OB Hemorrhage Survey

Maternal hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Of the estimated 550,000 births a year in California, approximately 2% involve maternal hemorrhage (n~11,000) (Lu et al).

The purpose of this study is to identify current structures, processes and barriers of identification and response to maternal hemorrhage, including hospital protocols, drills, means of communicating blood loss, and perceived barriers to response.

The results will inform interventions aimed at reducing delays in diagnosis and treatment. Finally, study results will provide baseline information to measure whether interventions and education improve current structures and processes for hemorrhage response.

The CMQCC Obstetric Hemorrhage Task Force research team, led by co-chairs David Lagrew, M.D. and Audrey Lyndon, Ph.D., R.N., developed a standardized on-line questionnaire (using SurveyMonkey). After final IRB approval, which included assurance of individual and hospital confidentiality, the questionnaire was distributed to region leaders statewide to solicit three clinician responses (one MD, two RNs, or midwives) from hospitals with labor and delivery services. Respondents completed the survey on-line and in some cases on a paper copy and returned it by FAX or mail.

Responses will be analyzed using standard descriptive statistical methods and categorized by hospital size: 1) less than 1000 deliveries per year, 2) 1000-3000 deliveries per year, and 3) greater than 3000 deliveries per year. Aggregate data will be reported so that no facility-specific data, individual respondent nor hospital names, will be released. Both quantitative and qualitative analyses will be conducted. Quantitative analysis will be performed using SAS (Statistical Analysis Software version 9.1.3). Qualitative analysis, including assessment of open-ended answers about barriers to prompt hemorrhage response, will be performed using ATLAS.ti (version 5.2).

Results from the survey will guide the CMQCC Obstetric Hemorrhage Expert Task Force to develop useful toolkits to better identify when hemorrhage is occurring, to more frequently and accurately measure blood loss, and to trigger a timely and effective response to prevent or respond to hemorrhage. Since hemorrhage is a relatively rare event, the average clinician, particularly one at a smaller hospital (ie: fewer number of births) may encounter this adverse event infrequently. Without repeated practice to respond to this type of emergency, using drills for example, response skills and speed atrophy. Visually informative and easy-to-follow flowcharts, checklists and other tactical means of guiding clinicians during labor and delivery will improve response at small and large hospitals. We plan to urge hospital leaders to standardize guidelines for obstetrical hemorrhage, including implementation of policies that require protocols, practice drills, and the presence of hemorrhage carts or kits in labor and delivery, along with flowcharts, and checklists to aid the process of response.

The aim is to educate and train maternal care providers to effectively and efficiently identify, measure and respond to maternal hemorrhage in order to prevent morbidities, or worse, deaths of the women in their care.