleeding and irreversible haemorrhagic shock.…”

“…12 The most common cause of massive obstetric haemorrhage in our study was PPH contributing to 41.4% and uterine atony was the commonest cause of PPH. The second most common cause was placenta previa/acreta (34%) and next was abruption (13%) Kodla CS et al have also identified uterine atony as the most common cause of obstetric haemorrhage in their study.…”

“…Stones et al reported a rate of 3.2/1000 births and V Brace et al reported a rate of 3.7/1000 births. 12,18 In this study, the mean age of our study population was 28.3 years. Brace V et al in their study identified the mean age of their study population as 30.9 years.…”

“…Brace V et al in their study identified the mean age of their study population as 30.9 years. 12 Kodla CS et al in their study identified the mean age of their study population as 25.5±4.14 years. 19 In our study, 75.5% of cases were multigravida and 40.2% were gravida 3 and above.Similar findings were studied by Kodla CS et al and Limaye et al 19,20 In this study group, the mode of delivery was caesarean section in 64.6% of cases and NVD was only 29.3% of cases.…”

High dependency care in an obstetric setting in the UK

“…Relevant factors are thought to be an increasing mean age of childbirth, more deliveries by Caesarean section, women with complex medical disorders choosing to become pregnant, multiple pregnancies following assisted reproduction and an increased likelihood of placenta praevia or accreta in recent years as identified by the most recent CEMACH report [20]. In addition to us, both Ryan [13] and Brace [21] report successful management of haemodynamic instability resulting from the obstetric haemorrhage in a HDU setting. We find the intra-arterial monitoring in HDU a useful tool for reasons of accuracy, reduced disturbance to mothers of frequent blood pressure readings through manual or automated cuffs and avoiding repeated venepuncture for blood sampling.…”