The challenge of adopting a collaborative information system for independent healthcare workers in France: a comprehensive study.

This study aimed to explore the perception of an underutilised collaborative information system through qualitative research, utilizing semi-structured, in-depth interviews with independent midwives and physician. PROSPERO, is a collaborative information system designed to bridge the communication gap between community-based healthcare workers and hospital-based care teams for parturients in Lyon, France. Through 27 semi-structured in-depth interviews with midwives, obstetricians, and general practitioners, we identified key themes related to the system's adoption: implementation challenges, utilisation barriers, interprofessional dynamics, and hidden variables affecting system use. Participants recognised the potential of PROSPERO to improve information sharing and care coordination but expressed concerns about the system's integration into existing workflows, time constraints, and the need for adequate training and technical support. Interprofessional dynamics revealed differing perspectives between hospital and independent practitioners, emphasising the importance of trust-building and professional recognition. Hidden variables, such as hierarchical influences and confidentiality concerns, further complicated the system's adoption. Despite the consensus on the benefits of a collaborative information system, its implementation was hindered by mistrust between healthcare workers (i.e. between independent practitioners and hospital staff). Our findings suggest that fostering trust and addressing the identified barriers are crucial steps towards successful system implementation. The study contributes to understanding the complex interplay of factors influencing the adoption of collaborative healthcare technologies and highlights the need for strategies that support effective interprofessional collaboration and communication.ClinicalTrials ID NCT02593292.

Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study.

This study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population.

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study.

BACKGROUND: Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. OBJECTIVE: This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). STUDY DESIGN: From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. RESULTS: Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. CONCLUSION: Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy.

Women's dissatisfaction with inappropriate behavior by health care workers during childbirth care in France: A survey study.

BACKGROUND: Quality care during childbirth requires that health care providers have not only excellent skills but also appropriate and considerate attitudes and behavior. Few studies have examined the proportion of women in Western countries expressing dissatisfaction with such inappropriate or inconsiderate behavior. This study evaluated this proportion in a sample presumably representative of French maternity units. METHODS: This prospective multicenter study, using data from a selfadministered questionnaire, took place in 25 French maternity units during one week in September 2018. The primary outcome measure was mothers' self-reported dissatisfaction with blatantly inappropriate behavior (ie, inappropriate attitude, inadequate respect for privacy, insufficient gentleness of care, and/or inappropriate language) by health care workers in the delivery room. The secondary outcome was their self-reported dissatisfaction with these workers' inconsiderate behavior (ie, unclear and inappropriate information, insufficient participation in decision-making, or deficient consideration of pain). RESULTS: Of 803 potentially eligible women, 627 completed the questionnaire after childbirth; 5.62% (35/623, 95% CI: 3.94-7.73) reported dissatisfaction with blatantly inappropriate behaviors and 9.79% (61/623, 95% CI: 7.57-12.40) with inconsiderate behaviors. The main causes of dissatisfaction reported by women in this survey were the inadequate consideration of their pain and the failure to share decision-making. CONCLUSIONS: Most of the women were satisfied with how health care workers behaved towards them in the delivery room. Nonetheless, health care staff must be aware of women's demands for greater consideration of their expressions of pain and of their voice in decisions.

Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans.

OBJECTIVE: Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome. DESIGN: Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency. RESULTS: The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code. CONCLUSION: The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network.

Multifaceted intervention to improve obstetric practices: The OPERA cluster-randomized controlled trial.

OBJECTIVE: Suboptimal care contributes to perinatal morbidity and mortality. We investigated the effects of a multifaceted program designed to improve obstetric practices and outcomes. STUDY DESIGN: A cluster-randomized trial was conducted from October 2008 to November 2010 in 95 French maternity units randomized either to receive an information intervention about published guidelines or left to apply them freely. The intervention combined an outreach visit with a morbidity/mortality conference (MMC) to review perinatal morbidity/mortality cases. Within the intervention group, the units were randomized to have MMCs with or without clinical psychologists. The primary outcome was the rate of suboptimal care among perinatal morbidity/mortality cases. The secondary outcomes included the rate of suboptimal care among cases of morbidity, the rate of suboptimal care among cases of mortality, the rate of avoidable morbidity and/or mortality cases, and the incidence of, morbidity and/or mortality. A mixed logistic regression model with random intercept was used to quantify the effect of the intervention on the main outcome. RESULTS: The study reviewed 2459 cases of morbidity or mortality among 165,353 births. The rate of suboptimal care among morbidity plus mortality cases was not significantly lower in the intervention than in the control group (8.1% vs. 10.6%, OR [95% CI]: 0.75 [0.50-1.12], p=0.15. However, the cases of suboptimal care among morbidity cases were significantly lower in the intervention group (7.6% vs. 11.5%, 0.62 [0.40-0.94], p=0.02); the incidence of perinatal morbidity was also lower (7.0 vs. 8.1‰, p=0.01). No differences were found between psychologist-backed and the other units. CONCLUSIONS: The intervention reduced the rate of suboptimal care mainly in morbidity cases and the incidence of morbidity but did not succeed in improving morbidity plus mortality combined. More clear-cut results regarding mortality require a longer study period and the inclusion of structures that intervene before and after the delivery room. (ClinicalTrials.gov ID: NCT02584166).

