Introduction
Postpartum hemorrhage (PPH) has been the leading cause of maternal death for at least
30 years, which means that, to reduce global maternal mortality, it is mandatory to
reduce deaths due to PPH.[1]
[2]
[3] The incidence of PPH varies worldwide, ranging from 5% to 15% of all deliveries,
being more frequent in low- and middle-income countries. Moreover, PPH is responsible
for severe morbidities, including maternal near-miss. It is expected that, for each
case of PPH, between 50 and 100 cases of severe maternal morbidity may occur.[4]
[5]
[6]
[7]
[8] To decrease PPH mortality, health providers need to identify potential the risk
factors and, more importantly, to make an early diagnosis and to establish a prompt
and effective treatment.
Early identification of these cases is the basis of the adequate treatment; nevertheless,
the current diagnostic criteria may lack the accuracy to identify women at risk of
death. The diagnosis of PPH is based on the assessment of the amount of blood loss,
usually by visual estimation, which has several limitations, including underestimation
of the total volume of the loss.[9]
[10]
In the clinical practice, therapeutic actions depend more on clinical judgment than
only on the volume of blood loss. Healthy women may not show signs and symptoms of
hemodynamic instability after bleeding 500 mL, while women with clinical or obstetrical
morbidities may exhibit signs earlier.[11]
[12] The aim is to identify women at risk of complications, regardless of any specific
amount of blood loss.[13] In addition to the amount of blood loss, vital signs and clinical conditions could
be helpful to identify women at risk of complications, as recognized by some clinical
guidelines.[14]
[15]
Health providers usually identify other sources of information to compose their clinical
judgment on PPH. Some of the vital signs and clinical conditions used in this decision
may include the speed of blood flow, heart rate, arterial blood pressure, respiratory
rate, dizziness, mental status alteration, among others.[16] However, it is not clear how health providers make the clinical judgment to identify
women at risk of a complication due to PPH. Considering this, we aimed to determine
how health providers make clinical judgments and recognize cases of PPH.
Methods
The present is an exploratory and descriptive study using a qualitative approach through
a semi-structured interview technique. Using purposive sampling, we selected and invited
to participate professionals who worked at the obstetric ward and obstetric labor
room at a reference tertiary-level unit for more than 60 cities, covering 5 million
people: Hospital da Mulher Prof. Dr. José Aristodemo Pinotti CAISM/Unicamp (Women's
Hospital Prof. Dr. José Aristodemo Pinotti CAISM/Unicamp), a hospital of Universidade
Estadual de Campinas (UNICAMP, in Portuguese), Brazil. Data were collected from January
to March 2018.
The CAISM is a tertiary service for referral of high-complexity cases that performs
more than 2 thousand deliveries a year. Training about PPH is carried out once a year
with nursing teams and doctors who work at the obstetric ward. Moreover, lectures
are offered to all professionals working at that hospital, as well as specific conferences
for residents in Obstetrics and Gynecology. The hospital does not have equipment that
helps health professionals quantify the amount of blood a woman loses in the postpartum
period. The health professionals were categorized as follows: a) nursing team: nurses
and nursing technicians (there are no midwives at the hospital); b) medical residents
in Gynecology and Obstetrics during the second and third years of residency; c) obstetricians:
medical doctors and professors at the School of Medical Sciences of UNICAMP.
We selected the participants from all health professionals who worked with obstetrics
at the hospital. The inclusion criteria were: having worked in obstetrics for at least
six months; having experienced or witnessed a case of PPH; and accepting to participate.
Those who refused to record the interview and who were not available to join after
the primary selection were excluded.
The hospital manager provided a list with the names of all health professionals working
in obstetrics to identify possible participants. For each participant category, through
a random selection process, we identified the order of participants who should be
invited to the study. The sample size was achieved in each category when content saturation
was reached.
The interviewers invited the participants and explained the objectives of the study;
after having their doubts clarified, all participants signed an informed consent form.
