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de Vries PLM, Deneux-Tharaux C, Baud D, Chen KK, Donati S, Goffinet F, Knight M, D'Souzah R, Sueters M, van den Akker T. Postpartum haemorrhage in high-resource settings: Variations in clinical management and future research directions based on a comparative study of national guidelines. BJOG 2023; 130:1639-1652. [PMID: 37259184 DOI: 10.1111/1471-0528.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 04/15/2023] [Accepted: 05/04/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare guidelines from eight high-income countries on prevention and management of postpartum haemorrhage (PPH), with a particular focus on severe PPH. DESIGN Comparative study. SETTING High-resource countries. POPULATION Women with PPH. METHODS Systematic comparison of guidance on PPH from eight high-income countries. MAIN OUTCOME MEASURES Definition of PPH, prophylactic management, measurement of blood loss, initial PPH-management, second-line uterotonics, non-pharmacological management, resuscitation/transfusion management, organisation of care, quality/methodological rigour. CONCLUSIONS Our study highlights areas where strong evidence is lacking. There is need for a universal definition of (severe) PPH. Consensus is required on how and when to quantify blood loss to identify PPH promptly. Future research may focus on timing and sequence of second-line uterotonics and non-pharmacological interventions and how these impact maternal outcome. Until more data are available, different transfusion strategies will be applied. The use of clear transfusion-protocols are nonetheless recommended to reduce delays in initiation. There is a need for a collaborative effort to develop standardised, evidence-based PPH guidelines. RESULTS Definitions of (severe) PPH varied as to the applied cut-off of blood loss and incorporation of clinical parameters. Dose and mode of administration of prophylactic uterotonics and methods of blood loss measurement were heterogeneous. Recommendations on second-line uterotonics differed as to type and dose. Obstetric management diverged particularly regarding procedures for uterine atony. Recommendations on transfusion approaches varied with different thresholds for blood transfusion and supplementation of haemostatic agents. Quality of guidelines varied considerably.
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Affiliation(s)
- Pauline L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
| | - David Baud
- Department of Gynaecology and Obstetrics, University Hospital of Lausanne, Lausanne, Switzerland
| | - Kenneth K Chen
- Departments of Medicine & ObGyn, Brown University, Providence, Rhode Island, USA
| | - Serena Donati
- National Centre for Disease Prevention and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, Rome, Italy
| | - Francois Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Rohan D'Souzah
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Departments of Obstetrics & Gynaecology and Health Research Methods Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Obstetrics and Gynaecology, Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marieke Sueters
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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Federspiel JJ, Eke AC, Eppes CS. Postpartum hemorrhage protocols and benchmarks: improving care through standardization. Am J Obstet Gynecol MFM 2023; 5:100740. [PMID: 36058518 PMCID: PMC9941009 DOI: 10.1016/j.ajogmf.2022.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 08/11/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Several state maternal morbidity and mortality committees have reviewed areas of opportunity concerning postpartum hemorrhage management and found that common patterns include delays in recognition and response to hemorrhage. Hospital systems and state perinatal quality collaboratives have found that comprehensive, interdisciplinary response to postpartum hemorrhage care improves patient outcomes and, in some instances, reduces racial disparities. A key component of this focus involves the implementation of stage-based hemorrhage protocols for postpartum hemorrhage management. Stage-based hemorrhage protocols are designed to reduce delays in the diagnosis and management and avoid the pitfalls of cognitive biases. These protocols are complex, and their effectiveness is tied to the quality of their implementation. Systematic benchmarking and development of quality metrics for adherence to postpartum hemorrhage bundles would be expected to improve clinical outcomes, but evidence regarding the effectiveness of this practice in the literature is limited. Here, key features of stage-based interventions and evidence regarding the use of quality metrics for postpartum hemorrhage protocol adherence have been outlined.
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Affiliation(s)
- Jerome J Federspiel
- From the Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC (Dr Federspiel).
