BJOG Release: New Study On The Causes And Treatment Of Major Obstetric Haemorrhage

Main Category: Pregnancy / Obstetrics
Also Included In: Blood / Hematology;  Women's Health / Gynecology
Article Date: 08 Nov 2007 - 2:00 PDT

email to a friend   printer friendly   view / write opinions   rate article

A new study published in BJOG: An International Journal of Obstetrics and Gynaecology examines current practice in the management of major obstetric haemorrhage during childbirth.

Over 500,000 women worldwide die each year as a result of pregnancy and childbirth. Whilst maternal mortality in developed countries such as the UK is relatively low, a leading cause of severe maternal morbidity in developed countries remains major obstetric haemorrhage.

The Scottish Programme for Clinical Effectiveness in Reproductive Health, based at the University of Aberdeen, undertook a study to examine why obstetric haemorrhage occurs to provide valuable information so that doctors can learn more reliably to predict it, and hence act more swiftly.

Major obstetric haemorrhage was defined as an estimated blood loss level (EBL) of at least 2500 ml, the transfusion of five or more units of blood, or receiving treatment for coagulopathy (fresh frozen plasma) during the acute event.

All consultant-led maternity units in Scotland took part in the study. 582 cases of major obstetric haemorrhage were reported over a period of three years (2003 - 05) and researchers had detailed notes of 517 cases.

Results show that major obstetric haemorrhage occurs at the rate of 3.7 per 1000 births. The average age of women experiencing the condition was 30.9 years and the median parity was 1. The common cause was uterine atony (failure to contract properly) (48%), followed by problems with the placenta such as a retained placenta (18%), placenta praevia (12%) and placental abruption (9%). Emergency caesarean section accounted for the majority of deliveries (41%).

In most cases, an appropriate clinical protocol was followed and consultant obstetricians and anaesthetists were alerted to attend. Blood bank staff, including haematologists, were also contacted.

12% of the women in the study underwent hysterectomy, representing a rate of 0.4 per 1000 deliveries. The study shows that conservative surgical methods to stop the bleeding are favoured by doctors. The main procedures used were intrauterine balloon tamponade (success rate 78%) and uterine compression (B-Lynch suture) (success rate 81%). Researchers observed that these techniques are relatively easy for obstetric registrars to use while waiting for senior assistance.

Researchers noted that a high incidence of women with obstetric haemorrhage were delivered by caesarean section. The association between emergency caesarean sections and major obstetric haemorrhage could be a result of the indication for the caesarean delivery or because of the procedure itself (a previous US-based study has shown that a common cause of bleeding was the extension of the uterine incision at caesarean section). The Scottish research also suggests that as the maternal population ages and the caesarean section rate rises, the incidence of placenta praevia in subsequent pregnancies is also likely to increase, leading to increased rate of haemorrhage in the future.

The findings show that high dependency care is usually available and is provided by obstetricians and anaesthetists in the labour ward for women who have had major obstetric haemorrhage. Women are only admitted into an intensive care unit if kidney failure occurs or when ventilation is required.

According to researchers, this study highlights the importance of senior staff presence in the labour ward to prevent adverse events. With the introduction of the European Working Time Directive (EWTD), junior doctors' working hours have decreased and this has resulted in trainees having less contact time with patients and consultants. Researchers state that adequate supervision of trainees by consultants is required to ensure safety in the labour ward.

Dr Victoria Brace, from the Department of Obstetrics and Gynaecology in Aberdeen Maternity Hospital, who co-authored the paper, said "Major obstetric haemorrhage is a largely unpredictable condition that can affect any woman in pregnancy or childbirth.

"The majority of women we studied can be thought of as 'great saves' rather than 'near misses' where good clinical care prevented severe morbidity progressing to maternal mortality. However, our research has highlighted a relatively low consultant presence during the management of major obstetric haemorrhage. The system failures identified (avoidable delays in diagnosis and treatment of bleeding, failure to follow guidelines, poor communication and inadequate training or supervision of junior doctors) would be amenable to improvement by increasing presence of consultant obstetricians on the labour ward.

"With the introduction of European Working Time Directive, there is a need for more trained consultant obstetricians in order to fulfil this role. Adequate staffing of the labour ward, both by midwives and consultant obstetricians, is required to ensure the safety of women during childbirth."

Professor Phil Steeer, BJOG editor in chief said "The results from this study regarding adherence to risk management protocols and guidelines in the treatment of major obstetric haemorrhage are promising. But this research also reveals that when expert help is required in severe cases of heavy bleeding during or after childbirth, it is needed immediately.

"We know that most cases of haemorrhage occur as a result of uterine atony and corrective treatment is available. However, in order for such treatment to be provided in a timely manner, more consultants are needed in our labour wards, not just to treat women but also to supervise trainees so that the best care is provided."

BJOG: An International Journal of Obstetrics and Gynaecology is owned by the Royal College of Obstetricians and Gynaecologists (RCOG) but is editorially independent and published monthly by Blackwell Publishing. The journal features original, peer-reviewed, high-quality medical research in all areas of obstetrics and gynaecology worldwide. Please quote 'BJOG' or 'BJOG: An International Journal of Obstetrics and Gynaecology' when referring to the journal.

Reference

Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-2005. BJOG 2007

Royal College of Obstetricians and Gynaecologists