Table 2 Quality criteria for validation of 25 earlier developed quality indicators of PPH in primary midwifery care
Category, indicators | Applicability | Feasibility | Amount of cases in adherence to indicator (%) | Improvement potential Yes, No or NA (not applicable) If adherence to indicator is <90% | |
|---|---|---|---|---|---|
n patients | % of patients with missing values | ||||
If number of patients is >10 | If availability of data is >70% | ||||
Prevention | |||||
Antenatally: identify | 94 | 0 | No | ||
1. | elevated- or high risk and agree on preventive strategies. | ||||
- No elevated- or high risk of PPH identified | 85 (90) | ||||
- Elevated- or high risk of PPH identified | 9 (10) | ||||
â—‹ Referred to secondary care | 9 (100) | ||||
â—‹ Not referred to secondary care | 0 (0) | ||||
high risk and agree (or adjust) on preventive strategies. | |||||
2. | At birth: identify elevated- or high risk | 94 | 100 | NA | NA |
3. | If high risk is assessed: have birth occur in hospital supervised by the obstetrician. | 94 | 100 | NA | NA |
4.* | Routinely administer uterotonics (at least 5 IU oxytocin intramuscular). | 94 | 0 | Yes | |
- Yes, at least 5 IU oxytocin | 54 (57) | ||||
- No | 40 (43) | ||||
In case of blood loss >500 mL, without signs of shock the midwife should; | |||||
5. ** | Objectify blood loss by weighing. | 94 | 28 | Yes | |
- Yes | 68 (72) | ||||
- No/unknown | 26 (28) | ||||
6. *** | Homebirth: in case of retained placenta; refer to secondary care after 30 minutes. | 35 | 0 | Yes | |
- Referral <35 minutes | 13 (37) | ||||
- Referral >35 minutes | 22 (63) | ||||
7. *** | Midwifery supervised hospital birth: in case of retained placenta; refer to secondary care after 30 minutes. | 9/ No | 11 | NA | |
- Referral <35 minutes | 3 (33) | ||||
- Referral >35 minutes | 5 (56) | ||||
8. | Home birth; if blood loss is not ceasing, refer to secondary care. | 35 | 0 | No | |
- Timely referral | 32 (91) | ||||
- No timely referral | 3 (9) | ||||
9. | Midwifery supervised hospital birth if blood loss is not ceasing, refer to secondary care. | 13 | 0 | No | |
- Timely referral | 13 (100) | ||||
- No timely referral | 0 (0) | ||||
10. | Treat PPH as uterine atony until proven otherwise. | 94 | 0 | Yes | |
A Catheter | 77 (82) | ||||
B Uterine massage | 66 (70) | ||||
C Oxytocin | 74 (79) | ||||
D Combination of catheter, uterine massage and oxytocin | 53 (56) | ||||
11. | Post placental: if blood loss is not ceasing despite administration of uterotonics; examine for vaginal and perineal lesions | 94 | 1 | 93 (99) | No |
In case of PPH of >1000 mL and/or signs of shock, the midwife should; | |||||
12. | Inform the secondary caregiver (obstetrician). | 94 | 0 | No | |
- Yes | 92 (98) | ||||
- No | 2 (2) | ||||
13. | Start an intravenous line and supply with fluids, using 0,9% sodium chloride | 94 | 1 | No | |
A. Midwife | 22 (23) | ||||
B. Ambulance personnel | 47 (50) | ||||
C. Hospital personnel (gynecologist or nurse) | 21 (22) | ||||
D. No intravenous line given | 3 (3) | ||||
E. Total given | 91 (97) | ||||
14 | Monitor vital signs frequently. | 94 | 60 | NA | |
β | A Blood pressure | 14 (15) | |||
B Pulse | 1 (1) | ||||
C Blood pressure & | 23 (25) | ||||
D pulse | |||||
E Total reported | 38 (40) | ||||
15. | Regardless of oxygen saturation, provide patient with 10–15 liter oxygen via non-rebreathing mask. | 94 | 0 | Yes | |
- Yes | 10 (11) | ||||
- No | 84 (89) | ||||
In case of PPH of >1000 mL with signs of shock and/or >2000 mL blood loss the midwife should; | |||||
16. | In case of persisting hemorrhaging with signs of shock, perform uterine and/ or aortal compression. | 94 | 100/No | NA | |
17. | Secure a second intravenous line (14 gauge). | 3/ No | 67 | NA | |
- Yes | 0 (0) | ||||
- No | 1 (33) | ||||
18. | If the patient has reduced consciousness due to hypovolemic shock, call for (paramedic) assistance in order to establish an open airway. | 3/ No | 100 | NA | NA |
19. | Immediately transfer patient to secondary care. | 3/ No | 0 | NA | |
- Yes | 2 (67) | ||||
- No | 1 (33) | ||||
Concerning cooperation, training and documentation | |||||
20. | Within every regional obstetric collaboration†a regional PPH protocol should be present, based on the national guidelines. | 94 | 100 | NA | NA |
21. | A regional PPH protocol should be the basis of regular audits | 94 | 100 | NA | NA |
22. | Every midwife should be aware that ambulance transportation in case of PPH or retained placenta is always of the highest urgency category (A1). | 94 | 32 | NA | |
- A1 (arrival at patient | 51 (54) | ||||
- within 15 minutes) | |||||
- A2 (arrival at patient within 30 minutes) | 13 (14) | ||||
23. | After each PPH with >2000 mL blood loss, the multidisciplinary team should debrief the situation. | 3/ No | 100 | NA | NA |
24. | Within the regional obstetric collaboration†an annual training in obstetric emergencies should be provided. | 94 | 100 | NA | NA |
25. | In a homebirth situation, anticipation on possible ambulance transport is necessary; make sure the patient is at an accessible place for (all) caregivers in time. | 94 | 100 | NA | NA |