European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Policies for management of postpartum haemorrhage: the HERA

cross-sectional study in France
Franoise Vendittellia,b,c,* , Chlo Barasinskia,b , Bruno Pereirad, Michel Dreyfuse,f ,
Didier Lmerya,b,c , Marie-Hlne Bouvier-Colleg , for the HERA Group1
a
Ple Femme et Enfant, Centre Hospitalier Universitaire de Clermont-Ferrand, 63003 Clermont-Ferrand, France
b
Clermont Universit, Universit dAuvergne, EA 4681, PEPRADE (Prinatalit, grossesse, Environnement, PRAtiques mdicales et DEveloppement), Clermont-
Ferrand, France
c
AUDIPOG (Association des Utilisateurs de Dossiers informatiss en Pdiatrie, Obsttrique et Gyncologie), Facult de mdecine RTH Laennec, Lyon, France
d
Direction de la Recherche clinique, Centre Hospitalier Universitaire de Clermont-Ferrand, 63003 Clermont-Ferrand, France
e
Gyncologie Obsttrique et Mdecine de la Reproduction, Centre Hospitalier Universitaire de Caen, France
f
Universit de Caen, Caen, France
g
Inserm, U 1153, Equipe Epop, CRESS, Universit Paris Descartes 5, Paris, France

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The principal objective of this study was to describe the policies reported by French maternity
Received 6 June 2016 units for the prevention and early management of postpartum haemorrhage (PPH). The second objective
Received in revised form 29 July 2016 was to assess their variation according to hospital level and status.
Accepted 1 August 2016
Study design: Cross-sectional observational study of French maternity units, from January 2010 to April
2011. The medical supervisor (obstetrician or midwife) of participating maternity wards completed a
Keywords: questionnaire designed to ascertain the units protocol for preventing and managing PPH after both
Caesareans
vaginal and caesarean deliveries at a gestational age >22 weeks (or a birth weight >500 g). The main
Delivery
Immediate postpartum haemorrhage
outcome measure was the percentage of units reporting protocols adhering to the principal criteria for
Third stage of labour adequate management dened by the 2004 French guidelines for PPH.
Results: 252 maternity units participated in the survey. Almost all units had a written protocol for PPH
(97.2%). For vaginal deliveries, 82.5% of units had a denition of PPH (>500 ml) and 92.8% had a policy of
preventive oxytocin use. For caesareans, only 23.8% dened PPH (as >1000 ml), 68.8% used manual
delivery of the placenta, and 76.9% recommended oxytocin injection immediately after the birth. The
rst-line medication for PPH was oxytocin (96.3%) and the second-line treatment a prostaglandin (97.5%).
Level III maternity units had a denition of haemorrhage for vaginal deliveries more often than did other
levels of care (P = 0.04). Manual removal of the placenta after caesareans was signicantly more frequent
in level I than level III units (P = 0.008) and in private than other types of maternity units. Medical
management of haemorrhage did not differ according to level of care or maternity status.
Conclusions: The responses by maternity unit supervisors showed signicant improvement in the
management of PPH accordingly to the 2004 French guidelines, especially for the third stage of labour.
This improvement did not differ between hospitals by levels of care or legal status.
2016 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author at: Centre Hospitalier Universitaire de Clermont-Ferrand,
Site Estaing, Ple Femme et Enfant, 1 Place Lucie et Raymond Aubrac,
63003 Clermont-Ferrand cedex 1, France.
E-mail address: fvendittelli@chu-clermontferrand.fr (F. Vendittelli).
1 is 6.09%, and the prevalence of severe PPH (blood loss  1000 ml)
HERA [postpartum HEmoRrhAge] GROUP: Bernard Branger (Fdration
Nationale des Rseaux de Sant en Prinatalit, Nantes, France), Laure Connan
(Centre Hospitalier Universitaire de Toulouse, France), Catherine Crenn-Hbert
(Assistance Publique des Hpitaux de Paris, Colombes, France), Caroline Da Costa
Correia (Centre Hospitalier Universitaire de Clermont-Ferrand, France), Paul Lefvre
(Centre Hospitalier de Bayeux, France), Anne Debost-Legrand (Clermont Universit,
Universit dAuvergne, EA 4681, PEPRADE; Centre Hospitalier Universitaire de
Clermont-Ferrand, 63003 Clermont-Ferrand, France).
Introduction
According to a 2008 review, the estimated prevalence of
postpartum haemorrhage (PPH) (blood loss  500 ml) worldwide
1.86% [1]. Of their direct obstetric causes, the largest portion of
maternal deaths in the European Union (EU) continue to result
from haemorrhages [2]. Obstetric haemorrhage is estimated to
cause 25% or more of all maternal deaths, and nearly half of
postpartum deaths are due to immediate PPH [25]. PPH is thus the
leading cause of maternal mortality in France with a ratio of 1.8