| | - Ahizechukwu C Eke
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr Eke); Division of Clinical Pharmacology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD (Dr Eke)
| | - Catherine S Eppes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Eppes)
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Mohammed S, Khuan L, Durai RPR, Ismail IZB, Garba SN. Barriers to reporting postpartum hemorrhage at different levels of healthcare facilities in Nigeria: A qualitative study. BELITUNG NURSING JOURNAL 2022; 8:538-545. [PMID: 37554233 PMCID: PMC10405656 DOI: 10.33546/bnj.2227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/01/2022] [Accepted: 09/22/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Maternal mortality reduction remains a world health priority. One of the causes of maternal death is bleeding after childbirth. However, little is known regarding barriers to reporting for postpartum hemorrhage care among postnatal women in Nigeria. OBJECTIVE This research aimed to understand the perceived barriers to reporting postpartum hemorrhage care experienced by women and healthcare workers in Birnin Kebbi, North west-Nigeria. METHODS Qualitative case research was employed in this study with face-to-face interviews among ten postnatal women who experienced bleeding and six healthcare workers. Data were collected from September to November 2021. The interviews were all audio-taped, transcribed verbatim, and analyzed using thematic analysis. NVivo Pro Version 12 was applied to organize further and manage the data. RESULTS Six themes were developed: (1) knowledge deficit, (2) poor attitudes, behaviors, and performances, (3) low socioeconomic status, (4) lack of healthcare personnel, (5) cultural norms, and (6) lack of access to healthcare facilities. CONCLUSION The study findings might serve as input for healthcare policymakers and healthcare workers to improve health and reduce maternal mortality. Enhancing knowledge and awareness about reporting process is necessary to improve reporting for postpartum hemorrhage care among women. Training and continuous professional development of health care workers are also highly suggested to enhance the quality of care.
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Affiliation(s)
- Sirajo Mohammed
- Department of Nursing, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
| | - Lee Khuan
- Department of Nursing, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
| | | | - Irmi Zarina Binti Ismail
- Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia
| | - Saleh Ngaski Garba
- Department of Nursing Sciences, Faculty of Allied Health Sciences, Bayero University, Kano, Nigeria
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Hut-Mossel L, Ahaus K, Welker G, Gans R. Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PLoS One 2021; 16:e0248677. [PMID: 33788894 PMCID: PMC8011742 DOI: 10.1371/journal.pone.0248677] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/03/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Several types of audits have been used to promote quality improvement (QI) in hospital care. However, in-depth studies into the mechanisms responsible for the effectiveness of audits in a given context is scarce. We sought to understand the mechanisms and contextual factors that determine why audits might, or might not, lead to improved quality of hospital care. METHODS A realist review was conducted to systematically search and synthesise the literature on audits. Data from individual papers were synthesised by coding, iteratively testing and supplementing initial programme theories, and refining these theories into a set of context-mechanism-outcome configurations (CMOcs). RESULTS From our synthesis of 85 papers, seven CMOcs were identified that explain how audits work: (1) externally initiated audits create QI awareness although their impact on improvement diminishes over time; (2) a sense of urgency felt by healthcare professionals triggers engagement with an audit; (3) champions are vital for an audit to be perceived by healthcare professionals as worth the effort; (4) bottom-up initiated audits are more likely to bring about sustained change; (5) knowledge-sharing within externally mandated audits triggers participation by healthcare professionals; (6) audit data support healthcare professionals in raising issues in their dialogues with those in leadership positions; and (7) audits legitimise the provision of feedback to colleagues, which flattens the perceived hierarchy and encourages constructive collaboration. CONCLUSIONS This realist review has identified seven CMOcs that should be taken into account when seeking to optimise the design and usage of audits. These CMOcs can provide policy makers and practice leaders with an adequate conceptual grounding to design contextually sensitive audits in diverse settings and advance the audit research agenda for various contexts. PROSPERO REGISTRATION CRD42016039882.
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Affiliation(s)
- Lisanne Hut-Mossel
- Centre of Expertise on Quality and Safety, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Kees Ahaus
- Department Health Services Management & Organisation, Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Gera Welker
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rijk Gans
- Department of Internal Medicine, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Tura AK, Aboul-Ela Y, Fage SG, Ahmed SS, Scherjon S, van Roosmalen J, Stekelenburg J, Zwart J, van den Akker T. Introduction of Criterion-Based Audit of Postpartum Hemorrhage in a University Hospital in Eastern Ethiopia: Implementation and Considerations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9281. [PMID: 33322495 PMCID: PMC7764538 DOI: 10.3390/ijerph17249281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 01/10/2023]
Abstract
With postpartum hemorrhage (PPH) continuing to be the leading cause of maternal mortality in most low-resource settings, an audit of the quality of care in health facilities is essential. The purpose of this study was to identify areas of substandard care and establish recommendations for the management of PPH in Hiwot Fana Specialized University Hospital, eastern Ethiopia. Using standard criteria (n = 8) adapted to the local hospital setting, we audited 45 women with PPH admitted from August 2018 to March 2019. Four criteria were agreed as being low: IV line-setup (32 women, 71.1%), accurate postpartum vital sign monitoring (23 women, 51.1%), performing typing and cross-matching (22 women, 48.9%), and fluid intake/output chart maintenance (6 women, 13.3%). In only 3 out of 45 women (6.7%), all eight standard criteria were met. Deficiencies in the case of note documentation and clinical monitoring, non-availability of medical resources and blood for transfusion, as well as delays in clinical management were identified. The audit created awareness, resulting in self-reflection of current practice and promoted a sense of responsibility to improve care among hospital staff. Locally appropriate recommendations and an intervention plan based on available resources were formulated.