The face-to-face interview either was performed at that moment, or it was scheduled
to take place in a private location or through a telephone call according to the availability
of the participants.
For data collection, a pretested semi-structured questionnaire was made available.
The questions were related to the experience of diagnosing PPH and the factors that
influence its identification. We also included questions about what should be done
to improve the identification of PPH. Subjects were identified by numbers (in order
to ensure confidentiality and anonymity), and the interviews were recorded and transcribed
afterwards.
A thematic analysis of the data was conducted based on Patton.[17] The transcription of the interviews was read, and the seemingly essential words
or phrases were highlighted according to the objectives of the study. Based on these
important words or phrases, and to group them by similarity, we created codes that
were applied to the text. Then, we analyzed thematically each set of texts based on
the categories proposed by our objectives.
The present article describes the analysis of the following categories: a) perception
of the severity: “there is something wrong with the women”; b) difficulties in the
early diagnosis of PPH; and c) the process to improve obstetrical care. The Institutional
Review Board at UNICAMP approved the research protocol (under CAAE 71178117.8.0000.5404).
Results
We interviewed 27 health providers: 9 obstetricians (medical doctors), 7 medical residents,
6 nurses, and 5 nursing technicians. The longest interview lasted 27 minutes, and
the shortest, 5.45 minutes. There was no refusal to participate. [Table 1] shows the characteristics of the sample.
Table 1
Characteristics of the study sample
|
Gender
|
n (%)
|
|
Female
|
22 (81.5%)
|
|
Male
|
5 (18.5%)
|
|
Age*
|
|
20 to 29 years
|
7 (27%)
|
|
30 to 39 years
|
10 (38.5%)
|
|
40 to 49 years
|
6 (23%)
|
|
≥50 years
|
3 (11.5%)
|
|
Schooling
|
|
High school
|
2 (7.4%)
|
|
Higher education
|
14 (52%)
|
|
Graduate studies
|
11 (40.6%)
|
|
Occupation
|
|
Obstetrician
|
9 (33.3%)
|
|
Resident
|
7 (26%)
|
|
Nurse
|
6 (22.2%)
|
|
Nursing Technician
|
5 (18.5%)
|
|
Years of experience
|
|
≤5
|
14 (52%)
|
|
6-10
|
5 (18%)
|
|
> 10 years
|
8 (30%)
|
|
Total
|
27
|
Note: 1 missing information for the age.
Three main categories of analysis were identified, and they are described and illustrated
below.
Perception of the Severity: ‘There Is something Wrong with the Women’
All participants identified PPH as a life-threatening condition that poses a problem
to the health providers.
Although being a concern, there was a lack of knowledge about the frequency and severity
of PPH cases, which was justified by the fewer number of severe cases in the institution.
In caes of women with risk factors, the staff is more attentive. However, some have
assumed that in cases of women without risk factors, providers end up distracted and
not paying proper attention to the risk of bleeding during the postpartum period.
The perception that there is something wrong with the women has been reported differently
across the four categories of participants. Training differences determine the focus
of attention and the actions that each category will perform. The nursing team is
more attentive to women's movements and subjective behaviors that differ from normal.
It is the way they identify the most serious cases. On the other hand, the medical
team is more focused on the objective surveillance of technical parameters, like specific
signs and symptoms. After checking the vital signs, symptoms, and performing a clinical
examination, when noting that the women are not well, the nursing team notifies the
medical team.
In the daily practice, those who observe the “external” signs are mainly the nursing
technicians. (Obstetrician 14)
In the daily practice, the nursing technicians are the professionals who spend the
most time close to the women during the postpartum period; when they realize that
something is different from the expected behavior, they call the nurse responsible
for the ward. The woman's “complaint” is a piece of critical information for the nursing
team, and awareness should be raised whenever a woman does not have complaints.
