Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study

Abstract

Background: Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. A national quality improvement programme called the Obstetric Bleeding Strategy for Wales (OBS Cymru) was introduced in all obstetric units in Wales. The aim was to reduce moderate PPH (1000 mL) progressing to massive PPH (> 2500 mL) and the need for red cell transfusion.

Methods: A PPH care bundle was introduced into all 12 obstetric units in Wales included all women giving birth in 2017 and 2018 (n = 61,094). The care bundle prompted: universal risk assessment, quantitative measurement of blood loss after all deliveries (as opposed to visual estimation), structured escalation to senior clinicians and point-of-care viscoelastometric-guided early fibrinogen replacement. Data were submitted by each obstetric unit to a national database. Outcome measures were incidence of massive PPH (> 2500 mL) and red cell transfusion. Analysis was performed using linear regression of the all Wales monthly data.

Results: Uptake of the intervention was good: quantitative blood loss measurement and risk assessment increased to 98.1 and 64.5% of all PPH > 1000 mL, whilst ROTEM use for PPH > 1500 mL increased to 68.2%. Massive PPH decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P = 0.011). Fewer women progressed from moderate to massive PPH in the last 6 months, 74/1490 (5.0%), than in the first 6 months, 97/1386 (7.0%), (P = 0.021). Units of red cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P = 0.015). Red cells were transfused to 350/15204 (2.3%) and 268/15150 (1.8%) (P = 0.001) in the first and last 6 months, respectively. There was no increase in the number of women with lowest haemoglobin below 80 g/L during this time period. Infusions of fresh frozen plasma fell and there was no increase in the number of women with haemostatic impairment.

Conclusions: The OBS Cymru care bundle was feasible to implement and associated with progressive, clinically significant improvements in outcomes for PPH across Wales. It is applicable across obstetric units of widely varying size, complexity and staff mixes.

Keywords: Blood transfusion; Coagulopathy; Postpartum haemorrhage; Quality improvement; Viscoelastometry.

Fig. 1

Uptake of OBS Cymru interventions. Legend: The data indicate the percentage of cases where interventions were performed in consecutive women, irrespective of blood loss. Box plots with median, interquartile range and range refer to the combination of paperwork being present in the notes, the risk assessment having been completed and measured blood loss being performed

Fig. 2

Change in incidence of postpartum haemorrhage > 2500 mL during OBS Cymru. Legend: Panel a shows the monthly rates for massive haemorrhage and the fitted regression line with 95% confidence interval shaded in grey. Funnel plots show the incidence of massive postpartum haemorrhages at each obstetric unit in the first (b) and last (c) 6 month periods of the quality improvement project. The line represents the mean and the limits shown are 2 and 3 standard deviations. The dashed line indicates a massive haemorrhage rate of 10/1000 maternities

Fig. 3

Change in incidence of red blood cell transfusion during OBS Cymru. Legend: Panel a shows the monthly rates for red blood cell transfusion and the fitted regression line with 95% confidence interval shaded in grey. Funnel plots show the incidence of RBC transfusion for postpartum haemorrhages at each obstetric unit in the first (b) and last (c) 6 month periods of the quality improvement project. The line represents the mean and the limits shown are 2 and 3 standard deviations. The dashed line represents a RBC transfusion rate of 50 units/1000 maternities