Inadequate prevention, detection and early management of PPH: organizational determinants assessed using a composite...

Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality, largely preventable. This study aimed to identify the organizational determinants of inadequate management of severe PPH using a previously established global adequacy score.

This retrospective study included patients with severe primary PPH (≥1000 mL blood loss within 24 h postpartum) in a French tertiary maternity unit from January 2019 to December 2021. Exclusion criteria were cases of antepartum or secondary, home deliveries, placenta accreta or praevia, uterine rupture, vaginal thrombus, vascular injury during cesarean section, deliveries before 24 weeks of gestation, and contraindications to second line uterotonics. Adequacy of care was evaluated using a composite global score. Inadequate care was defined as a score ≤ 25th percentile calculated among included women. Organizational determinants studied were number of deliveries within 12 h, timing of PPH midwife and nurse transmission timing, medical turnover.

Among 325 patients with severe PPH, 83 had an inadequate score (score ≤ 78.57%). Inadequate care was more frequent during weekday daytime than at night or during weekends/public holidays (absolute differences: -14.7 and - 16.6 percentage points, respectively; 95% CI [-26.4; -3.0] and [-28.1; -5.1]). Inadequate care was more frequent during weekday daytime than at night or during weekends/public holidays (absolute differences: -14.7 and - 16.6 percentage points, respectively; 95% CI [-26.4; -3.0] and [-28.1; -5.1]). The main clinical factors contributing to the inadequacy of the results include delays in laboratory analyses (hemoglobin measurement and hemostasis measurement ≤ 60 min) and the need to use second-line uterotonics (prostaglandins).

Proportion of inadequate care was higher during weekday daytime and among women who delivered by cesarean section. This global adequacy score could help other teams assess and improve PPH management according to local organizational determinants.