Maternal mortality: What can we learn from stories of postpartum haemorrhage?

Death from pregnancy is rare in developed countries such as Australia but is still common in third world and developing countries. The investigation of each maternal death yields valuable information and lessons that all health care providers involved with the care of women can learn from. The aim of these investigations is to prevent future maternal morbidity and mortality.Obstetric haemorrhage remains a leading cause of maternal death internationally. It is the most common cause of death in developing countries. In Australia and the United Kingdom, obstetric haemorrhage is ranked as the 4th and 3rd most common cause of direct maternal death respectively. In a number of cases there are readily identifiable factors associated with the care that the women received that may have contributed to their death. It is from these identifiable factors that both midwives and doctors can learn to help prevent similar episodes from occurring.This article will identify some of the lessons that can be learnt from the recent Australian and UK maternal death reports. This paper presents an overview of the process and systems for the reporting of maternal death in Australia. It will then specifically focus on obstetric haemorrhage, with a focus on postpartum haemorrhage, for the 12-year period, 1994–2005. Vignettes from the maternal mortality reports in Australia and the United Kingdom are used to highlight the important lessons for providers of maternity care.     

Relationship between duration of second stage of labour and postpartum anaemia

Aim

To assess the relationship between the duration of the second stage of labour and postpartum anaemia during vaginal birth.

“It’s like a bus,going downhill,without a driver”: A qualitative study of how postpartum haemorrhage is experienced by women,their birth partners,and healthcare professionals

ProblemPostpartum haemorrhage [PPH] remains a major cause of maternal morbidity and mortality. Whilst low-resource settings bear the greatest burden of deaths, women live with associated morbidities in all healthcare settings. Limited data exists regarding the experience for women, their partners, or healthcare professionals [HCPs], affected by PPH.AimTo qualitatively investigate the experience of PPH, for women (n = 9), birth partners (n = 4), and HCPs (n = 9) in an inner-city tertiary referral centre. To provide multi-faceted insight into PPH and improve understanding and future care practices.MethodsParticipants were interviewed about their experiences within two weeks of a PPH. Data were analysed using thematic analysis.FindingsFour distinct, but related, themes were identified: ‘Knowledge specific to PPH’; ‘Effective and appropriate responses to PPH’; ‘Communication of risk factors’; and ‘Quantifying blood loss’; which collected around a central organising concept of ‘Explaining the indescribable’.DiscussionPPH was viewed as a ‘crisis-style emergency’, generating respectful fear in HCPs, whilst women and partners had little-to-no prior knowledge. Specific PPH knowledge dictated HCPs’ response and risk communication. PPH risks were typically linked to quantification of blood loss, assessment of which varied with acknowledged questionable accuracy. Women’s and partners’ confidence in HCPs’ ability to deal with PPH was unquestionable. Non-verbal communication was highlighted, with HCP body language betraying professional confidence.ConclusionInformation about blood loss during childbirth must be imparted in a sensitive, timely manner. Whilst training for HCPs results in effective PPH management, consideration should be given to their non-verbal cues and the impact of dealing with this stressful, ‘everyday emergency’.     

Spontaneous vaginal birth following induction with intravenous oxytocin: Three oxytocic regimes to minimise blood loss post birth

BackgroundNo evidence was identified in relation to the downward titration/cessation of intravenous oxytocin post spontaneous vaginal birth, in the absence of postpartum haemorrhage (PPH); suggesting clinicians’ management is based on personal preference in the absence of evidence.AimTo determine the proportion of induced women with a spontaneous vaginal birth and PPH, when intravenous oxytocin was utilised intrapartum and ceased 15, 30 or 60 minutes post birth.MethodsThis three armed pilot randomised controlled trial, was undertaken on the Birth Suite of an Australian tertiary obstetric hospital. Incidence of PPH was assessed using univariable and adjusted logistic regression, which compared the effect of titrating intravenous oxytocin post birth on the likelihood of PPH, relative to the 15 minute titration group.FindingsPostpartum haemorrhage occurred in 26% (30 of 115), 20% (23 of 116), and 22% (30 of 134) of women randomised to a 15, 30 and 60 minute titration time post birth, with no statistically significant differences between groups.ConclusionThere was no difference in the incidence of PPH between the three groups. Therefore, we question the benefit of delaying cessation of intravenous oxytocin for 60 minutes post birth. Further investigation in this cohort is recommended, to compare the incidence of PPH when intravenous oxytocin is ceased either immediately, or 30 minutes post birth. This research is warranted, as an evidence-based framework is lacking, to guide midwives globally in relation to their management of intravenous oxytocin post an induced spontaneous vaginal birth, in the absence of PPH.     