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Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Yasmin Aboul-Ela
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
| | - Sagni Girma Fage
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, P.O. Box 235 Harar, Ethiopia;
| | - Semir Sultan Ahmed
- Department of Obstetrics and Gynaecology, Hiwot Fana Specialized University Hospital, P.O. Box 235 Harar, Ethiopia;
| | - Sicco Scherjon
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands;
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, 9700 AD Groningen, The Netherlands;
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, 8934 AD Leeuwarden, The Netherlands
| | - Joost Zwart
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, 7416 SE Deventer, The Netherlands;
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, 2300 RC Leiden, The Netherlands; (Y.A.-E.); (J.v.R.); (T.v.d.A.)
- Athena Institute, Vrije Universiteit Amsterdam, 1081 HV Amsterdam, The Netherlands
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Bazirete O, Nzayirambaho M, Umubyeyi A, Uwimana MC, Evans M. Influencing factors for prevention of postpartum hemorrhage and early detection of childbearing women at risk in Northern Province of Rwanda: beneficiary and health worker perspectives. BMC Pregnancy Childbirth 2020; 20:678. [PMID: 33167935 PMCID: PMC7654175 DOI: 10.1186/s12884-020-03389-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reduction of maternal mortality and morbidity is a major global health priority. However, much remains unknown regarding factors associated with postpartum hemorrhage (PPH) among childbearing women in the Rwandan context. The aim of this study is to explore the influencing factors for prevention of PPH and early detection of childbearing women at risk as perceived by beneficiaries and health workers in the Northern Province of Rwanda. METHODS A qualitative descriptive exploratory study was drawn from a larger sequential exploratory-mixed methods study. Semi-structured interviews were conducted with 11 women who experienced PPH within the 6 months prior to interview. In addition, focus group discussions were conducted with: women's partners or close relatives (2 focus groups), community health workers (CHWs) in charge of maternal health (2 focus groups) and health care providers (3 focus groups). A socio ecological model was used to develop interview guides describing factors related to early detection and prevention of PPH in consideration of individual attributes, interpersonal, family and peer influences, intermediary determinants of health and structural determinants. The research protocol was approved by the University of Rwanda, College of Medicine and Health Sciences Institutional Ethics Review Board. RESULTS We generated four interrelated themes: (1) Meaning of PPH: beliefs, knowledge and understanding of PPH: (2) Organizational factors; (3) Caring and family involvement and (4) Perceived risk factors and barriers to PPH prevention. The findings from this study indicate that PPH was poorly understood by women and their partners. Family members and CHWs feel that their role for the prevention of PPH is to get the woman to the health facility on time. The main factors associated with PPH as described by participants were multiparty and retained placenta. Low socioeconomic status and delays to access health care were identified as the main barriers for the prevention of PPH. CONCLUSIONS Addressing the identified factors could enhance early prevention of PPH among childbearing women. Placing emphasis on developing strategies for early detection of women at higher risk of developing PPH, continuous professional development of health care providers, developing educational materials for CHWs and family members could improve the prevention of PPH. Involvement of all levels of the health system was recommended for a proactive prevention of PPH. Further quantitative research, using case control design is warranted to develop a screening tool for early detection of PPH risk factors for a proactive prevention.
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Affiliation(s)
- Oliva Bazirete
- College of Medicine and Health Sciences, University of Rwanda, 3286 Kigali, Rwanda
| | - Manassé Nzayirambaho
- College of Medicine and Health Sciences, University of Rwanda, 3286 Kigali, Rwanda
| | - Aline Umubyeyi
- College of Medicine and Health Sciences, University of Rwanda, 3286 Kigali, Rwanda
| | | | - Marilyn Evans
- University of Western Ontario, Arthur Labatt Family School of Nursing, 1151 Richmond St, London, ON N6A 3K7 Canada
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Teklewold B, Deresse T, Kinfe G, Teshome H. Participants' Opinion about Conduct of Morbidity and Mortality Conferences in Surgical Practice in a Tertiary Hospital, Ethiopia. Ethiop J Health Sci 2020; 30:355-362. [PMID: 32874078 PMCID: PMC7445942 DOI: 10.4314/ejhs.v30i3.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Morbidity and mortality conference has both educational and quality improvement purposes. However clear evidences for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. Methods A facility based cross sectional study was conducted at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia, to assess participants' opinion on benefits and functioning of morbidity and mortality conferences. Univariate analysis was used to determine the influence of professional type on participants' opinion about the morbidity and mortality conferences. Result A total of 98 participants completed the survey. The majority of the participants agreed that there was a structured system of case identification (67.3%), meeting format (72.4%), the conferences were conducted every month (79.6%), it is blame free (71.4%) and system of care was focus of discussion (70%). Most (88.8%) participants agreed that the conferences were important for improvement of patient safety and quality of care, whereas 67.3% of the participants believed that there is no written term of reference and prior dissemination of agendas. Only 40% agreed that there is multidisciplinary team involvement. Fifty one percent of them disagreed that there is a follow up on the implementation of the forwarded recommendations. Conclusion Even though the majority of the participants were satisfied with the mortality and morbidity conferences, most disagreed on the presence of written term of reference, earlier dissemination of agendas, multidisciplinary team involvement and follow up on the implementation of the forwarded recommendations.
