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    How to prepare for postpartum hemorrhage

    Lapses in safety culture play a significant role in maternal mortality




    Postpartum hemorrhage (PPH) is estimated to occur in 3% of US deliveries1 and is probably the most common life-threatening emergency encountered by obstetricians. In contrast to other serious obstetric conditions encountered less frequently (e.g., hypertensive crisis, sepsis, cardiac disease, pulmonary embolism, amniotic fluid embolism), PPH will likely be managed by obstetricians on a regular, perhaps weekly or monthly basis. The aim of this paper is not to outline a specific medical-surgical algorithm for managing PPH, but rather to give an overview for system-wide preparedness that should be considered in planning to mitigate this frequent, potentially life-threatening, obstetrical emergency.

    Defining PPH

    There are a multitude of definitions for PPH in the medical literature. When interpreting published reports on PPH, it is important to recognize these differences and keep in mind that population-based studies often rely upon ICD codes, which themselves do not incorporate a quantitative definition. Recently the American College of Obstetricians and Gynecologists’ (ACOG) reVITALize program, 2 which aims to standardize clinical terms, defined PPH as a cumulative blood loss ≥ 1,000 mL, or blood loss accompanied by signs and symptoms of hypovolemia, within 24 hours after the birth process. This definition is also used in the recently updated 2017 ACOG “Postpartum Hemorrhage” Practice Bulletin #183.3 Going forward, the development of “core outcome sets” to define critical clinical parameters in research should serve to accelerate discovery and improvements in PPH management.4

    Scope of the problem         

    Obstetric hemorrhage is the leading cause of global maternal mortality.5 In a chart review of 95 maternal deaths among 1.5 million deliveries from 2000 to 2006, Clark and colleagues found PPH to be the third leading cause of maternal death, behind complications of preeclampsia and amniotic fluid embolism.6 Multiple studies from various developed countries including the United States have reported increasing trends in PPH over the last several decades.1 In this country, all-cause maternal mortality is increasing,7 bringing with it an increase in PPH-related maternal mortality and severe morbidity, much of which is preventable. 


    NEXT: PPH-related mortality and its root causes

    Gary A. Dildy, MD, FACOG, CPHQ, CPPS
    Dr. Dildy is Professor and Vice Chair of Quality & Patient Safety, Department of Obstetrics and Gynecology ay Baylor College of Medicine ...


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