Association Between Planned Cesarean Delivery and Neonatal Mortality and Morbidity in Twin Pregnancies.

OBJECTIVE: To evaluate the association between the planned mode of delivery and neonatal mortality and morbidity in an unselected population of women with twin pregnancies. METHODS: The JUmeaux MODe d'Accouchement (JUMODA) study was a national prospective population-based cohort study. All women with twin pregnancies and their neonates born at or after 32 weeks of gestation with a cephalic first twin were recruited in 176 maternity units in France from February 2014 to March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Comparisons were performed according to the planned mode of delivery, planned cesarean or planned vaginal delivery. The primary analysis to control for potential indication bias used propensity score matching. Subgroup analyses were conducted, one according to gestational age at delivery and one after exclusion of high-risk pregnancies. RESULTS: Among 5,915 women enrolled in the study, 1,454 (24.6%) had planned cesarean and 4,461 (75.4%) planned vaginal deliveries, of whom 3,583 (80.3%) delivered both twins vaginally. In the overall population, composite neonatal mortality and morbidity was increased in the planned cesarean compared with the planned vaginal delivery group (5.2% compared with 2.2%; odds ratio [OR] 2.38, 95% confidence interval [CI] 1.86-3.05). After matching, neonates born after planned cesarean compared with planned vaginal delivery had higher composite neonatal mortality and morbidity rates (5.3% compared with 3.0%; OR 1.85, 95% confidence interval 1.29-2.67). Differences in composite mortality and morbidity rates applied to neonates born before but not after 37 weeks of gestation. Multivariate and subgroup analyses after exclusion of high-risk pregnancies found similar trends. CONCLUSION: Planned vaginal delivery for twin pregnancies with a cephalic first twin at or after 32 weeks of gestation was associated with low composite neonatal mortality and morbidity. Moreover, planned cesarean compared with planned vaginal delivery before 37 weeks of gestation might be associated with increased composite neonatal mortality and morbidity.

Duration of Expulsive Efforts and Risk of Postpartum Hemorrhage in Nulliparous Women: A Population-Based Study.

OBJECTIVE: To assess the specific association between the duration of expulsive efforts and the risk of postpartum hemorrhage. METHODS: Population-based cohort-nested case-control study of nulliparous women delivering vaginally in 106 French maternity units between December 2004 and November 2006, including 3,852 women with PPH (blood loss ≥ 500 mL and/or peripartum Hb decrease ≥ 2 g/dL), 1,048 of them severe (peripartum Hb decrease ≥ 4 g/dL or transfusion of ≥ 2 units of red blood cells), and 762 controls from a representative sample of deliveries without hemorrhage in the same population. The association between duration of expulsive efforts and postpartum hemorrhage was estimated by multilevel logistic regression models adjusted for individual and hospital characteristics. RESULTS: Median duration of expulsive efforts was 18 minutes among controls, 20 minutes among postpartum hemorrhage and 23 minutes among severe postpartum hemorrhage (p<0.01). Duration of expulsive efforts was significantly, positively, and linearly associated with both postpartum hemorrhage and severe postpartum hemorrhage. After adjustment for other risk factors, every additional 10 minutes of expulsive efforts was associated with about a 10% increase in the risk of postpartum hemorrhage (aOR = 1.11 [1.02-1.21]) and severe postpartum hemorrhage (aOR = 1.14 [1.03-1.27]). Oxytocin during labor, duration of active phase of labor, forceps use, episiotomy, perineal tears, and birth weight were also independently associated with both risks. CONCLUSION: Duration of expulsive efforts was independently associated with postpartum hemorrhage and severe postpartum hemorrhage. Interventions to shorten the duration of this stage, such as oxytocin, forceps, and episiotomy, are also associated with higher risks of postpartum hemorrhage. Beyond duration, other aspects of the management of active second stage should be evaluated as some might allow it to last longer with a minimal increase in postpartum hemorrhage risk.

