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Maternal mortality remains a significant issue, not only in sub-Saharan Africa, but in the United States as well. In his inaugural address last month at the Annual Meeting of the American College of Obstetrician and Gynecologists Dr. Jim Martin highlighted the need to address obstetric hemorrhage and hypertensive disorders as dominant causes of severe maternal morbidity and mortality (Obstet Gynecol 2011; 117(6): 1268-71). We have the capability and the resources to address these issues.
Postpartum hemorrhage (PPH) is still the leading cause of maternal mortality worldwide, and previous studies have indicated that at least 70%-95% of these deaths are preventable. A recent study “Postpartum Hemorrhage Resulting From Uterine Atony After Vaginal Delivery,” by Dr. Marine Driessen (Obstet Gynecol 117(1):21-31) sought to identify the various factors associated with severe postpartum hemorrhage due to atony, the most common etiology.
The study revealed several independent risk factors for severe blood loss in women with postpartum hemorrhage due to atony, including a delay in an initial course of action after diagnosis. Though somewhat expected, Driessen notes that these results contribute to the evidence we need in our practices to “support the recommendations for immediate management of excessive bleeding.” The more studies that confirm our management guidelines and our accepted procedures and courses of action, the more evidence-based they become. As their level of proof increases, we as clinicians are more likely to follow these guidelines and perform the appropriate procedures correctly.
The evidence provided by Driessen and her colleagues suggests that by “reducing the use of cervical ripening, episiotomy, or cesarean delivery, in particular in situations in which these interventions do not provide clear benefits as well as improving the rapidity of first care once postpartum hemorrhage has occurred, may reduce the incidence of severe postpartum hemorrhage.” Following the diagnosis of PPH, severe bleeding can be limited by promptly administering oxytocics, manually examining the uterine cavity, and calling for additional assistance when needed.
Making the diagnosis of PPH in a timely manner and then transitioning quickly from a normal delivery to a hemorrhagic emergency is critical to improving outcomes. At Advanced Practice Strategies, our Postpartum Hemorrhage course enables obstetrical teams to intervene quickly and aggressively and operates on the “recommendations for immediate management of excessive bleeding” that Driessen mentions. The course provides the tools, guidelines, and approaches for managing postpartum hemorrhage effectively, including how to recognize abnormal bleeding and quantify blood loss quickly and accurately. Additionally, doctors and nurses learn the common risk factors for postpartum hemorrhage and what early interventions they should attempt in response, including pharmacologic remedies, options for surgical repair, and blood component therapy.
There is significant benefit when doctors and nurses receive common education and subsequently develop a shared language and understanding of PPH. Effective, collaborative care is the key to improving perinatal safety. By empowering the obstetric clinical care team with common education, like the APS Postpartum Hemorrhage course, we enable them to reduce the incidence of severe blood loss with PPH and limit the associated morbidity and mortality.
Dr. Martin November, Chief Medical Officer Dr. November is an OB/GYN physician and was a member of the teaching faculty at Harvard Medical School for more than 10 years. He held various administrative positions at the Beth Israel Deaconess Medical Center including Director of the Division of Community Medicine. His academic research focused on patient safety, cost effectiveness analysis, and process improvement in healthcare. He worked with researchers at the Harvard School of Public Health on The Malpractice Insurers’ Medical Error Prevention Study (MIMEPS), a nationwide study of malpractice claims and medical errors. Prior to joining APS in 2008, Dr. November worked with the Harvard Business School Healthcare Initiative to develop the first Harvard Business School Health Science and Business Immersion Program in January 2006. He earned a Bachelor of Arts degree at Duke University, a Doctor of Medicine degree at the University of North Carolina at Chapel Hill, and a Master of Business Administration degree at the Harvard Business School.