Everything that is above the expected evolution has to be watched more closely. Everyone
needs to be more suspicious that something may be happening. Every complaint needs
to be valued, and the woman who does not complain has to be observed. (Nurse 4)
On the other hand, some providers assumed that during the process of care, some changes
might be neglected and go unnoticed.
Sometimes, I think it is a bit of a lack of attention. Oh, she is fine, she is talking.
Or, sometimes, I don't go to lift her sheet to check the bleeding. If she were bleeding
above the normal rate, the multiparameter monitor would be indicating abnormalities... (Nursing Technician 6)
From the reports of the nursing team, we detected that behavioral changes and the
appearance of the woman are very important signs that something is not going well.
They say that these signs can be observed even before there are changes in vital signs,
or the bleeding is abnormal. They perceived that the women display behavioral changes,
such as irritability with the baby, asking to take the baby away, restlessness or
paleness, pale, wet, or complaining about weakness, dizziness, and nausea. The nursing
team noted that any minor complaint should be considered.
Irritation/Irritability with the baby, constantly wanting to get out of bed. This
behavior is not normal. And what mother does not care about the crying baby who has
just been born? These are signs that we monitor also. (Nurse 2)
Irritability was considered a confounding factor. Women need attention if they become
irritated with the baby, feeling uncomfortable in the bed, and wanting to get out
of bed frequently. The intervewees consider that, in general, women are happy with
their babies and want to be close to them. Nurse and nurse technicians have mentioned
that it is possible to differentiate women's mental confusion and disorientation from
tiredness due to labor. Other symptoms are also considered very important to identify
women at risk of complications, such as when they cannot get up from bed to take a
shower, or when, at bath time, their blood pressure drops, and they feel discomfort.
The medical team said they are called by the nursing staff to evaluate the women when
there is an issue such as those aforementioned. Doctors are more attached to vital
signs and physical examaniations than behavioral signs / symptoms. When noted, doctors
mentioned pallor, darkening of vision, lethargy, dizziness, tiredness, and disconnected
speech. Medical residents reported, on the other hand, that the main issue for observation
and action is the amount of bleeding. [Table 2] shows some of the words and strategies used to identify PPH for each category of
health professionals.
Table 2
Words and criteria used by each category of professionals to identify women at risk
of complications due to PPH and the amount of bleeding
|
Category
|
Words used to identify the problem
|
Words used to determine the amount of bleeding
|
|
Nurse technicians
|
Irritability with the baby, asking to take the baby away, uneasiness, or the woman
turns pale, wet, or complaining about weakness, dizziness, nausea, constantly wanting
to get out of bed
|
Subjective, visual estimate, provider experience
|
|
Nurses
|
Every complaint needs to be valued
|
Subjective, visual estimate of blood loss in the sheets, provider experience
|
|
Medical residents
|
The amount of bleeding, vital signs
|
Subjective, “insight,” visual estimate of blood loss in the sheets and compresses,
velocity and intensity of blood loss, vital signs, provider experience
|
|
Obstetricians
|
Pallor, darkening of vision, lethargy, dizziness, tiredness, disconnected speech
|
Subjective, massive number of clots, visual estimate of blood loss in the sheets and
compresses, vital signs, provider experience
|
Among all participants, one thing was unanimous: the perception of the amount of postpartum
bleeding is subjective. The health provider is the one who will decide if the amount
of blood is normal or abnormal. It is worth noting that there was no available resource
to assist the professional in quantifying this bleeding, except their own experience,
which can be critical for an early-treatment action.
We trained our eyes to identify when the bleeding is abnormal. Sometimes, when I have
doubts, I call my supervisor for a second opinion. (Nursing technician 6)
The participants reported that they use some strategies to determine if the amount
of blood loss is average. One participant stated they go back to the operation theater
to count the number of compresses used during delivery to identify a PPH case. Others
evaluate if the bleeding is contained to the bed or if it has spilled to the floor,
if there are any clots, and if the bleeding is very intense. Medical residents, for
example, realize something is wrong when the vaginal bleeding is highly continuous,
running down the bed and with many clots.