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Affiliation(s)
| | - Tilahun Deresse
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Goytom Kinfe
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
| | - Henok Teshome
- St. Paul's Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia
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Non-clinical interventions to prevent postpartum haemorrhage and improve its management: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 240:300-309. [DOI: 10.1016/j.ejogrb.2019.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
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Abstract
BACKGROUND The literature provides scant guidance in effective quality assurance strategies concerning the use of electroconvulsive therapy (ECT) for the treatment of psychiatric conditions. Numerous guidelines are published that provide guidance in the delivery of care; however, little has been done to determine how a program or facility might ensure compliance to best practice for safety, tolerability, and efficacy in performing ECT. OBJECTIVE The objective of this project was to create a quality assurance strategy specific to ECT. Determining standards for quality care and clarifying facility policy were key outcomes in establishing an effective quality assurance strategy. METHODS An audit tool was developed utilizing quality criteria derived from a systematic review of ECT practice guidelines, peer review, and facility policy. All ECT procedures occurring over a 2-month period of May to June 2017 were retrospectively audited and compared against target compliance rates set for the facility's ECT program. Facility policy was adapted to reflect quality standards, and audit findings were used to inform possible practice change initiatives, were used to create benchmarks for continuous quality monitoring, and were integrated into regular hospital quality meetings. RESULTS Clarification on standards of care and the use of clinical auditing in ECT was an effective starting point in the development of a quality assurance strategy. Audit findings were successfully integrated into the hospital's overall quality program, and recognition of practice compliance informed areas for future quality development and policy revision in this small community-based hospital in the southeastern United States. CONCLUSIONS This project sets the foundation for a quality assurance strategy that can be used to help monitor procedural safety and guide future improvement efforts in delivering ECT. Although it is just the first step in creating meaningful quality improvement, setting clear standards and identifying areas of greatest clinical need were crucial beginning for this hospital's growing program.
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Firmin M, Carles G, Mence B, Madhusudan N, Faurous E, Jolivet A. Postpartum hemorrhage: incidence, risk factors, and causes in Western French Guiana. J Gynecol Obstet Hum Reprod 2018; 48:55-60. [PMID: 30476677 DOI: 10.1016/j.jogoh.2018.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/20/2018] [Accepted: 11/22/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Postpartum hemorrhage remains the leading cause of maternal death in France. Parturients in western French Guiana have specific sociodemographic features and a high rate of pathological pregnancies. The objective of this study was to determine the incidence of immediate postpartum hemorrhage (IPPH) in western French Guiana, and to describe the etiologies and risk factors. METHODS A case control study with incident cases was conducted in the Maternity Department of the Western French Guiana Hospital over a period of one year. The cases included women giving birth to a child of 22 weeks' GA and/or a child weighing 500 g, and who presented with IPPH. Two control subjects were included per case (after pairing for mode of delivery). The data were collected by questionnaire and from medical records. Multivariate analyses by logistic regression were conducted. RESULTS 154 cases and 308 controls were included. The incidence rate of IPPH was 6.7%. The primary etiologies were: atony, placenta retention, and cervico-vaginal lesions. The factors associated with IPPH were: past history of IPPH (ORadj = 3.36 [1.65-6.87]), pre-eclampsia (ORadj = 2.56 [1.07-6.14]), labor induction by oxytocin (ORadj = 2.03 [1.03-3.99]), the absence of managed placental delivery (ORadj = 2.46 [1.24-4.91]), a gap of more than 30 min between birth and placental delivery (ORadj = 10.92 [2.17-54.99]), and macrosomia (ORadj = 6.38 [1.97-20.67]). CONCLUSION The incidence rate of IPPH is similar to that found in metropolitan France and in the literature. The risk factors identified here will enable the development of appropriate preventive protocols.