http://dx.doi.org/10.1016/j.ejogrb.2016.08.008
0301-2115/ 2016 Elsevier Ireland Ltd. All rights reserved.

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
22 F. Vendittelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126

(200709) deaths per 100,000 live births compared with a ratio of
0.87 for the EU as a whole. More than 75% of these deaths are
avoidable, according to the French National Committee on
Maternal Mortality [6]. PPH also appears to be the most common
contributor to serious obstetric morbidity in Europe [79].
Nevertheless, the extent of the morbidity associated with PPH
is signicantly underestimated, primarily because there is no
international consensus about its denition or diagnosis [10].
Immediate PPH is generally dened as blood loss from the genital
tract in the rst 24 h after delivery of 500 ml or more, and severe
PPH as blood loss of 1000 ml or more [11]. But no universal
diagnostic rules are applied. As a consequence, large discrep-
ancies exist in the quality of the policies for PPH management.
In 19951996, a European study by the EUPHRATES group
underlined the differences between the policies for PPH preven-
tion and rst-line treatment both amongst French maternity units
and amongst those of several European countries [12,13].
The absence of any national guidelines before then may explain
the absence of denitions of PPH or written protocols for its care in
some French maternity units and the widespread variance in
reported care policies then [13]. In 2004, for PPH management
guidelines were published by the French National College of
Obstetricians (CNGOF) and the National Society of Anaesthetists
(SFAR) [14].
The principal objective of this study was to describe the policies
reported by French maternity units for the prevention and early
management of PPH. The second objective was to assess their
variation according to hospital level and status.
Questionnaire
The questionnaire comprised mainly closed questions and was
to be completed by the supervisor of each maternity ward. With
the kind permission of the EUPHRATES group, we used the same
questionnaire that they did in 2003, but added some items to take a
few new medications and practices into account [12,13]. The
questionnaire included a section on the prevention of PPH in cases
of delivery at a gestational age 22 weeks (or a birth weight
500 g) and another about the management of PPH. Finally,
another section covered the organisation and activity (number of
deliveries) of each unit.
The survey took place from January 2010 to April 2011. Three
reminders were sent to units that had not yet responded. The
participation rate was 84% (n = 252 of 300 maternity units). Table 1
summarises the characteristics of the units that participated
compared with all other French maternity units. The levels of care
considered were primary, secondary, and tertiary (I, II, and III).
Three types of legal status were assessed: public, private, and
academic maternity units.
Statistical analysis
Vaginal and caesarean deliveries were analysed separately, and
the qualitative variables were compared with a Chi2 test (or
Fishers exact test when appropriate). Signicance was set at 0.05.
We used SAS software (version 9, SAS Institute, Cary, NC,
20022010) for data collection and analysis.

