Retraction: Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

[This retracts the article DOI: 10.7759/cureus.26819.].

Implementation of Postpartum Hemorrhage Emergency Care Using a Bundle Approach at a Tertiary Care Hospital in North India.

Background The major cause of maternal death globally is postpartum hemorrhage (PPH). When PPH develops, early detection of bleeding and rapid treatment with evidence-based guidelines can prevent most PPH-related severe morbidity and mortality. The bundle care approach for PPH management could be a potential solution to inefficient and uneven evidence-based practice implementation worldwide. Bundle care is a collection of discrete, evidence-based interventions given to every eligible person simultaneously or in quick succession and requires teamwork, communication, and cooperation. The primary objective of this study was to analyze whether implementing a PPH bundle of care may reduce maternal morbidity and mortality in our institution. Methods This was a single-center retrospective pre-post case-control study was carried out at a tertiary care center and teaching hospital in Varanasi, eastern Uttar Pradesh state, India. From January 2021 to June 2021, pretraining data (PRE) were collected retrospectively on all births from the department of Obstetrics and Gynecology, Sir Sunderlal Hospital, Institute of Medical Sciences, Banaras Hindu University. Subsequently, medical and paramedical personnel of our hospital were trained in Postpartum Hemorrhage Emergency Care Using a Bundle Approach (PPH EmC) as per the guidelines laid down by the World Health Organization (WHO) for PPH management and implemented in July 2021. Post-training data (POST) were then collected retrospectively on all deliveries at our hospital from August 2021 to January 2022. All the data within two periods were computed and analyzed. The results were then compared for any significant changes in the incidences of maternal mortality and morbidity in terms of the rates of blood transfusion required and the type of management used (medical or medical-surgical), use of tranexamic acid, and additional uterotonics. The results were expressed as proportions, and p≤0.05 was considered statistically significant using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY, USA). Results A total of 1304 women gave birth from January 2021 to January 2022, of whom 107 patients (61 in the PRE and 57 in the POST group) were diagnosed and treated for PPH. There was no significant difference in the incidence of PPH in the PRE and POST groups (p=0.581). There was a significant increase in the use of tranexamic acid (p=0.041) and a significant reduction in blood transfusion rates (p=0.032) after the implementation of bundled care in the POST group. The odds of PPH non-occurrence after pre- and post-test was 1.103 (95% CI=0.747 to 1.635). No significant difference was observed in maternal mortality in the PRE and POST groups (p=0.96). The requirement for radical surgical treatment of PPH, which included hysterectomies, was also significantly reduced, from 27.27% in the PRE group to 11.54% in the POST group (p=0.032). Conclusions PPH care bundles might improve the morbidity of PPH with the use of fewer resources and fewer interventions required. While these data are promising, further studies are needed to analyze bundle care's long-term effects.

Increasing postpartum IUCD coverage through a QI initiative: a step towards reducing the unmet need of postpartum contraception.

BACKGROUND: Unintended pregnancies have a negative impact on the health and economy of a nation, which can be prevented by effective family planning (FP) services. Postpartum intrauterine device (PPIUCD) is a safe and effective FP method which allows women to obtain long-acting contraception before discharge from the point of delivery. We observed poor coverage of deliveries with PPIUCD at our facility. This was the trigger to initiate a quality improvement (QI) initiative to increase the PPIUCD coverage from current rate of 4.5%-10% in 3-month period. METHOD: A fishbone analysis of the problem was done and the following causes were identified: lack of focused counselling for FP, lack of sensitisation and training of resident doctors and inconsistent supply of intrauterine contraceptive devices (IUCDs). A QI team was constituted with representatives from faculty members, residents, interns, nursing officers and FP counsellors. The point of care quality improvement methodology was used. INTERVENTIONS: Daily counselling of antenatal women was started by the counsellors and interns in antenatal wards. A WhatsApp group of residents was made initially to sensitise them; and later for parking of problems and trouble shooting. The residents were provided hands-on training at skills lab. Uninterrupted supply of IUCDs was ensured by provision of buffer stock of IUCDs with respective store keepers. RESULT: The PPIUCD insertion rates improved from 4.5% to 19.2% at 3 months and have been sustained to a current 30%-35% after 1 ½ years of initiation of the project tiding through the turbulence during the COVID-19 pandemic using QI techniques. CONCLUSION: Sensitisation and training of residents as well as creation of awareness among antenatal women through targeted counselling helped improve PPIUCD coverage at the facility. QI initiatives have the potential to facilitate effective implementation of the FP programmes by strategic utilisation of the resources.