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Affiliation(s)
- Mathilde Firmin
- Department of Gynecology and Obstetrics, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana.
| | - Gabriel Carles
- Department of Gynecology and Obstetrics, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana
| | - Bénédicte Mence
- Department of Gynecology and Obstetrics, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana
| | - Nikila Madhusudan
- Department of Gynecology and Obstetrics, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana
| | - Emilie Faurous
- Department of Gynecology and Obstetrics, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana
| | - Anne Jolivet
- Department of Public Health, Centre Hospitalier de l'Ouest Guyanais, Saint-Laurent du Maroni, French Guiana; INSERM, Sorbonne Université, Institut Pierre Louis d'Epidémiologie et Santé Publique, Department of Social Epidemiology, Paris, France
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Lumala A, Sekweyama P, Abaasa A, Lwanga H, Byaruhanga R. Assessment of quality of care among in-patients with postpartum haemorrhage and severe pre-eclampsia at st. Francis hospital nsambya: a criteria-based audit. BMC Pregnancy Childbirth 2017; 17:29. [PMID: 28086822 PMCID: PMC5237263 DOI: 10.1186/s12884-016-1219-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 12/31/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The maternal mortality ratio of Uganda is still high and the leading causes of maternal mortality are postpartum haemorrhage (PPH), severe pre-eclampsia and eclampsia. Criteria-based audit (CBA) is a way of improving quality of care that has not been commonly used in low income countries. This study aimed at finding out the quality of care provided to patients with these conditions and to find out if the implementation of recommendations from the audit cycle resulted in improvement in quality of care. METHODS This study was a CBA following a time series study design. It was done in St. Francis Hospital Nsambya and it involved assessment of adherence to standards of care for PPH, severe pre-eclampsia and eclampsia. An initial audit was done for 3 consecutive months, then findings were presented to health workers and recommendations made; we implemented the recommendations in a subsequent month and this comprised three interventions namely continuing medical education (CME), drills and displaying guidelines; a re-audit was done in the proceeding 3 consecutive months and analysis compared adherence rates of the initial audit with those of the re-audit. RESULTS Pearson Chi-Square test revealed that the adherence rates of 7 out of 10 standards of care for severe pre-eclampsia/eclampsia were statistically significantly higher in the re-audit than in the initial audit; also, the adherence rates of 3 out of 4 standards of care for PPH were statistically significantly higher in the re-audit than in the initial audit. CONCLUSION The giving of feedback on quality of care and the implementation of recommendations made during the CBA including CME, drills and displaying guidelines was associated with improvements in the quality of care for patients with PPH, severe pre-eclampsia and eclampsia.
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Affiliation(s)
| | - Peter Sekweyama
- Uganda Martyrs University Mother Kevin Postgraduate Medical School, Kampala, Uganda
| | | | | | - Romano Byaruhanga
- Uganda Martyrs University Mother Kevin Postgraduate Medical School, Kampala, Uganda
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Branger B, Velupillai C, François S, Coutin AS, Paumier A, Gillard P, Collin R, Sentilhes L, Winer N. [Clinical audit of screening for gestational diabetes among 848 pregnant women in 23 maternity units of the Pays de la Loire, 2014]. J Gynecol Obstet Hum Reprod 2016; 45:876-889. [PMID: 27068754 DOI: 10.1016/j.jgyn.2016.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 02/10/2016] [Accepted: 02/24/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Guidelines for screening for gestational diabetes mellitus (GDM) were published in 2010. An audit of the maternity units of the Pays de la Loire network sought to determine the adherence rate and to study the factors affecting it in order to propose corrective measures to improve it. METHODS The perinatal network in Pays de la Loire provided obstetricians of the 23 participating maternity units with a set of criteria to be collected from the files of women giving birth. The methodology of the audit was designed to enable calculation of the adherence rate overall and according to indications (risk factors, hyperglycemia, and macrosomia): adherence, non-adherence, and over-adherence (screening in the absence of an indication). To obtain around 900 pregnancies, the audit was planned to cover a week of deliveries in June 2014. RESULTS The analysis included 848 pregnancies and 872 newborns. Risk factors were found for 46.6% of the women (43.2 to 49.9): 13.2% for maternal age≥35years and 30.8% for BMI≥25kg/m2. GDM was diagnosed for 14.6% (12.4 to 17.2). The adherence rate for screening was 45.5% (42.2 to 49.9), the non-adherence rate 27.6% (24.7 to 30.7), and the over-adherence rate 26.9% (24.0 to 30.0). Among the factors potentially associated with adherence, we observed only the second-trimester factor (macrosomia); there was no "professional" effect on adherence criteria. No evidence of overmanagement was observed for the pregnancies/deliveries/newborns with overdiagnosis. Oral glucose tolerance tests were performed in accordance with the guidelines (95.9%). Follow-up of women with GDM by specialists was satisfactory (84.6%). DISCUSSION This audit showed that adherence to the guidelines was insufficient in the Pays de la Loire network. The reasons for this are numerous: ignorance of the guidelines, in part due to their relative recency, the change in the blood sugar levels defining GDM (perceived as too low), and the absence of strong evidence about these thresholds from publications and practices in other countries, the need to select women for risk factors, and sometimes the late onset of prenatal care at the maternity unit. CONCLUSION In view of this audit, the Perinatal Network of Pays de la Loire must work to improve the knowledge and screening practices for GDM among its professionals, by the repeated dissemination of these guidelines and chart review sessions.
