Population-based study of eclampsia: Lessons learnt to improve maternity care.

BACKGROUND: Among hypertensive disorders of pregnancy (HDP), eclampsia is a rare but serious event, often considered avoidable. Detailed assessment of the adequacy of care for the women who have eclampsia can help identify opportunities for improvement and for prevention of the associated adverse maternal and neonatal outcomes. OBJECTIVE: 1/ To estimate the incidence and describe the characteristics of women with eclampsia and to compare them with those of women with non-eclamptic hypertensive disorders of pregnancy (HDP)-related severe maternal morbidity (SMM) and of control women without SMM 2/ To analyse the quality of management in women who had eclampsia, at various stages of their care pathway. METHODS: It was a planned ancillary analysis of the EPIMOMS population-based study, conducted in six French regions in 2012-2013. Among the 182,309 maternities of the source population, all women with eclampsia (n = 51), with non-eclamptic HDP-related SMM (n = 351) and a 2% representative sample of women without SMM (n = 3,651) were included. Main outcome was the quality of care for eclampsia assessed by an independent expert panel at three different stages of management: antenatal care, care for pre-eclampsia and care for eclampsia. RESULTS: The eclampsia incidence was 2.8 per 10,000 (95%CI 2.0-4.0). Antenatal care was considered completely inadequate or substandard in 39% of women, as was pre-eclampsia care in 76%. Care for eclampsia was judged completely inadequate or substandard in 50% (21/42), mainly due to inadequate use of magnesium sulphate. CONCLUSION: The high proportion of inadequate quality of care underlines the need for an evidence-based standardisation of care for HDP.

Understanding maternal mortality in women with obesity and the role of care they receive: a national case-control study.

OBJECTIVE: Obesity has significant implications for the health of pregnant women. However, few studies have quantified its association with maternal mortality or examined the relevant underlying causes and the role of care, although this remains the most severe maternal outcome. Our objectives were to quantify the risk of maternal death by prepregnancy body mass index and to determine whether obesity affected the quality of care of the women who died. DESING: This is a national population-based case-control study in France. Cases were 364 maternal deaths from the 2007-2012 National Confidential Enquiry. Controls were 14,681 parturients from the nationally representative 2010 perinatal survey. We studied the association between categories of prepregnancy BMI and maternal death by multivariable logistic regression, estimating adjusted odds ratios and 95% confidence intervals, overall and by specific causes of death. Individual case reviews assessed the quality of care provided to the women who died, by obesity status. RESULTS: Compared with women with normal BMI, underweight women (<18.5 kg/m2) had an adjusted OR of death of 0.75 (95% CI, 0.42-1.33), overweight women (25-29.9 kg/m2) 1.65 (95% CI, 1.24-2.19), women with class 1 obesity (30-34.9 kg/m2) 2.22 (95% CI, 1.55-3.19) and those with class 2-3 obesity (≥35 kg/m2) 3.40 (95% CI, 2.17-5.33). Analysis by cause showed significant excess risk of maternal death due to cardiovascular diseases, venous thromboembolism, hypertensive complications and stroke in women with obesity. Suboptimal care was as frequent among women with (35/62, 57%) as without obesity (136/244, 56%), but this inadequate management was directly related to obesity among 14/35 (40%) obese women with suboptimal care. Several opportunities for improvement were identified. CONCLUSIONS: The risk of maternal death increases with BMI; it multiplied by 1.6 in overweight women and more than tripled in pregnant women with severe obesity. Training clinicians in the specificities of care for pregnant women with obesity could improve their outcomes.

A Framework Proposal for Quality and Safety Measurement in Gynecologic Emergency Care.

