Taking on a Leading Cause of Maternal Death: Improving Postpartum Hemorrhage Care
These are alarming numbers, especially given that postpartum hemorrhage is a leading cause of pregnancy-related deaths.
A recent study from the CDC Foundation notes that hospitals may be able to prevent up to 70 percent of hemorrhage-relate obstetric deaths. This means that, with the right strategies, we can drastically reduce one of the most common causes of maternal mortality. And since black women have a greater risk of death from postpartum hemorrhage than white women, improving postpartum hemorrhage care has significant implications for improving health equity.
“This potential preventability makes postpartum hemorrhage an important target for quality improvement efforts,” says Patricia Heinrich, RN, MSN, CLE, executive project director for NICHQ’s work on the New York State Department of Health’s New York State Perinatal Quality Collaborative (, which seeks to improve maternal and infant health outcomes through evidence-based perinatal interventions. “By identifying what needs to be improved in a clinical setting, we can test our way to solutions in hospitals across the state and then across the country.”
The NYS Obstetric Hemorrhage Project—a joint effort of the NYSPQC, American College of Obstetricians and Gynecologists District II, Greater New York Hospital Association, Healthcare Association of New York State and NICHQ—is seeking to do just that by testing a set of evidence-based strategies that hospitals can implement to improve postpartum hemorrhage care. Here, Peter Cherouny, MD, a clinical advisor for the project, offers insight on three areas those strategies seek to improve.
One: Relying on Objective Methods to Identify Blood Loss
“If we don’t know how much blood a mother loses, it’s hard to know if she is in danger,” says Cherouny. “And right now, most hospitals use poorly effective means to gauge blood loss. Care teams can look and guess based on what they see, but their guesses are rarely accurate.”
As a result, many care teams base interventions on the mother’s physiological response, a strategy that is fraught with uncertainty. According to Cherouny, women’s bodies often mask the signs and symptoms of distress when they hemorrhage. And by the time interventions occur, the mother may already be in an unstable state that can further deteriorate quickly. Identifying a standard way to assess blood loss would lessen this uncertainty and spark proactive interventions.
“In quality improvement work, we can’t let perfect get in the way of good,” says Cherouny. “We’re trying to identify better strategies for identifying blood loss, strategies like teaching nurses to estimate the amount of blood loss based on the weight or soakage of materials in the delivery room. These strategies may not be perfect, but they provide a foundation our improvement work can build on.”
Two: Standardizing a Plan for Emergencies
“In severe cases, women can lose their blood volume in six to ten minutes,” says Cherouny. “These cases are rare, but hospitals need to be prepared for any eventuality. Establishing a standard massive transfusion protocol, with details on how to coordinate with the hospital’s blood bank, and staff roles and responsibilities, can make all the difference in an emergency.”
Cherouny also recommends having a standard obstetric hemorrhage cart with any medicines needed to manage hemorrhage. Labeling each medicine with the correct dose and the interval for the dosing sets teams up for success during a hectic delivery.
“And remember, practice is a must,” says Cherouny. “Simulating the process of managing different degrees of a postpartum hemorrhage will maximize preparedness of all those involved.”
Three: Improving Communication and Reporting
Hospitals also need to be prepared for hemorrhages that happen over a period of hours rather than minutes. In these situations, women may lose blood during labor and delivery, when transferred between floors, and during recovery. These changing settings, not to mention changing staff and changing shifts, leave room for error. A standard reporting system to continuously track the amount of blood lost can ensure that no loss is overlooked.
“The closer we come to achieving these goals, the closer we come to improving maternal health, which is a central goal for the NYSPQC,” says Heinrich. “Healthier, safer care for mothers translates to better outcomes for the mother-child dyad, both at birth and in the years to come.”
Interested in learning more about improving maternal and infant health outcomes and reducing disparities? Our Infant Mortality Prevention Toolkit includes case studies and lessons-learned on improving women’s pre- and interconception care to achieve better birth outcomes. Click in to get started. For more information on the NYSPQC, visit www.nyspqc.org.
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