Results
Methods
In all, 82.5% of respondents reported they had a denition of
Participants and settings PPH (>500 ml), although only 41.7% dened severe PPH. For vaginal
deliveries, 92.8% recommended preventive use of oxytocin for the
This multicentre cross-sectional observational study was third stage of labour (Table 2). Most of them used a collection bag
conducted and supported by 25 coordinators of perinatal networks to measure blood loss (90.8%) (Table 2). More than 70% of
including 300 French maternity units, all of which were asked to respondents chose to perform a manual delivery of the placenta if
participate. it was not delivered spontaneously within 30 min (Table 2).

Table 1
Characteristics of French maternity units that participated in the survey versus all other French maternity units.

Participants (N = 252) n (%) Non-participantsa,g (N = 313) n (%) P

Total n. deliveriesb
<500 17 (6.7) 42 (13.4) 0.005
5001499 150 (59.5) 149 (47.6)
1500 85 (33.8) 122 (39.0)

Level of care
Level Ic 118 (46.8) 160 (51.1) 0.48
Level IId 97 (38.5) 116 (37.1)
Level IIIe 37(14.7) 37 (11.8)

Status of facility
Academic hospital 25 (9.9) 28 (8.9) 0.07
General hospital 153 (60.7) 164 (52.4)
Private hospital 74 (29.4) 121 (38.7)

Region
Provinces 210 (83.3) 257 (82.1) 0.70
le de Francef 42 (16.7) 56 (17.9)
a
Corresponding to all French maternity units that did not participate in this study.
b
Deliveries per year.
c
Level 1 = maternity ward without a paediatrics department.
d
Maternity ward with a neonatology department.
e
Maternity unit with a neonatology department and a NICU.
f
Includes the entire Paris metropolitan region.
g
2010 data from the statisties of health facility activities [https://www.sae-diffusion.sante.gouv.fr/sae-diffusion/accueil.htm].

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 F. Vendittelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126 23

Table 2
Reported policies for prevention of immediate postpartum haemorrhages for vaginal deliveries according to maternity unit level and status.

PPH prevention for vaginal births Total Maternity levels Test Maternity status Test
f
% N = 252 I II III P Public Private Academic Pg
na n = 118 n = 97 n = 37 n = 153 n = 74 n = 25
% % % % % %
Delivery of placenta:
Preventive oxytocinb 92.8 250 92.2 90.7 97.2 0.47 91.5 94.5 95.8 0.59
Early cord clamping 87.6 249 84.6 89.7 94.3 0.24 84.9 90.4 100 0.08
Controlled cord traction 29.3 249 26.7 32.0 30.6 0.69 25.7 37.0 29.2 0.22
Active management of the third stage of labourc 24.5 249 23.3 24.7 27.8 0.86 20.5 31.5 29.2 0.17

Uterotonic timing:
At delivery of anterior shoulder 87.5 231 87.2 85.1 94.3 0.38 87.1 84.1 95.7 0.36
Just after birth 7.5 200 6.5 9.2 6.3 0.77 8.3 8.8 0 0.52
After delivery of the placenta 33.5 206 34.4 34.2 29.0 0.85 27.4 47.5 28.6 0.02

PPH denition:
>500 ml 82.5 252 76.3 87.6 89.2 0.04 95.6 89.8 100.0 0.12
Severe (>1000 ml) 41.7 252 36.4 48.5 40.5 0.20 77.2 66.7 85.0 0.22

Measurement of blood loss:

Collection bag 90.8 249 92.2 89.7 88.9 0.75 96.7 82.2 79.2 0.0002
Weighing used suppliesd 9.6 218 6.2 11.2 15.6 0.23 11.1 8.2 4.6 0.74
Clinical estimates 39.1 220 42.0 41.4 24.2 0.16 32.8 40.7 34.8 0.02

Manual placenta delivery:

Delay 30 min with PAe 73.4 222 72.7 70.5 82.9 0.36 79.4 56.9 78.3 0.004
Delay 30 min without PAe 75.7 218 73.5 72.9 88.6 0.15 75.4 70.2 91.3 0.14
a
The responses do not always total 252, because not all respondents answered every question.
b
Regardless of the time, before or after delivery of the placenta.
c
Active management of the third stage of labour was dened as the early administration of oxytocin, early cord clamping, and controlled cord traction.
d
Weighing supplies, that is, drapes, dressing, pads, swabs, etc. to assess the added weight of blood.
e
PA = peridural analgesia. This is the time between birth and manual removal of the placenta.
f
The test compares the maternity units according to their level (I, II, and III).
g
The test compares the maternity units according to their status (public, private, and academic).