OBJECTIVE: To define and assess the prevalence of potentially life-threatening gynecologic emergencies among women presenting for acute pelvic pain for the purpose of developing measures to audit quality of care in emergency departments. METHODS: We conducted a mixed-methods multicenter study at gynecologic emergency departments in France and Belgium. A modified Delphi procedure was first conducted in 2014 among health care professionals to define relevant combinations of potentially life-threatening conditions and near misses in the field of gynecologic emergency care. A prospective case-cohort study in the spring of 2015 then assessed the prevalence of these potentially life-threatening emergencies and near misses among women of reproductive age presenting for acute pelvic pain. Women in the case group were identified at 21 participating centers. The control group consisted of a sample of women hospitalized for acute pelvic pain not caused by a potentially life-threatening condition and a 10% random sample of outpatients. RESULTS: Eight gynecologic emergencies and 17 criteria for near misses were identified using the Delphi procedure. Among the 3,825 women who presented for acute pelvic pain, 130 (3%) were considered to have a potentially life-threatening condition. The most common diagnoses were ectopic pregnancies with severe bleeding (n=54; 42%), complex pelvic inflammatory disease (n=30; 23%), adnexal torsion (n=20; 15%), hemorrhagic miscarriage (n=15; 12%), and severe appendicitis (n=6; 5%). The control group comprised 225 hospitalized women and 381 outpatients. Diagnostic errors occurred more frequently among women with potentially life-threatening emergencies than among either hospitalized (odds ratio [OR] 1.7, 95% CI 1.1-2.7) or outpatient (OR 14.7, 95% CI 8.1-26.8) women in the control group. Of the women with potentially life-threatening conditions, 26 met near-miss criteria compared with six with not potentially life-threatening conditions (OR 25.6, 95% CI 10.9-70.7). CONCLUSIONS: Potentially life-threatening gynecologic emergencies are high-risk conditions that may serve as a useful framework to improve quality and safety in emergency care.

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France.

BACKGROUND: The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH). METHODS: This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death. RESULTS: The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019). CONCLUSIONS: After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

Maternal Death Due to Amniotic Fluid Embolism: A National Study in France.

BACKGROUND: A structured definition of amniotic fluid embolism (AFE) based on 4 criteria was recently proposed for use in research by the Society for Maternal-Fetal Medicine (SMFM) and the Amniotic Fluid Embolism Foundation. The main objective of this study was to review all AFE-related maternal deaths in France during 2007-2011 according to the presence or not of all these 4 diagnostic criteria. METHODS: Maternal deaths due to AFE were identified by the national experts committee of the French Confidential Enquiry into Maternal Deaths during 2007-2011 (n = 39). The maternal mortality ratio for AFE was calculated. We applied the structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation to AFE-related maternal deaths identified by the national experts committee. Characteristics of women, pregnancies and deliveries; clinical and biological features of AFE; and specific laboratory tests used were described by the presence or not of all 4 diagnostic criteria. Management of obstetric hemorrhage and quality of care according to the experts were also described. RESULTS: The maternal mortality ratio from AFE was 0.95/100,000 live births (95% confidence interval, 0.67-1.3). Detailed clinical data were collected for 36 women who died from AFE: 21 (58%) had all 4 proposed diagnostic criteria and 15 (42%) had 1 or more missing criterion. Documented early disseminated intravascular coagulopathy was missing for 14 women, and 2 women exhibited more than 1 missing criterion. Ten of the 15 women with missing criteria had clinical coagulopathy, with standard hemostasis tests performed in only 3. Specific diagnostic examinations for AFE were performed in similar proportions by the presence or not of all diagnostic criteria. Opportunities to improve care included timely performance of indicated hysterectomy (n = 13) and improved transfusion practices (n = 9). In the context of maternal cardiac arrest, for 5 of 13 women, fetal extraction was performed within 5 minutes. CONCLUSIONS: The structured definition of AFE for research studies would exclude more than one-third of AFE-related maternal deaths identified by the national experts committee. Inclusion of clinical coagulopathy as a diagnostic criterion for AFE would reduce this proportion to 14%. There is still room for improvement in the management of obstetric hemorrhage and timely fetal extraction in the context of maternal cardiac arrest, frequently observed in AFE-related maternal death.

Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France.

OBJECTIVE: The principal objective of this study was to describe the policies reported by French maternity units for the prevention and early management of postpartum haemorrhage (PPH). The second objective was to assess their variation according to hospital level and status. STUDY DESIGN: Cross-sectional observational study of French maternity units, from January 2010 to April 2011. The medical supervisor (obstetrician or midwife) of participating maternity wards completed a questionnaire designed to ascertain the unit's protocol for preventing and managing PPH after both vaginal and caesarean deliveries at a gestational age >22 weeks (or a birth weight >500g). The main outcome measure was the percentage of units reporting protocols adhering to the principal criteria for adequate management defined by the 2004 French guidelines for PPH. RESULTS: 252 maternity units participated in the survey. Almost all units had a written protocol for PPH (97.2%). For vaginal deliveries, 82.5% of units had a definition of PPH (>500ml) and 92.8% had a policy of preventive oxytocin use. For caesareans, only 23.8% defined PPH (as >1000ml), 68.8% used manual delivery of the placenta, and 76.9% recommended oxytocin injection immediately after the birth. The first-line medication for PPH was oxytocin (96.3%) and the second-line treatment a prostaglandin (97.5%). Level III maternity units had a definition of haemorrhage for vaginal deliveries more often than did other levels of care (P=0.04). Manual removal of the placenta after caesareans was significantly more frequent in level I than level III units (P=0.008) and in private than other types of maternity units. Medical management of haemorrhage did not differ according to level of care or maternity status. CONCLUSIONS: The responses by maternity unit supervisors showed significant improvement in the management of PPH accordingly to the 2004 French guidelines, especially for the third stage of labour. This improvement did not differ between hospitals by levels of care or legal status.

Caesarean Delivery and Postpartum Maternal Mortality: A Population-Based Case Control Study in Brazil.

BACKGROUND: Cesarean delivery rates continue to increase worldwide and reached 57% in Brazil in 2014. Although the safety of this surgery has improved in the last decades, this trend is a concern because it carries potential risks to women's health and may be a modifiable risk factor of maternal mortality. This paper aims to investigate the risk of postpartum maternal death directly associated with cesarean delivery in comparison to vaginal delivery in Brazil. METHODS: This was a population-based case-control study performed in eight Brazilian states. To control for indication bias, deaths due to antenatal morbidity were excluded. We included 73 cases of postpartum maternal deaths from 2009-2012. Controls were selected from the Birth in Brazil Study, a 2011 nationwide survey including 9,221 postpartum women. We examined the association of cesarean section and postpartum maternal death by multivariate logistic regression, adjusting for confounders. RESULTS: After controlling for indication bias and confounders, the risk of postpartum maternal death was almost three-fold higher with cesarean than vaginal delivery (OR 2.87, 95% CI 1.63-5.06), mainly due to deaths from postpartum hemorrhage and complications of anesthesia. CONCLUSION: Cesarean delivery is an independent risk factor of postpartum maternal death. Clinicians and patients should consider this fact in balancing the benefits and risks of the procedure.

Duration of Expulsive Efforts and Risk of Postpartum Hemorrhage in Nulliparous Women: A Population-Based Study.

OBJECTIVE: To assess the specific association between the duration of expulsive efforts and the risk of postpartum hemorrhage. METHODS: Population-based cohort-nested case-control study of nulliparous women delivering vaginally in 106 French maternity units between December 2004 and November 2006, including 3,852 women with PPH (blood loss ≥ 500 mL and/or peripartum Hb decrease ≥ 2 g/dL), 1,048 of them severe (peripartum Hb decrease ≥ 4 g/dL or transfusion of ≥ 2 units of red blood cells), and 762 controls from a representative sample of deliveries without hemorrhage in the same population. The association between duration of expulsive efforts and postpartum hemorrhage was estimated by multilevel logistic regression models adjusted for individual and hospital characteristics. RESULTS: Median duration of expulsive efforts was 18 minutes among controls, 20 minutes among postpartum hemorrhage and 23 minutes among severe postpartum hemorrhage (p<0.01). Duration of expulsive efforts was significantly, positively, and linearly associated with both postpartum hemorrhage and severe postpartum hemorrhage. After adjustment for other risk factors, every additional 10 minutes of expulsive efforts was associated with about a 10% increase in the risk of postpartum hemorrhage (aOR = 1.11 [1.02-1.21]) and severe postpartum hemorrhage (aOR = 1.14 [1.03-1.27]). Oxytocin during labor, duration of active phase of labor, forceps use, episiotomy, perineal tears, and birth weight were also independently associated with both risks. CONCLUSION: Duration of expulsive efforts was independently associated with postpartum hemorrhage and severe postpartum hemorrhage. Interventions to shorten the duration of this stage, such as oxytocin, forceps, and episiotomy, are also associated with higher risks of postpartum hemorrhage. Beyond duration, other aspects of the management of active second stage should be evaluated as some might allow it to last longer with a minimal increase in postpartum hemorrhage risk.

Pregnancy-related ICU admissions in France: trends in rate and severity, 2006-2009.

OBJECTIVE: To determine the national rate per delivery of pregnancy-related ICU admissions of women in France, the characteristics and severity of these cases, and their trends over the 4-year study period. DESIGN: Descriptive study from the national hospital discharge database. SETTING: All ICUs in France. PATIENTS: All women admitted to an ICU during the pregnancy, the delivery, or the postpartum period from January 1, 2006, to December 31, 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 3,262,526 deliveries, 11,824 women had pregnancy-related ICU admissions, for an overall rate of 3.6 per 1,000 deliveries. The conditions reported most frequently were obstetric hemorrhages (34.2%) and hypertensive disorders of pregnancy (22.3%). Case severity was assessed with four markers: case-fatality rate (1.3%), length of ICU stay (mean, 3.0 ± 0.1 d), Simplified Acute Physiology Score II score (mean: 19.7 ± 0.1), and a SUP REA code, which indicates the combination of a Simplified Acute Physiology Score II score more than or equal to 15 and at least one specific procedure related to life support or organ failure (23.0%). The most frequent causes of ICU admission were those associated with the least severity in the ICU. During the study period, the rate of pregnancy-related ICU admissions decreased from 3.9 to 3.4 per 1,000 deliveries (p < 0.001), whereas the overall severity of cases increased with longer stays, higher Simplified Acute Physiology Score II scores, and a greater proportion of SUP REA codes (all p < 0.001). Analysis by principal diagnosis showed that the severity of the condition of women admitted to ICU significantly increased over time for hemorrhages and hypertensive complications. CONCLUSIONS: The rate of women with pregnancy-related ICU admissions decreased and the severity of their cases increased. Most ICU admissions remained related to the least severe conditions. This raises the issue of the most appropriate organization of care for women with pregnancy-related conditions who require continuous surveillance but not necessarily intensive care.

Pitfalls of national routine death statistics for maternal mortality study.

BACKGROUND: The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths. METHODS: National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described. RESULTS: Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians. CONCLUSION: Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study.

Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement.

UNLABELLED: Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement OBJECTIVE: To use statistical process control charts to describe trends in the prevalence of severe postpartum haemorrhage after vaginal delivery. This assessment was performed 7 years after we initiated a continuous quality improvement programme that began with regular criteria-based audits STUDY DESIGN: Observational descriptive study, in a French maternity unit in the Rhône-Alpes region. INTERVENTION: Quarterly clinical audit meetings to analyse all cases of severe postpartum haemorrhage after vaginal delivery and provide feedback on quality of care with statistical process control tools. MAIN OUTCOME MEASURES: The primary outcomes were the prevalence of severe PPH after vaginal delivery and its quarterly monitoring with a control chart. The secondary outcomes included the global quality of care for women with severe postpartum haemorrhage, including the performance rate of each recommended procedure. Differences in these variables between 2005 and 2012 were tested. RESULTS: From 2005 to 2012, the prevalence of severe postpartum haemorrhage declined significantly, from 1.2% to 0.6% of vaginal deliveries (p<0.001). Since 2010, the quarterly rate of severe PPH has not exceeded the upper control limits, that is, been out of statistical control. The proportion of cases that were managed consistently with the guidelines increased for all of their main components. CONCLUSION: Implementation of continuous quality improvement efforts began seven years ago and used, among other tools, statistical process control charts. During this period, the prevalence of severe postpartum haemorrhage after vaginal delivery has been reduced by 50%.

Ten years of confidential inquiries into maternal deaths in France, 1998-2007.

OBJECTIVE: To assess trends in the maternal mortality ratio over a 10-year period in France and the causes, risk factors, quality of care, and avoidability of maternal deaths. METHODS: Maternal deaths up to 1 year after the end of the pregnancy from 1998 to 2007 were identified and studied through the French Confidential Enquiry Into Maternal Deaths system. Time trends were analyzed by comparing the two 5-year periods for maternal mortality ratios, both overall and by women's characteristics, causes of death, existence of suboptimal care, and avoidability. RESULTS: For the 10-year period, 660 maternal deaths were identified. The maternal mortality ratio was similar in the two 5-year periods, 8.8 per 100,000 live births (95% confidence interval [CI] 7.8-9.8) for 1998-2002 and 8.4 per 100,000 live births (95% CI 7.6-9.4) for 2003-2007. The distributions of maternal age, nationality, and of causes of death did not change. Overall, hemorrhage was the leading cause of death, responsible for 18% of maternal deaths, followed by amniotic fluid embolism, thromboembolism, hypertensive disorders, and cardiovascular conditions, each of which contributed to 10-12% of deaths. Suboptimal care decreased from 70% in 1998-2002 to 60% in 2003-2007 (P<.03). Half of all deaths were considered avoidable and this proportion did not change. The most frequent contributory factor was inadequate management. CONCLUSION: The ratio and profile of maternal mortality in France remained unchanged from 1998 to 2007. Half of all maternal deaths are still considered avoidable, which indicates that improvement remains possible. LEVEL OF EVIDENCE: : III.

Postpartum haemorrhage in Canada and France: a population-based comparison.

OBJECTIVE: Maternal mortality ratio due to postpartum haemorrhage (PPH) is higher in France than in Canada. We explored this difference by comparing PPH features between these two countries. METHODS: Using data between 2004 and 2006, we compared the incidence, risk factors, causes and use of second-line treatments, of PPH between France (N = 6,660 PPH) and Canada (N = 9,838 PPH). We assessed factors associated with PPH through multivariate logistic models. RESULTS: PPH incidence, overall (4.8% (95% CI 4.7-4.9) in Canada and 4.5% (95% CI 4.4-4.7) in France), and after vaginal delivery (5.3% (95%CI 5.2-5.4) in Canada and 4.8 (95%CI 4.7-4.9) in France), were significantly higher in Canada than in France, but not after caesarean delivery. Women delivering without PPH were similar between the two populations, except for macrosomia (11% in Canada, 7% in France, p<0.001), caesarean delivery (27% in Canada, 18% in France, p<0.001), and episiotomy (17% in Canada, 34% in France, p<0.001). After vaginal delivery, factors strongly associated with PPH were multiple pregnancy, operative delivery and macrosomia in both populations, and episiotomy only in France (Odds Ratio 1.39 (95% CI 1.23-1.57)). The use of second-line treatments for PPH management was significantly more frequent in France than in Canada after both vaginal and caesarean delivery. CONCLUSION: PPH incidence was not higher in France than in Canada and there was no substantial difference in PPH risk factors between the 2 countries. Greater use of second-line treatments in PPH management in France suggests a more frequent failure of first-line treatments and a higher rate of severe PPH, which may be involved in the higher maternal mortality ratio due to PPH.

Induction of labor and risk of postpartum hemorrhage in low risk parturients.

OBJECTIVE: Labor induction is an increasingly common procedure, even among women at low risk, although evidence to assess its risks remains sparse. Our objective was to assess the association between induction of labor and postpartum hemorrhage (PPH) in low-risk parturients, globally and according to its indications and methods. METHOD: Population-based case-control study of low-risk women who gave birth in 106 French maternity units between December 2004 and November 2006, including 4450 women with PPH, 1125 of them severe, and 1744 controls. Indications for labor induction were standard or non-standard, according to national guidelines. Induction methods were oxytocin or prostaglandins. Multilevel multivariable logistic regression modelling was used to test the independent association between induction and PPH, quantified as odds ratios. RESULTS: After adjustment for all potential confounders, labor induction was associated with a significantly higher risk of PPH (adjusted odds ratio, AOR1.22, 95%CI 1.04-1.42). This excess risk was found for induction with both oxytocin (AOR 1.52, 95%CI 1.19-1.93 for all and 1.57, 95%CI 1.11-2.20 for severe PPH) and prostaglandins (AOR 1.21, 95%CI 0.97-1.51 for all and 1.42, 95%CI 1.04-1.94 for severe PPH). Standard indicated induction was significantly associated with PPH (AOR1.28, 95%CI 1.06-1.55) while no significant association was found for non-standard indicated inductions. CONCLUSION: Even in low risk women, induction of labor, regardless of the method used, is associated with a higher risk of PPH than spontaneous labor. However, there was no excess risk of PPH in women who underwent induction of labor for non-standard indications. This raises the hypothesis that the higher risk of PPH associated with labor induction may be limited to unfavorable obstetrical situations.

Transfusion practices in postpartum hemorrhage: a population-based study.

OBJECTIVE: To describe transfusion practices and anemia in women with postpartum hemorrhage (PPH), according to the clinical context. DESIGN: Population-based cohort study. SETTING: A total of 106 French maternity units (146 781 deliveries, December 2004 to November 2006). POPULATION: All women with PPH (n = 9365). METHODS: Description of the rate of red blood cell (RBC) transfusion in PPH overall and compared with transfusion guidelines. MAIN OUTCOME MEASURES: Transfusion practices and postpartum anemia by mode of delivery and cause of PPH in women given RBCs within 12 h after PPH. RESULTS: A total of 701 women received RBCs (0.48 ± 0.04% of all women and 7.5 ± 0.5% of women with PPH). Half the women with clinical PPH and hemoglobin lower than 7.0 g/dL received no RBCs. In the group with clinical PPH and transfusion within 12 h (n = 426), operative vaginal delivery was associated with a larger maximal hemoglobin drop, more frequent administration of fresh-frozen plasma (FFP) and pro-hemostatic agents [odds ratio (OR) 3.54, 95% confidence interval (95% CI) 1.12-11.18], transfusion of larger volumes of RBCs and FFP, a higher rate of massive RBCs transfusion (OR 5.22, 95% CI 2.12-12.82), and more frequent use of conservative surgery (OR 3.2, 95% CI 1.34-7.76), compared with spontaneous vaginal delivery. CONCLUSIONS: The RBC transfusion for PPH was not given in a large proportion of women with very low hemoglobin levels despite guidelines to the contrary. Operative vaginal delivery is characterized by higher blood loss and more transfusions than spontaneous vaginal delivery.

Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study.

Objectives Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association. Design Population-based, cohort-nested case-control study. Setting 106 French hospitals from December 2004 through November 2006. Participants Women with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH. Main outcome measures The independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling. Results Oxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories. Conclusions Oxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the minimal useful regimens.

Use of routinely collected data to assess maternal mortality in seven tertiary maternity centers in Cameroon.

OBJECTIVE: To analyze the data available on obstetric complications, maternal deaths, and types of admission in 7 tertiary maternity centers in Cameroon. METHODS: A descriptive retrospective study of all obstetric complications and maternal deaths that occurred in 7 tertiary level maternity hospitals between January 2005 and December 2006. Data were collected using the same registers, file records, and standardized questionnaires. RESULTS: During the study period there were 34898 deliveries and 4069 cesareans were performed. There were 11014 obstetric complications and 249 maternal deaths were recorded, giving an MMR of 713 per 100000 deliveries. The risk of mortality among women referred to the tertiary level facilities was higher compared with women who were directly admitted to the facilities (odds ratio 3; 95% CI, 2.2-4.0). CONCLUSION: The high rates of maternal mortality recorded in tertiary maternity centers among women who were referred reveal the urgent need for interventions to improve the referral system.

Clinical audit: a useful tool for reducing severe postpartum haemorrhages?

OBJECTIVE: Reducing the rate of severe postpartum haemorrhage (PPH) is a major challenge in obstetrics today. One potentially effective tool for improving the quality of care is the clinical audit, that is, peer evaluation and comparison of actual practices against explicit criteria. Our objective was to assess the impact of regular criteria-based audits on the prevalence of severe PPH. DESIGN: Quasi-experimental before-and-after survey. SETTING: Two French maternity units in the Rhône-Alpes region, with different organization of care. PARTICIPANTS: All staff of both units. INTERVENTION: Quarterly clinical audit meetings at which a team of reviewers analysed all cases of severe PPH and provided feedback on quality of care and where all staff actively participated. MAIN OUTCOME MEASURES: The primary outcome was the prevalence of severe PPH. Secondary outcomes included the global quality of care for women with severe PPH, including the performance rate for each recommended procedure. Differences in these variables between 2005 and 2008 were tested. RESULTS: The prevalence of severe PPH declined significantly in both units, from 1.52 to 0.96% of deliveries in the level III hospital (P = 0.048) and from 2.08 to 0.57% in the level II hospital (P < 0.001). From 2005 to 2008, the proportion of deliveries with severe PPH that was managed consistently with the guidelines increased for all of its main components, in both units. CONCLUSION: Regular clinical audits of cases severe PPH were associated with a persistent reduction in the prevalence of severe PPH.

Prostaglandin E2 analogue sulprostone for treatment of atonic postpartum hemorrhage.

OBJECTIVES: Use of prostaglandins, including sulprostone (an E2 analog), is recommended for second-line uterotonic treatment of atonic postpartum hemorrhage and might be considered as an indicator of quality of care in severe atonic postpartum hemorrhage management. Our objective was to estimate whether sulprostone was appropriately used and how it was tolerated in women with atonic postpartum hemorrhage. METHODS: This large population-based study (146,781 deliveries) included 4,038 women with clinically assessed atonic postpartum hemorrhage in 106 French hospitals during 1 year. Severe postpartum hemorrhage was defined as one of the following: hemoglobin decline of 4 g/dL or more, transfusion, arterial embolization, surgical procedures, transfer to intensive care unit, or death. Sulprostone use in severe atonic postpartum hemorrhage was analyzed according to the mode of delivery and the characteristics of the maternity units. RESULTS: Rates of sulprostone use were only 33.9% (n = 1,370) and 53.5% (n = 657) among women with atonic (n = 4 ,038) and severe atonic (n = 1,227) postpartum hemorrhage, respectively. In the latter population, sulprostone administration was less frequent after vaginal delivery than after cesarean delivery (45.6% compared with 86.5%, P<.01) in units performing fewer than 1,500 annual deliveries in public nonuniversity hospitals and in units where the obstetrician or anesthesiologist was not present 24 hours per day, 7 days per week. Fifty-one of the 1,370 women with sulprostone-treated atonic postpartum hemorrhage (3.7%, 95% confidence interval [CI] 2.7-4.7) experienced side effects, including seven (0.5%, 95% CI 0.2-1.0) with severe cardiovascular or respiratory symptoms that resolved when the hypovolemic shock was corrected and drug administration was stopped. CONCLUSION: Sulprostone is underused for treating severe atonic postpartum hemorrhage after vaginal delivery, despite low rates of severe side effects in this population-based study. LEVEL OF EVIDENCE: : III.