Correlation between three-dimensional rectosonography and magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: a preliminary study on the first fifty cases.

OBJECTIVES: Deep infiltrating endometriosis (DIE) raises a number of diagnostic and therapeutic problems. Magnetic resonance imaging (MRI), the reference technique in endometriosis, is questioned for posterior pelvic lesions, especially in rectosigmoid locations. In this study, we describe a new technique called three-dimensional rectosonography (3D-RSG), which combines standard transvaginal ultrasonography (TVUS), 3-dimensional (3D) ultrasonography and the use of water for rectal contrast. We also assess the correlation between 3D-RSG and MRI in the diagnosis of rectosigmoid endometriosis. STUDY DESIGN: This study included 50 consecutive women with symptoms suggestive of DIE. After colorectal enema, they underwent a gynecological examination and a 3D TVUS during which 120ml of water was injected in the rectosigmoid to improve the performance of the examination. All patients also underwent an MRI and surgery was offered to the patient if there was discordance between the two procedures. RESULTS: Fifty women underwent 3D-RSG between May and November 2012. All procedures were well tolerated by patients. Two examinations (4%) were stopped for technical reasons. Nineteen rectosigmoid nodules were diagnosed in 18 women (36%). Eighteen of these nodules were also identified on MRI, and one (2%) nodule seen on MRI was not diagnosed by 3D-RSG. In 31 examinations (62%), neither technique identified an intestinal lesion. There was a concordance rate of 96% between the two techniques. Using MRI as the reference technique, 3D-RSG had a sensitivity of 0.95, a specificity of 0.97, a positive predictive values of 0.95, and a negative predictive value of 0.97. There was a 30.3 positive likelihood ratio and a 0.05 negative likelihood ratio. CONCLUSIONS: 3D-RSG seems an interesting new method for diagnosis of rectosigmoid endometriosis and is both feasible and well tolerated. 3D-RSG is highly concordant with MRI in this indication, although further studies are needed to confirm these primary results.

Severity of post-partum hemorrhage after vaginal delivery is not predictable from clinical variables available at the time post-partum hemorrhage is diagnosed.

AIM: Identify women at risk of severe post-partum hemorrhage (PPH) by building a prediction model based on clinical variables available at PPH diagnosis. METHODS: We analyzed data on a cohort of 7236 women with PPH after vaginal delivery from 106 maternity units. Severe PPH was defined as the loss of more than 2000 mL of blood, peripartum drop in hemoglobin of 4 g/dL or more, transfusion of at least four packed red blood cells, embolization, hemostasis surgery, transfer to an intensive care unit or death. The Akaike criterion helped selecting the covariates of a multivariate logistic regression model. The performance of the model was studied through building a receiver-operator curve (ROC). The relative utility of the final model was used to determine the importance of the model in decision-making. RESULTS: Among all PPH, the prevalence of severe cases was 18.5%. Several clinical variables were significantly associated with severe PPH (e.g. parity, multiple pregnancy, labor induction, instrumental delivery). The multivariate prediction model was built. The area under the ROC for prediction of severe cases was 0.63 (95% confidence interval, 0.62-0.65). Nevertheless, the sensitivity and specificity of the prediction model were 0.49 and 0.70, respectively, for a threshold at 0.20 (near prevalence). The relative utility was 0.19 for a threshold near prevalence (20%). CONCLUSION: Because of important misclassifications, even the best model we could build with the available clinical data cannot be reasonably recommended for routine use. Every patient with PPH should receive most optimal management. Other types of information, possibly laboratory data, are probably needed.

In situ simulation training for neonatal resuscitation: an RCT.