For caesarean deliveries, only 23.8% of the respondents used the
French guidelines denition (>1000 ml) (Table 2). Blood loss from
caesareans was assessed mainly by the amount collected in the
suction canister (88.3%). We note that 68.8% of units recommended
manual delivery of the placenta and 76.9% an injection of oxytocin
immediately after the birth. Finally, 33.2% recommended exteri-
orisation of the uterus for hysterorraphy (Table 2).
Nearly all units (97.2%) had a written departmental protocol for
PPH prevention and management (Table 4). The rst-line
medication for PPH was oxytocin (96.3%) and the second-line
treatment a prostaglandin (97.5) (Table 4). Recombinant activator
factor VII was the haemostatic agent used by 27.24% of the units;
30.54% used a puried, pasteurized brinogen concentrate. Finally,
uterine massage was widely recommended (Table 4).
Compared with level I and level II units, the level III maternity
units had a specic denition of PPH for both vaginal and for
caesarean deliveries (P = 0.04 and P < 0.01) (Table 2). Manual
removal of the placenta after caesareans was signicantly more
frequent in level I than level III units (P = 0.008). Blood loss after
caesareans was estimated clinically more often in level I units
(P = 0.02) and by volume in level III units (P = 0.03) (Table 3).
Neither pharmaceutical management nor the use of mechanical
methods for PPH differed signicantly by level of care (Table 4).
These results were fairly similar according to the maternity units
legal status (general hospitals, private institutions, and academic
hospitals) (Tables 24). We nonetheless note that use of collection
bags was most frequent in general hospitals and a denition of
severe PPH most common in academic hospitals.
Discussion
Our results show that oxytocin is currently widely used for
placental delivery after vaginal birth in France. The rst-line
treatment for stopping PPH is mainly oxytocin and the second-line
treatment prostaglandins, as described in the 2004 and 2014
guidelines [11,14]. Some heterogeneity between levels nonetheless
persists for some practices (such as manual placental delivery after
caesareans). This can be explained in part by the fact that
individual characteristics and institutional beliefs may have more
inuence than training on adherence to protocols for the
prevention of postpartum haemorrhage [15]. Accordingly, it is
not surprising that studies nd that guidelines do not always
appear to have an effect on practices [16].
Study strengths and limitations
The survey participation rate was satisfactory and higher than
in some other surveys [17]. This study included 252 maternity
units, which accounted for 44.6% of French maternity units and
376,359 of the 828,108 deliveries (45.4%) recorded in France in
2010. Our sample is fairly representative of all French maternity
units in terms of the distribution of different levels of care and
types of facilities (Table 1), although private hospitals, which
account for only 30% of deliveries in France, are slightly under-
represented.
The study does not cover the practices actually used in the
maternity units but rather those that are reported. There is
probably a gap between the internal policies reported by units and
their real practices. In addition, some participants did not answer
all the questions, probably in part because some proposed answers
to the European questionnaire did not make sense to French
obstetricians.
This survey allows us to compare how French maternity units
have improved their protocols over time [13]. Compared with
the EUPHRATES study in the mid-1990s, which was also based on

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
24 F. Vendittelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126

Table 3
Reported policies for prevention of immediate postpartum haemorrhages after caesarean delivery to maternity levels and status.