In any case, it is important to monitor bleeding even if the woman has delivered without
any complications. One participant pointed out that the bleeding should be checked
even if the woman is sleeping, because she may be in hypovolemic shock rather than
asleep.
Difficulties for Early PPH Diagnosis
Several participants mentioned some difficulties in the daily practice that work as
a barrier to the early identification of PPH cases. The work overload has been related
to suboptimal care during the postpartum period. This situation becomes worse when
there are few staff members, and it is not possible to check the status of the woman
as preconized by the institutional protocol.
When you have too much work to do, you become negligent. You stop observing, and when
you decide to perform a clinical evaluation, the woman has bled profusely without
you noticing. (Obstetrician 16)
It was mentioned that the residents do not have enough experience to perform the early
identification of PPH, despite the training offered by the institution. A nursing
technician reported that inspection of the uterine tonus sometimes increases women's
pain; therefore, they do not use the necessary strength to perform a proper evaluation.
I remember I did not perform [the uterine massage] with the necessary strength. If I did not feel so much pity, maybe I would have have
seen the big clots, and we could be started the treatment for PPH before. (Nursing technician 6)
The distance between the rooms and the nursing station is another difficulty mentioned.
Not all women are accompanied at all moments by relatives, who could help identify
that there is something wrong.
The Process to Improve Obstetrical Care
Most health providers interviewed requested a handbook or an easy-to-access flowchart
with guidelines on PPH diagnosis and treatment. Due to inexperience, the residents
often forget the sequence of steps to treat PPH. Furthermore, besides containing the
suggested treatment sequence, the material regarding PPH management should have information
about laboratory exams, fluid administration, and blood bank protocols. It has also
been recommended that a better criterion to define PPH should be created. Some have
cited alternative triggers to start PPH treatment, besides the visual estimate of
the blood loss or changes in vital signs.
A visual scale may be useful. There is the Shock Index. However, we don't have a clear
cut-off point to start the treatment. But it is an excellent index, and I think… maybe
it should have a more objective diagnostic criterion. (Obstetrician 25)
Moreover, the medications used to treat PPH should be available at all wards, inside
the emergency carts, eliminating the need to go to the pharmacy when necessary. Some
interviewees suggested periodic training to improve the diagnosis and treatment of
PPH. Otherwise, the training should be performed every time the institution's protocol
changes.
When you perform training, they [the residents] become more attentive, but, after a while, they relax their vigilance again. So, the
training should be performed a couple of times during the year. (Obstetrician 26)
The discussion of PPH cases after their resolution was pointed out as a possibility
to review and learn from the mistakes and to appreciate potential successful behaviors.
In addition, a permanent audit of cases that had a bad maternal outcome should be
performed to verify what happened and to implement new actions.
Teamwork and communication should be increased and valorized. Doctors should value
more the women's subjective changes reported by the nursing team and clinical evaluation
should be performed immediately.
Discussion
Our findings show that all categories of health providers are very worried about the
early identification of PPH to avoid maternal mortality/morbidity. However, the strategies
they use to diagnose are different. The nursing team is more alert to behavioral changes
as potential early signs/symptoms of PPH. On the other hand, physicians look for objective
changes to diagnose and start the treatment. They tend to privilege protocols, changes
in vital signs or the estimation of blood loss to diagnose PPH. This difference is
probably due to differences in training and the long period that the nursing team
spends in close contact with the puerperal woman.
Adequate perception is fundamental, since the nursing team identifies some abnormality
and notifies the medical team to initiate the treatment. Subjective and objective
assessments complement each other, and should be part of the decision tree to start
treatment.
