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To Curb Maternal Death, U.S. Hospitals Urged to Weigh Bleeding Pads

Atlanta (female) —How much blood do you lose during childbirth?

Some researchers recently asked that question in a study of hospitals in New Jersey and Georgia, which are competing with the worst rankings of maternal mortality in the United States.

Knowing exactly how much blood a woman is losing during childbirth, and whether it is safe, saves lives from postpartum bleeding, one of the leading causes of death in the delivery room, PPH. It is very useful for. .. It can lead to cardiac arrest and hospitalization in the intensive care unit.

this is, 18 months study Recently announced by AWHONN, an association of women’s health, obstetrics and newborn nurses About 95 hospitals in two states.

The authors find that many maternal mortality ratios (54% to 93%) caused by postpartum bleeding can be prevented by improving the clinical response.

AWHONN studies in two states confirm and quantify some observations made by nurses and physicians since the 1960s on the inaccuracy of visually estimating blood loss.

Renée Byfield, AWHONN’s Nurse Program Development Specialist and one of the authors of the study, said:

“It’s a concern. The estimation of bleeding, which is a very important decision to save lives, was determined by subjective means.”

Byfield, who spoke on the phone from Washington, DC, has over 23 years of experience in high-risk obstetric nursing. She says that in many delivery rooms, the usual procedure is to simply estimate the amount of blood loss at birth when the baby is born, usually by observing the absorption pad underneath the woman’s body. With this visual assessment, nurses and doctors look at the pad to determine if blood loss is small, moderate, or large.

“But what does that mean?” Ask Byfield. “My” large “may not be your” large “. You are just guessing. “

Signs of danger

The Average blood loss The vaginal delivery is about 500 milliliters (about 0.5 quarts), and the caesarean delivery is about 1,000 milliliters. Any more than that is considered a dangerous sign.

Byfield says the decision to treat PPH is based on the amount of blood lost.Therefore, we know these standard thresholds The team can be prepared for the appropriate response.

Quantified bleeding, or QBL, requires weighing those pads to calculate a much more accurate amount.

Lashea Wattie is a clinical nurse at Wellstar Kennestone Hospital in Marietta, near Atlanta, Georgia.

“It’s often too late to find out how much blood loss you’ve experienced,” says Watty, who coordinated the AWHONN study in Georgia and talked about the findings over the phone. “Therefore, by using that quantified bleeding, we can properly stage where the patient is and know what the patient’s condition is and how important the patient is.”

Another concern about postpartum bleeding that is not fully explained is racial disparity. Of the 4 million women who give birth each year in the United States, 125,000 suffer from postpartum bleeding. Black women have far more deaths associated with PPH (68.3 per 100,000) than white women (21.0 per 100,000).

“We are still looking at the data,” says Byfield. “What we know is that African-American women have more postpartum bleeding than other races. Gap is not just related to economics. It is a function of access to care. [A lot of ] No regional hospital is prepared. “

In addition to the inequality faced by pregnant African-American women: For every 10% increase in the total proportion of African-American women who gave birth in the hospitals surveyed, one preparatory factor is reduced in that hospital. did. As a result, hospitals that are most prepared for postpartum bleeding often lack the necessary tools and training.

Based on the experience of AWHONN, who enrolled the hospital in this study, “In many cases, we have the highest need for improvement and serve more African-American women than women of other races and ethnicities. Hospitals that are likely to be there have chosen not to attend. “

Higher maternal mortality rate

And it’s not just postpartum bleeding that affects black women disproportionately. African-American women are said to have three to four times higher maternal mortality rates than women in all other groups. American College of Obstetrics and Gynecology..

The United States is miserable 33rdrd Of the 179 countries surveyed in 2015, in the world of maternal mortality “Save the Children 16th World mother status report. “

Georgia is part of the problem. According to the Georgia Medical and Labor Relations Commission, the lowest states have made some progress, including the establishment of a Maternal Mortality Review Board, but only 79 of the 159 counties in the state have OB-GYN. I am.

18 months AWHONN survey completed Supported in February Merck for mothers, We checked for the presence of 38 PPH preparatory elements. They found that less than 50% of hospitals had heavy bleeding protocols, performing risk assessments and drills, and measuring blood loss. There are also standard checklists for dealing with emergency medical care such as stroke and heart attack, but this is not always the case with bleeding in the delivery room.

Many emergency rooms provide specific preparatory training for prominent crises such as plane crashes and mass shootings. However, far fewer people do such training at PPH.

Watty says more training is needed in many places. Medical staff in small hospitals that do not have a specific delivery room or delivery room but still give birth to babies need it. Especially in rural areas, so is the emergency medical technician.

She said that these small hospitals “may be able to handle normal deliveries, but the high risk of these populations may require them to go further, including a postpartum bleeding preparation course. There is. “

Such training requires time and commitment from hospital staff. Byfield says that time is often used. The team can go back and practice in a safer environment with more confidence. She says that even a short 15-minute report after each delivery, whether regular or complex, is worth it.

Watty says it’s absolutely important to be proactive. If a woman has already given birth in the hospital, it is too late to determine if the team can handle the very complex cases that can involve large blood transfusions.

Lack of policies and procedures

The study found that less than half of hospitals underwent regular risk assessments for PPH when women were hospitalized. And only 41 percent had policies and procedures for dealing with mass transfusions.

“How much blood can this hospital provide to this patient?” Watty asks.

“If a patient has many risk factors and may need more than 4 units of blood and can’t provide more than 4 units without going to an outside company, it’s even wise for the patient to come here and deliver. am. ?”

“You just sit down and understand what your facility’s safety level is, and what you can do,” Watty adds. “If your facility is a small town facility with 6 units [of blood] This is all I have. Have a discussion so that things can be arranged for proper forwarding. “

Byfield says both doctors and hospital managers respond to the numbers. It is the more accurately quantified blood loss numbers that cause a well-drilled emergency response, or the new mother who had to undergo intensive care because the delivery team was prepared for blood loss complications. Is it a decrease in numbers? It’s easier to establish a protocol if you can budget for training and quantify events.

And evidence, not quotes, can save you money. At one hospital, the total number of blood transfusions required was reduced by 27%. Studies show that after a comprehensive PPH review.

Changing hospitals from blood loss estimation to quantification, that is, moving from EBL (estimated blood loss, visual approximation) to QBL (weight-based quantitative measurement), is currently AWHONN’s primary outreach goal.

The plan is to disseminate these safety findings across Georgia and New Jersey. Watty teaches, for example, how to measure and quantify blood loss, and how to perform efficient debriefing so that everyone involved can learn from what went well and what went wrong during delivery. Therefore, I applied for a travel instructor.

Whether it’s the extreme rural areas of North Dakota or hundreds of miles without a delivery hospital, whether it’s the surprisingly busy delivery ward in Washington, DC, Watty is both more prepared. Say you can make a profit.

What do you think?

Written by Fem Society

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