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Affiliation(s)
- B Branger
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France
| | - C Velupillai
- Maternité, pôle mère-enfant, CHU, 38, boulevard Jean-Monnet, 44093 Nantes cedex, France
| | - S François
- Maternité, hôpital Sud-Francilien, 91100 Corbeil-Essonnes, France
| | - A S Coutin
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France
| | - A Paumier
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France; Maternité, clinique de l'Atlantique, avenue Claude-Bernard, BP 419, 44819 Saint-Herblain, France
| | - P Gillard
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France; Maternité, CHU, 4, rue Larrey, 49933 Angers cedex 09, France
| | - R Collin
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France
| | - L Sentilhes
- Maternité, CHU, 4, rue Larrey, 49933 Angers cedex 09, France
| | - N Winer
- Réseau « Sécurité Naissance des Pays de la Loire », 2, rue de la Loire, 44200 Nantes, France; Maternité, pôle mère-enfant, CHU, 38, boulevard Jean-Monnet, 44093 Nantes cedex, France.
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13
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Abstract
Postpartum Haemorrhage (PPH) is a major cause of maternal morbidity and mortality. Treatment of acquired coagulopathy observed in severe PPH is an important part of PPH management, but is mainly based on literature in trauma patients, and data thus should be interpreted with caution. This review describes recent advances in transfusion strategy and in the use of tranexamic acid and fibrinogen concentrates in women with PPH.
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Affiliation(s)
- Marie Pierre Bonnet
- Department of Anaesthesia and Intensive Care Medicine, Paris Descartes University, Paris, France
| | - Dan Benhamou
- Department of Anaesthesia and Intensive Care Medicine, Paris Sud University, Paris, France
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14
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Lecoanet A, Vidal-Trecan G, Prate F, Quaranta JF, Sellier E, Guyomard A, Seigneurin A, François P. Assessment of the contribution of morbidity and mortality conferences to quality and safety improvement: a survey of participants' perceptions. BMC Health Serv Res 2016; 16:176. [PMID: 27169924 PMCID: PMC4865106 DOI: 10.1186/s12913-016-1431-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/05/2016] [Indexed: 11/24/2022] Open
Abstract
Background Evidence for the effectiveness of the morbidity and mortality conferences in improving patient safety is lacking. The aim of this survey was to assess the opinion of participants concerning the benefits and the functioning of morbidity and mortality conferences, according to their organizational characteristics. Methods We conducted a survey of professionals involved in a morbidity and mortality conference using a self-administered questionnaire in three French teaching hospitals in 2012. The questionnaire focused on the functioning of morbidity and mortality conferences, the perceived benefits, the motivations of participants, and how morbidity and mortality conferences could be improved. The perception of participants was analysed according to the characteristics of morbidity and mortality conferences. Results A total of 698 participants in 54 morbidity and mortality conferences completed the questionnaire. Most of them (91 %) were satisfied with how the morbidity and mortality conference they attended was conducted. The improvements in healthcare quality and patient safety were the main benefits perceived by participants. Effectiveness in improving safety was mainly perceived when cases were thoroughly analysed (adjusted odds ratio [a0R] =2.31 [1.14–4.66]). The existence of a written charter (p = 0.05), the use of a standardized case presentation (p = 0.049), and prior dissemination of the meeting agenda (p = 0.02) were also associated with the perception of morbidity and mortality conference effectiveness. The development and achievement of improvement initiatives were associated with morbidity and mortality conferences perceived as being more effective (p < 0.01). Participants suggested improving the attendance of medical and paramedical professionals to enhance the effectiveness of morbidity and mortality conferences. Conclusions Morbidity and mortality conferences were positively perceived. These results suggest that a structured framework and thoroughly analyzing cases improve their effectiveness.
