Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003–05

• Published in: BJOG : an international journal of obstetrics and gynaecology 2007-11, Vol.114 (11), p.1388-1396
• Main Authors: Brace, V, Kernaghan, D, Penney, G
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Balloon Occlusion; Biological and medical sciences; Blood Transfusion - statistics & numerical data; Catheterization - statistics & numerical data; Cesarean Section - statistics & numerical data; Childbirth & labor; Clinical outcomes; Critical incident audit; Delivery. Postpartum. Lactation; Feasibility Studies; Female; Gynecology. Andrology. Obstetrics; Hemorrhage; Hemorrhage - epidemiology; Hemorrhage - prevention & control; Humans; major obstetric haemorrhage; Medical Audit; Medical sciences; Middle Aged; Obstetrics; Obstetrics - statistics & numerical data; Placenta Previa - etiology; Pregnancy; Pregnancy Complications - epidemiology; Pregnancy Complications - prevention & control; Professional Practice - statistics & numerical data; Prospective Studies; Resuscitation - statistics & numerical data; Risk Management; Scotland - epidemiology; severe maternal morbidity; Uterine Inertia - etiology
• ISSN: 1470-0328; 1471-0528
• DOI: 10.1111/j.1471-0528.2007.01533.x

Objective  To describe a system for learning from cases of major obstetric haemorrhage. Design  Prospective critical incident audit. Setting  All consultant‐led maternity units in Scotland, between 1 January 2003 and 31 December 2005. Population  Women suffering from major obstetric haemorrhage (estimated blood loss ≥2500 ml or transfused ≥5 units of blood or received treatment for coagulopathy during the acute event). Methods  Hospital clinical risk management teams reviewed local cases using a standard, national assessment pro forma. Main outcome measures  Standard of care provided and learning points identified. Results  Rate of major haemorrhage was 3.7 (3.4–4.0) per 1000 births. Pro formas returned for 517 of 581 reported cases (89%); 41% were delivered by emergency caesarean section (compared with 15% of all Scottish births). Uterine atony was the most common cause (250 women, 48%); 32% had multiple causes. A consultant obstetrician gave hands‐on care to 368 (71%) and a consultant anaesthetist to 262 (50%). Placenta praevia as a cause was independently associated with consultant presence. Central venous pressure monitoring was used in 164 (31%) women, and 108 (21%) women were admitted to intensive care. Parity, blood loss, and placenta praevia as a cause were independently associated with peripartum hysterectomy (performed in 62 women, 12%). Balloon tamponade and haemostatic uterine suturing were successful in 92 of 116 women (79%). Most cases were assessed as well managed, with ‘major suboptimal’ care identified in only 14 cases (3%). Conclusions  It is feasible to identify and assess cases of major obstetric haemorrhage prospectively on a national basis. Most women received appropriate care, but many learning points and action plans were identified.