OBJECTIVES: High-fidelity simulation is an effective tool in teaching neonatal resuscitation skills to professionals. We aimed to determine whether in situ simulation training (for ∼80% of the delivery room staff) improved neonatal resuscitation performed by the staff at maternities. METHODS: A baseline evaluation of 12 maternities was performed: a random sample of 10 professionals in each unit was presented with 2 standardized scenarios played on a neonatal high-fidelity simulator. The medical procedures were video recorded for later assessments. The 12 maternities were then randomly assigned to receive the intervention (a 4-hour simulation training session delivered in situ for multidisciplinary groups of 6 professionals) or not receive it. All maternities were evaluated again at 3 months after the intervention. The videos were assessed by 2 neonatologists blinded to the pre-/postintervention as well as to the intervention/control groups. The performance was assessed using a technical score and a team score. RESULTS: After intervention, the median technical score was significantly higher for scenarios 1 and 2 for the intervention group compared with the control group (P = .01 and 0.004, respectively), the median team score was significantly higher (P < .001) for both scenarios. In the intervention group, the frequency of achieving a heart rate >90 per minute at 3 minutes improved significantly (P = .003), and the number of hazardous events decreased significantly (P < .001). CONCLUSIONS: In situ simulation training with multidisciplinary teams can effectively improve technical skills and teamwork in neonatal resuscitation.

Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement.

UNLABELLED: Severe postpartum haemorrhage after vaginal delivery: a statistical process control chart to report seven years of continuous quality improvement OBJECTIVE: To use statistical process control charts to describe trends in the prevalence of severe postpartum haemorrhage after vaginal delivery. This assessment was performed 7 years after we initiated a continuous quality improvement programme that began with regular criteria-based audits STUDY DESIGN: Observational descriptive study, in a French maternity unit in the Rhône-Alpes region. INTERVENTION: Quarterly clinical audit meetings to analyse all cases of severe postpartum haemorrhage after vaginal delivery and provide feedback on quality of care with statistical process control tools. MAIN OUTCOME MEASURES: The primary outcomes were the prevalence of severe PPH after vaginal delivery and its quarterly monitoring with a control chart. The secondary outcomes included the global quality of care for women with severe postpartum haemorrhage, including the performance rate of each recommended procedure. Differences in these variables between 2005 and 2012 were tested. RESULTS: From 2005 to 2012, the prevalence of severe postpartum haemorrhage declined significantly, from 1.2% to 0.6% of vaginal deliveries (p<0.001). Since 2010, the quarterly rate of severe PPH has not exceeded the upper control limits, that is, been out of statistical control. The proportion of cases that were managed consistently with the guidelines increased for all of their main components. CONCLUSION: Implementation of continuous quality improvement efforts began seven years ago and used, among other tools, statistical process control charts. During this period, the prevalence of severe postpartum haemorrhage after vaginal delivery has been reduced by 50%.

[Non elective cesarean section: use of a color code to optimize management of obstetric emergencies]. / Césariennes urgentes non programmées: intérêt des codes couleur pour la gestion optimale des urgences obstétricales.

The medical team of the Croix Rousse teaching hospital maternity unit has developed, over the last ten years, a set of procedures designed to respond to various emergency situations necessitating Caesarean section. Using the Lucas classification, we have defined as precisely as possible the degree of urgency of Caesarian sections. We have established specific protocols for the implementation of urgent and very urgent Caesarean section and have chosen a simple means to convey the degree of urgency to all team members, namely a color code system (red, orange and green). We have set time goals from decision to delivery: 15 minutes for the red code and 30 minutes for the orange code. The results seem very positive: The frequency of urgent and very urgent Caesareans has fallen over time, from 6.1 % to 1.6% in 2013. The average time from decision to delivery is 11 minutes for code red Caesareans and 21 minutes for code orange Caesareans. These time goals are now achieved in 95% of cases. Organizational and anesthetic difficulties are the main causes of delays. The indications for red and orange code Caesarians are appropriate more than two times out of three. Perinatal outcomes are generally favorable, code red Caesarians being life-saving in 15% of cases. No increase in maternal complications has been observed. In sum: Each obstetric department should have its own protocols for handling urgent and very urgent Caesarean sections. Continuous monitoring of their implementation, relevance and results should be conducted Management of extreme urgency must be integrated into the management of patients with identified risks (scarred uterus and twin pregnancies for example), and also in structures without medical facilities (birthing centers). Obstetric teams must keep in mind that implementation of these protocols in no way dispenses with close monitoring of labour.

Postpartum haemorrhage in Canada and France: a population-based comparison.