Some authors[18] have proposed using clinical experience and intuitive decision-making as an essential
tool for the early recognition of PPH. More experienced health professionals should
help less experienced staff to identify any early signs/symptoms of PPH.[18] In the present study, the health provider's experience in assisting women in childbirth
and the postpartum period was considered relevant support in the decision-making.
This finding also corroborates the data in the literature, in which intuition/feeling
and professional experience are reported to play a critical role in clinical judgment
in terms of classifying bleeding according to its severity.[10]
[19] In the present study, for the diagnosis of PPH, the health professionals consider
the amount of blood loss, as well as other individual criteria, like vital signs,
but also the provider's experience and intuition/feeling.
Nevertheless, other studies[10]
[12]
[20]
[21] have shown that health providers often underestimate blood loss after childbirth,
even after training. The underestimation is even more considerable when the postpartum
bleeding is higher. Although there are physical methods to quantify bleeding, their
implementation did not decrease morbidity, and it is costly.[9]
[22]
[23]
[24] It is worth noting that there was no available resource to assist the professionals
in quantifying this bleeding, except their own experience, which was cited as the
most critical factor for early diagnosis.
Diagnosing PPH based on a visual estimate of blood loss is difficult and inaccurate.[10]
[19]
[25]
[26] To enhance the accuracy of PPH diagnosis, some authors[13]
[18]
[25] propose to use clinical signs (like the shock index and other clinical components)
as an adjuvant tool to perform a visual estimate of blood loss as part of the decision
tree to promptly start the treatment for PPH.
In a clinical scenario, simulations and clinical reconstructions have been performed,
increasing self-efficacy and reducing stress. However, the long-term benefits of these
strategies have not yet been proven.[10]
[27]
Work demand and lack of staff were also pointed out as components challenging the
early recognition of PPH. Staff problems, fatigue, and work overload deteriorate the
quality of care and potentially decrease the vigilance for a possible PPH diagnosis.[28]
[29] Facing difficulties and lack of resources, health providers have developed inexpensive
strategies that help them identify abnormalities in the postpartum period. These suggestions
can have an effect on the diagnosis and prevention of PPH, such as setting PPH protocols
in strategic spots and promoting ongoing educational courses. These courses help providers
learn to implement a sequence of treatment interventions, and should also include
teaching on the importance of non-clinical components such as teamwork, appreciation,
communication, and facility readiness.
The present study has demonstrated some gaps, differences, and barriers to the early
diagnosis of PPH. Nevertheless, it has offered no solutions. It has already been established
that problems with communication are a leading cause of medical errors, including
the delay in the diagnosis of PPH. But there is insufficient discussion on the fact
that care can be improved with the implementation of bundles of attention, such as
the “obstetric hemorrhage bundle”. Such efforts address the reality of different perspectives
through education, formal team training (such as shared mental models, conflict resolution,
drills, checklists, hemorrhage carts, to name a few elements). This kind of “bundles
intervention” may an excellent alternative to implement the necessary changes to improve
the early diagnosis and treatment of postpartum hemorrhage. Additional research should
assess its feasibility, acceptability, effectiveness and the best strategies to implement
it.[30]
The present study has some limitations. We included professionals from a university
hospital; therefore, we expect that the staff should be more trained than in smaller
hospitals. We also included professionals that work in the obstetric ward, and the
majority of PPH cases in hospital settings happens in the obstetric room. The present
is also a qualitative study, and cannot be generalized; however, it can help scientists
to better understand how clinicians develop the clinical judgment for PPH diagnosis.
This information can be further investigated using different methodologies to identify
factors that could be part of a decision tree for the diagnosis and treatment of PPH.
Caregivers believe teamwork and communication should be improved, as they are considered
essential non-clinical components of the diagnosis and management of PPH. Besides
the visual estimate of blood loss, the nursing team is attentive to behavioral symptoms
like irritability and “constantly wanting to get out of bed” to identify women developing
PPH, while the medical staff follow protocols and look for objective signs, such as
altered vital signs.