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Affiliation(s)
- André Lecoanet
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Gwenaëlle Vidal-Trecan
- Public health unit: Risk Management and Quality of Care, Paris Centre University Hospital Group, AP-HP, Paris, F-75014, France.,Research Unit: METHODS team, INSERM U1153 (Centre de Recherche Epidémiologie Biostatistique, Sorbonne Paris Cité), Paris, F-75005, France.,Medical School, Paris Descartes University, Paris, F-75006, France
| | - Frédéric Prate
- Public Health Department, University Hospital, Nice, F-06003, France
| | | | - Elodie Sellier
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Alizé Guyomard
- Public Health Department, University Hospital, Grenoble, F-38043, France
| | - Arnaud Seigneurin
- Public Health Department, University Hospital, Grenoble, F-38043, France.,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France
| | - Patrice François
- Public Health Department, University Hospital, Grenoble, F-38043, France. .,Research Unit TIMC-IMAG (UMR 5525 CNRS/UJF-Grenoble 1), Grenoble, F-38041, France.
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15
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Influencing factors for high quality care on postpartum haemorrhage in the Netherlands: patient and professional perspectives. BMC Pregnancy Childbirth 2015; 15:272. [PMID: 26497307 PMCID: PMC4619207 DOI: 10.1186/s12884-015-0707-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 10/15/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a major contributor to maternal morbidity even in high resource settings, despite the development and dissemination of evidence-based guidelines and Advance-Trauma-Life-Support (ATLS) based courses for optimal management of PPH. We aimed to assess current influencing factors (obstacles and facilitators) for the delivery of high quality PPH-care from both patient and professional perspective. METHODS We qualitatively explored influencing factors for delivering high quality PPH-care, by having individual interviews with PPH-patients and focus group interviews with the different types of professionals working in the delivery room. For both perspectives, the theoretical frameworks of Grol and Cabana were used to classify the influencing factors for optimal PPH-care (factors of the guidelines, of professionals, of patients, of the social setting and of the organisation). In order to assess the importance of the influencing factors found among the professionals, we quantified these factors in a web-based questionnaire. RESULTS A total of 12 patients and 41 professionals participated in the interviews, and 315 complete surveys were analyzed. The main obstacle for high quality PPH-care identified by patients was the lack of information given by the professionals to the patient and partner before, during and after the PPH event. An informative patient website, a patient leaflet and a follow-up consultation were mentioned as facilitators. The main obstacles according to the professionals were: lack of clarity of the guidelines, lack of knowledge and failing team-communication. Team training and checklists/ flowcharts were considered facilitators. CONCLUSIONS Different obstacles to the delivery of high quality PPH-care were identified by both patients and professionals. These data can be used to develop a focused strategy to improve PPH-care. TRIAL REGISTRATION NCT 00928863.
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16
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Hancock A, Weeks AD, Lavender DT. Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: an integrative review of the literature. BMC Pregnancy Childbirth 2015; 15:230. [PMID: 26415952 PMCID: PMC4587838 DOI: 10.1186/s12884-015-0653-6] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 09/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) is the leading cause of maternal mortality in low-income countries and severe maternal morbidity in many high-income countries. Poor outcomes following PPH are often attributed to delays in the recognition and treatment of PPH. Experts have suggested that improving the accuracy and reliability of blood loss estimation is the crucial step in preventing death and morbidity from PPH. However, there is little guidance on how this can be achieved. The aim of this integrative review was to evaluate the various methods of assessing maternal blood loss during childbirth. METHODS A systematic, integrative review of published research studies was conducted. All types of studies were included if they developed, tested, or aimed to improve methods and skills in quantifying blood loss during childbirth, or explored experiences of those involved in the process. RESULTS Thirty-six studies were included that evaluated the accuracy of visual estimation; tested methods to improve skills in measurement; examined their effect on PPH diagnosis and treatment, and / or explored additional factors associated with blood loss evaluation. The review found that health professionals were highly inaccurate at estimating blood loss as a volume. Training resulted in short term improvements in skills but these were not retained and did not improve clinical outcomes. Multi-faceted interventions changed some clinical practices but did not reduce the incidence of severe PPH or the timing of responses to excessive bleeding. Blood collection bags improved the accuracy of estimation but did not prevent delays or progression to severe PPH. Practitioners commonly used the nature and speed of blood flow, and the condition of the woman to indicate that the blood loss was abnormal. CONCLUSIONS Early diagnosis of PPH should improve maternal outcomes, but there is little evidence that this can be achieved through improving the accuracy of blood loss volume measurements. The diagnosis may rely on factors other than volume, such as speed of blood flow and nature of loss. A change in direction of future research is required to explore these in more detail.
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Affiliation(s)
- Angela Hancock
- School of Nursing, Midwifery & Social Work, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Andrew D Weeks
- Department of Women's and Children's Health, Liverpool Women's Hospital, University of Liverpool, Crown Street, Liverpool, L8 7SS, UK.
| | - Dame Tina Lavender
- School of Nursing, Midwifery & Social Work, The University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK.