Impact of the Helping Mothers Survive Bleeding After Birth learning programme on care provider skills and maternal health outcomes in low-income countries — An integrative review

BackgroundTo improve maternal health outcomes, highly competent healthcare providers are needed. One strategy used to improve performance among healthcare providers is simulation-based learning. An integrative review was designed with the aim of synthesising available research on Helping Mothers Survive (HMS), a learning programme used in low-income countries, and its impact on care provider skills and maternal health outcomes.MethodA systematic search was conducted in June 2020 in CINAHL, PubMed, Scopus, and Web of Science. All stages of inclusion, quality assessment, and data extraction were done independently by four reviewers. A narrative synthesis was used for the outcomes of care provider skills and knowledge, as well as maternal health outcomes.FindingsThe search identified 50 articles, 22 of which were excluded due to being duplicates, 16 based on their title and abstract, and two based on their full text. Eleven papers were included in the synthesis: eight quantitative, two qualitative, and one mixed-method study, originating from India, Malawi, Tanzania, Uganda, and Zanzibar. The Helping Mothers Survive-Bleeding After Birth (HMS-BAB) learning programme was found to have a positive impact on care providers’ competencies and maternal health outcomes, with a reduced number of postpartum haemorrhages and a reduction in maternal mortality.ConclusionThe HMS-BAB learning programme has the potential to increase competence among care providers and improve maternal health outcomes in low-income settings. A successful use of the programme to maintain improved care routines for mothers requires multi-professional teams, facility readiness, a low-dose high-frequency approach, a local coordinator, and accountability and ownership.     

The neurodevelopmental outcome in infants who have sustained a subdural haemorrhage from non‐accidental head injury

Subdural haemorrhage (SDH) in infants arises most commonly from non‐accidental head injury (NAHI) from shaking. Patients present with a varied severity of illness and a variety of symptoms and signs. Data on long‐term outcome of the survivors are not widely reported. The aim of this paper is to describe the physical and educational outcomes of children <2 years diagnosed with non‐accidental head injury and formulate guidelines on follow‐up. Data on 65 children <2 years with non‐accidental head injury and subdural haemorrhage diagnosed on CT/MRI/postmortem were extracted from the hospital and community notes and education reports. The Kings Outcome Scale for Childhood Head Injury (KOSCHI) was used. Sixteen children died (24.6%), 13 within 6 weeks and three 5 years after the injury. Of the 45 children followed up (follow‐up time 21.7–103 months), 25 had a good outcome, six were moderately disabled and 11 were severely disabled, while three were in persistent vegetative state. Problems identi?ed included cerebral palsy—16, ongoing seizures—5, visual problems—11, speech and language problems—17 and behavioural problems—13. Of the 29 children of school age on whom data were available, 12 children had a statement of educational needs. In conclusion, young children who survive non‐accidental head injury can have signi?cant physical, cognitive and behavioural problems. Regular follow‐up by a multidisciplinary team, which includes a community paediatrician, therapists, school health personnel and ophthalmologic services, until the child is established in school may facilitate early identi?cation of emerging problems and optimize management. Care must be taken not to discharge children with good outcomes, as behavioural and cognitive problems can emerge with time. Only a prospective study will help outline the subtle problems that can emerge with time in children with a so‐called good outcome. Copyright © 2004 John Wiley & Sons, Ltd.     

Monitoring postpartum haemorrhage in Australia: Opportunities to improve reporting

Problem

The rate and severity of postpartum haemorrhage (PPH) are increasing, according to research reports and clinical anecdote, causing a significant health burden for Australian women giving birth. However, reporting a national Australian rate is not possible due to inconsistent reporting of PPH.

Less or more? Maternal requests that go against medical advice

Problem and background

This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth.