Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using Video Analysis.

OBJECTIVE: To assess adherence to the national postpartum hemorrhage guideline and Managing Obstetric Emergencies and Trauma course instructions and its determinants in the Netherlands. METHODS: A prospective observational multicenter study in 16 Dutch hospitals analyzing data from medical records of 398 women at high risk for postpartum hemorrhage, of which 293 were supplemented with data from prospective video recordings. Adherence to guideline-based quality indicators for prevention, management, and organization of postpartum hemorrhage care was measured. Indicators for prevention and management of postpartum hemorrhage were categorized according to the amount of blood loss (less than 500, greater than 500, greater than 1,000, and greater than 2,000 mL). RESULTS: Overall, a lack of adherence was observed, particularly for the actions to be undertaken with blood loss greater than 1,000 mL (69 patients). Actions were not or only taken in a later stage when the blood loss had already increased to greater than 2,000 mL (21 patients). In almost 41% (n=119/293) of the deliveries, no active management was performed, and in almost 80% (n=89/112), vital signs were not monitored (blood loss greater than 500 mL) or monitored too late with respect to blood loss. The video recordings showed that in general the actual care given was considerably underreported in medical records. Postpartum hemorrhage care in the hospitals was well organized. Fifteen hospitals had a local postpartum hemorrhage protocol, and in 12 hospitals, team trainings were organized. Regarding the determinants, high-risk patient identification and type of hospital (university vs nonuniversity hospital) were mostly associated with better adherence. CONCLUSION: This study showed low adherence to the guideline-based quality indicators, indicating a problem with Dutch quality care. The unique video observations provided additional, valuable information at which level improvement can be made. A tailor-made implementation strategy to improve quality of postpartum hemorrhage care has been developed. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT00928863.

Major obstetric hemorrhage: Patients' perspective on the quality of care.

OBJECTIVES: Major obstetric hemorrhage (MOH) is the leading cause of severe maternal morbidity and mortality, and can have a significant impact on a woman's life. This study aims to gain insight into the patients reported experiences (PREs) and outcomes (PROs) after a major obstetric hemorrhage, and to investigate which patients are most at risk for negative experiences. MATERIAL AND METHODS: A Consumer Assessment of Healthcare Providers and Systems (CAHPS) based questionnaire was developed covering items on the PREs and PROs, and send to all patients with blood loss exceeding 2500 ml in six hospitals over the period of 2008-2012. A regression analysis was performed to find determinants for negative experiences. RESULTS: In total 372 of the 570 questionnaires were returned. Women scored the overall care before, during and after the MOH with a mean of 7.67, 7.62 and 7.28, respectively. However, most PRE items individually were scored suboptimal, with items regarding information supply scoring the lowest. Our results on the PROs showed 81% of the women (362) sustaining extreme fatigue, whereas problems with concentration (53% of 373 women), memory (49% of 353), or reliving (49% of 356) and irritability (51% of 355) were also frequently endured. Negative long term effects were observed in 28% of the women (106 of 372). We found 'year of the MOH longer ago', 'a lower total blood loss' and 'a large location of birth' to be determinants for negative experiences. CONCLUSIONS: Women frequently reported negative experiences and outcomes following a MOH. Information supply after an MOH concerning both physical and psychological complaints is essential for the improvement of care.

Onset of vacuum-related complaints in neonates.

Since vacuum-related neonatal morbidity has been described in many studies clinical observation of neonates is common practice after vacuum-assisted vaginal delivery. However, no guidelines are available regarding the required length of hospital stay of these infants, because little is known about the first onset of complaints due to vacuum extraction-related morbidity. In a prospective observational cohort study we found that vacuum extraction-related complaints occurred in term neonates within 10 h following birth. Mild to moderate morbidity was frequently seen, whereas severe morbidity was infrequently seen. Previous artificial delivery, Apgar score lower than 7 at 1 min, and birth weight >4.0 kg were risk factors for morbidity after vacuum extraction. We suggest that it is justified to discharge neonates at least 10 h after vacuum delivery when no vacuum extraction-related complaints have occurred.