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17
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Schlembach D, Mörtl MG, Girard T, Arzt W, Beinder E, Brezinka C, Chalubinski K, Fries D, Gogarten W, Hackelöer BJ, Helmer H, Henrich W, Hösli I, Husslein P, Kainer F, Lang U, Pfanner G, Rath W, Schleussner E, Steiner H, Surbek D, Zimmermann R. [Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. Anaesthesist 2014; 63:234-42. [PMID: 24584885 DOI: 10.1007/s00101-014-2291-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.
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Affiliation(s)
- D Schlembach
- Abteilung für Geburtshilfe, Universitätsfrauenklinik, Universitätsklinikum Jena, Bachstr. 18, 07732, Jena, Deutschland,
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18
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Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement. Eur J Obstet Gynecol Reprod Biol 2014; 178:169-75. [DOI: 10.1016/j.ejogrb.2014.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 04/08/2014] [Accepted: 04/15/2014] [Indexed: 11/22/2022]
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19
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Bailit JL, Grobman WA, Rice MM, Spong CY, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Shubert PJ, Tita AT, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE, Van Dorsten JP. Risk-adjusted models for adverse obstetric outcomes and variation in risk-adjusted outcomes across hospitals. Am J Obstet Gynecol 2013; 209:446.e1-446.e30. [PMID: 23891630 PMCID: PMC4030746 DOI: 10.1016/j.ajog.2013.07.019] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/30/2013] [Accepted: 07/22/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Regulatory bodies and insurers evaluate hospital quality using obstetrical outcomes, however meaningful comparisons should take preexisting patient characteristics into account. Furthermore, if risk-adjusted outcomes are consistent within a hospital, fewer measures and resources would be needed to assess obstetrical quality. Our objective was to establish risk-adjusted models for 5 obstetric outcomes and assess hospital performance across these outcomes. STUDY DESIGN We studied a cohort of 115,502 women and their neonates born in 25 hospitals in the United States from March 2008 through February 2011. Hospitals were ranked according to their unadjusted and risk-adjusted frequency of venous thromboembolism, postpartum hemorrhage, peripartum infection, severe perineal laceration, and a composite neonatal adverse outcome. Correlations between hospital risk-adjusted outcome frequencies were assessed. RESULTS Venous thromboembolism occurred too infrequently (0.03%; 95% confidence interval [CI], 0.02-0.04%) for meaningful assessment. Other outcomes occurred frequently enough for assessment (postpartum hemorrhage, 2.29%; 95% CI, 2.20-2.38, peripartum infection, 5.06%; 95% CI, 4.93-5.19, severe perineal laceration at spontaneous vaginal delivery, 2.16%; 95% CI, 2.06-2.27, neonatal composite, 2.73%; 95% CI, 2.63-2.84). Although there was high concordance between unadjusted and adjusted hospital rankings, several individual hospitals had an adjusted rank that was substantially different (as much as 12 rank tiers) than their unadjusted rank. None of the correlations between hospital-adjusted outcome frequencies was significant. For example, the hospital with the lowest adjusted frequency of peripartum infection had the highest adjusted frequency of severe perineal laceration. CONCLUSION Evaluations based on a single risk-adjusted outcome cannot be generalized to overall hospital obstetric performance.
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Affiliation(s)
- Jennifer L Bailit
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH
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20
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Medical prevention and treatment of postpartum hemorrhage: a comparison of different guidelines. Arch Gynecol Obstet 2013; 289:555-67. [DOI: 10.1007/s00404-013-3016-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
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Dupont C, Occelli P, Fassier T, Gaucher L, Colin C, Francois P, Deneux-Tharaux C, Rudigoz RC. Évaluation de l’impact des revues de morbi-mortalité en obstétrique : revue de la littérature. ACTA ACUST UNITED AC 2012; 41:255-61. [DOI: 10.1016/j.jgyn.2012.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/17/2012] [Accepted: 03/07/2012] [Indexed: 11/24/2022]
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Dupont C, Deneux-Tharaux C, Cortet M, Colin C, Touzet S, Rabilloud M, Lansac J, Harvey T, Tessier V, Chauleur C, Pennehouat G, Morin X, Bouvier-Colle MH, Rudigoz RC. Prise en charge des hémorragies graves du post-partum après un accouchement par voie basse : étude en population dans 106 maternités françaises. ACTA ACUST UNITED AC 2012; 41:279-89. [DOI: 10.1016/j.jgyn.2012.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 02/04/2012] [Accepted: 02/17/2012] [Indexed: 11/29/2022]
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MARKOVA VERONIKA, SØRENSEN JETTELED, HOLM CHARLOTTE, NØRGAARD ASTRID, LANGHOFF-ROOS JENS. Evaluation of multi-professional obstetric skills training for postpartum hemorrhage. Acta Obstet Gynecol Scand 2012; 91:346-52. [DOI: 10.1111/j.1600-0412.2011.01344.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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