OBJECTIVE: Maternal mortality ratio due to postpartum haemorrhage (PPH) is higher in France than in Canada. We explored this difference by comparing PPH features between these two countries. METHODS: Using data between 2004 and 2006, we compared the incidence, risk factors, causes and use of second-line treatments, of PPH between France (N = 6,660 PPH) and Canada (N = 9,838 PPH). We assessed factors associated with PPH through multivariate logistic models. RESULTS: PPH incidence, overall (4.8% (95% CI 4.7-4.9) in Canada and 4.5% (95% CI 4.4-4.7) in France), and after vaginal delivery (5.3% (95%CI 5.2-5.4) in Canada and 4.8 (95%CI 4.7-4.9) in France), were significantly higher in Canada than in France, but not after caesarean delivery. Women delivering without PPH were similar between the two populations, except for macrosomia (11% in Canada, 7% in France, p<0.001), caesarean delivery (27% in Canada, 18% in France, p<0.001), and episiotomy (17% in Canada, 34% in France, p<0.001). After vaginal delivery, factors strongly associated with PPH were multiple pregnancy, operative delivery and macrosomia in both populations, and episiotomy only in France (Odds Ratio 1.39 (95% CI 1.23-1.57)). The use of second-line treatments for PPH management was significantly more frequent in France than in Canada after both vaginal and caesarean delivery. CONCLUSION: PPH incidence was not higher in France than in Canada and there was no substantial difference in PPH risk factors between the 2 countries. Greater use of second-line treatments in PPH management in France suggests a more frequent failure of first-line treatments and a higher rate of severe PPH, which may be involved in the higher maternal mortality ratio due to PPH.

Induction of labor and risk of postpartum hemorrhage in low risk parturients.

OBJECTIVE: Labor induction is an increasingly common procedure, even among women at low risk, although evidence to assess its risks remains sparse. Our objective was to assess the association between induction of labor and postpartum hemorrhage (PPH) in low-risk parturients, globally and according to its indications and methods. METHOD: Population-based case-control study of low-risk women who gave birth in 106 French maternity units between December 2004 and November 2006, including 4450 women with PPH, 1125 of them severe, and 1744 controls. Indications for labor induction were standard or non-standard, according to national guidelines. Induction methods were oxytocin or prostaglandins. Multilevel multivariable logistic regression modelling was used to test the independent association between induction and PPH, quantified as odds ratios. RESULTS: After adjustment for all potential confounders, labor induction was associated with a significantly higher risk of PPH (adjusted odds ratio, AOR1.22, 95%CI 1.04-1.42). This excess risk was found for induction with both oxytocin (AOR 1.52, 95%CI 1.19-1.93 for all and 1.57, 95%CI 1.11-2.20 for severe PPH) and prostaglandins (AOR 1.21, 95%CI 0.97-1.51 for all and 1.42, 95%CI 1.04-1.94 for severe PPH). Standard indicated induction was significantly associated with PPH (AOR1.28, 95%CI 1.06-1.55) while no significant association was found for non-standard indicated inductions. CONCLUSION: Even in low risk women, induction of labor, regardless of the method used, is associated with a higher risk of PPH than spontaneous labor. However, there was no excess risk of PPH in women who underwent induction of labor for non-standard indications. This raises the hypothesis that the higher risk of PPH associated with labor induction may be limited to unfavorable obstetrical situations.

Transfusion practices in postpartum hemorrhage: a population-based study.

OBJECTIVE: To describe transfusion practices and anemia in women with postpartum hemorrhage (PPH), according to the clinical context. DESIGN: Population-based cohort study. SETTING: A total of 106 French maternity units (146 781 deliveries, December 2004 to November 2006). POPULATION: All women with PPH (n = 9365). METHODS: Description of the rate of red blood cell (RBC) transfusion in PPH overall and compared with transfusion guidelines. MAIN OUTCOME MEASURES: Transfusion practices and postpartum anemia by mode of delivery and cause of PPH in women given RBCs within 12 h after PPH. RESULTS: A total of 701 women received RBCs (0.48 ± 0.04% of all women and 7.5 ± 0.5% of women with PPH). Half the women with clinical PPH and hemoglobin lower than 7.0 g/dL received no RBCs. In the group with clinical PPH and transfusion within 12 h (n = 426), operative vaginal delivery was associated with a larger maximal hemoglobin drop, more frequent administration of fresh-frozen plasma (FFP) and pro-hemostatic agents [odds ratio (OR) 3.54, 95% confidence interval (95% CI) 1.12-11.18], transfusion of larger volumes of RBCs and FFP, a higher rate of massive RBCs transfusion (OR 5.22, 95% CI 2.12-12.82), and more frequent use of conservative surgery (OR 3.2, 95% CI 1.34-7.76), compared with spontaneous vaginal delivery. CONCLUSIONS: The RBC transfusion for PPH was not given in a large proportion of women with very low hemoglobin levels despite guidelines to the contrary. Operative vaginal delivery is characterized by higher blood loss and more transfusions than spontaneous vaginal delivery.

Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case-control study.

Objectives Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association. Design Population-based, cohort-nested case-control study. Setting 106 French hospitals from December 2004 through November 2006. Participants Women with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH. Main outcome measures The independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling. Results Oxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories. Conclusions Oxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the minimal useful regimens.

Clinical audit: a useful tool for reducing severe postpartum haemorrhages?

OBJECTIVE: Reducing the rate of severe postpartum haemorrhage (PPH) is a major challenge in obstetrics today. One potentially effective tool for improving the quality of care is the clinical audit, that is, peer evaluation and comparison of actual practices against explicit criteria. Our objective was to assess the impact of regular criteria-based audits on the prevalence of severe PPH. DESIGN: Quasi-experimental before-and-after survey. SETTING: Two French maternity units in the Rhône-Alpes region, with different organization of care. PARTICIPANTS: All staff of both units. INTERVENTION: Quarterly clinical audit meetings at which a team of reviewers analysed all cases of severe PPH and provided feedback on quality of care and where all staff actively participated. MAIN OUTCOME MEASURES: The primary outcome was the prevalence of severe PPH. Secondary outcomes included the global quality of care for women with severe PPH, including the performance rate for each recommended procedure. Differences in these variables between 2005 and 2008 were tested. RESULTS: The prevalence of severe PPH declined significantly in both units, from 1.52 to 0.96% of deliveries in the level III hospital (P = 0.048) and from 2.08 to 0.57% in the level II hospital (P < 0.001). From 2005 to 2008, the proportion of deliveries with severe PPH that was managed consistently with the guidelines increased for all of its main components, in both units. CONCLUSION: Regular clinical audits of cases severe PPH were associated with a persistent reduction in the prevalence of severe PPH.

Prostaglandin E2 analogue sulprostone for treatment of atonic postpartum hemorrhage.

OBJECTIVES: Use of prostaglandins, including sulprostone (an E2 analog), is recommended for second-line uterotonic treatment of atonic postpartum hemorrhage and might be considered as an indicator of quality of care in severe atonic postpartum hemorrhage management. Our objective was to estimate whether sulprostone was appropriately used and how it was tolerated in women with atonic postpartum hemorrhage. METHODS: This large population-based study (146,781 deliveries) included 4,038 women with clinically assessed atonic postpartum hemorrhage in 106 French hospitals during 1 year. Severe postpartum hemorrhage was defined as one of the following: hemoglobin decline of 4 g/dL or more, transfusion, arterial embolization, surgical procedures, transfer to intensive care unit, or death. Sulprostone use in severe atonic postpartum hemorrhage was analyzed according to the mode of delivery and the characteristics of the maternity units. RESULTS: Rates of sulprostone use were only 33.9% (n = 1,370) and 53.5% (n = 657) among women with atonic (n = 4 ,038) and severe atonic (n = 1,227) postpartum hemorrhage, respectively. In the latter population, sulprostone administration was less frequent after vaginal delivery than after cesarean delivery (45.6% compared with 86.5%, P<.01) in units performing fewer than 1,500 annual deliveries in public nonuniversity hospitals and in units where the obstetrician or anesthesiologist was not present 24 hours per day, 7 days per week. Fifty-one of the 1,370 women with sulprostone-treated atonic postpartum hemorrhage (3.7%, 95% confidence interval [CI] 2.7-4.7) experienced side effects, including seven (0.5%, 95% CI 0.2-1.0) with severe cardiovascular or respiratory symptoms that resolved when the hypovolemic shock was corrected and drug administration was stopped. CONCLUSION: Sulprostone is underused for treating severe atonic postpartum hemorrhage after vaginal delivery, despite low rates of severe side effects in this population-based study. LEVEL OF EVIDENCE: : III.