PPH prevention for caesareans Total Maternity unit level Test Maternity unit status Test
e
% N = 252 I II III P Public Private Academic Pf
na n = 118 n = 97 n = 37 n = 153 n = 74 n = 25
% % % % % %
Manual removal of the placentab 68.8 250 74.4 70.1 47.2 0.008 69.3 78.1 37.5 0.001

Oxytocin injection:
Just after birth 76.9 225 75.7 76.4 81.8 0.76 77.1 73.0 86.4 0.47
After delivery of the placenta 51.0 206 53.5 53.2 36.7 0.24 52.4 53.1 33.3 0.30

PPH denition:
>1000 ml 23.8 252 16.1 26.8 40.5 <0.01 31.4 23.9 54.6 0.04
Severe PPH (>1500 ml) 13.1 252 9.3 13.4 24.3 0.06 22.9 12.8 50.0 0.009

Measurement of blood loss:

Collection bag 36.9 217 41.2 34.9 28.1 0.37 36.4 35.9 42.9 0.83
Weighing suppliesc 12.8 211 9.4 13.4 21.2 0.21 13.2 9.7 20.0 0.44
Clinical estimates 60.1 223 68.9 56.5 42.9 0.02 53.7 73.4 60.9 0.03
Volume suction canister/drain 88.3 248 82.6 92.8 94.4 0.03 90.2 84.5 87.5 0.43

Exteriorisation of the uterusd 33.2 247 37.6 29.8 27.8 0.37 36.0 30.1 25.0 0.47
a
The responses do not always total 252, because not all respondents answered every question.
b
Manual removal of the placenta.
c
Weighing supplies (drapes, dressing, pads, swabs, etc. to to assess the added weight of blood).
d
This involves exteriorisation of the uterus via a laparotomy.
e
The test compares the maternity units according to their level (I, II, and III).
f
The test compares the maternity units according to their status (public, private, and academic).

self-report [12,13], we observed protocols improvement closer to PPH prevention

the French 2004 guidelines [14].
Moreover, maternal mortality due to haemorrhages caused by
uterine atony has fallen in France, which can be explained in part
by changes in the PPH management protocol of a large number of
maternity units [18]. This is a point that supports the accuracy of
the questionnaire responses.
Active management of the third stage of labour remains
relatively rare in France, especially after vaginal deliveries; it has
nonetheless doubled since 2003 [13]. This practice remains lower
than that observed in United Kingdom and Ireland [12], despite the
clear evidence supporting its use [19,20]. On the other hand, the

Table 4
Reported policies for the pharmacologic and mechanical management of immediate postpartum haemorrhages according to maternity unit level and status.

Pharmacologic management and mechanical methods Total Maternity unit level Test Maternity unit status Test
d
% N = 252 I II III P General Private Academic Pe
na n = 118 n = 97 n = 37 n = 153 n = 74 n = 25
% % % % % %
Written protocol for PPH 97.2 248 97.4 96.9 97.1 1.00 98.7 94.5 95.8 0.11

First-line pharmacologic treatmentb: 246

Oxytocin 96.3 94.7 97.9 97.1 0.53 98.0 93.0 95.8 0.05
Misoprostol 0.8 1.9 0 0 0.7 1.4 0 0.63
Sulprostone 2.9 43.7 2.1 2.9 0.87 1.3 5.6 4.2 0.12

Time until second-line treatmentc: 252

30 min 82.5 80.5 85.6 81.1 0.87 85.0 78.4 80.0 0.44
>30 min 2.8 3.4 2.0 2.7 2.0 5.4 0
Not dened 14.7 16.1 12.4 16.2 13.1 16.2 20.0

Second-line treatment: 244

Misoprostol 1.6 2.7 1.0 0 0.80 1.3 2.8 0 0.74
Prostaglandins 97.5 96.5 99.0 97.1 0.52 98.7 95.8 100 0.28
Other 0.9 0.9 0.0 2.9 0.27 0 1.4 0

Uterine massage 92.3 248 94.8 88.7 94.3 0.22 92.1 94.5 87.5 0.52

Bimanual compression of the uterus 27.6 243 29.8 26.6 22.7 0.70 26.9 31.4 20.8 0.58

Urinary tract probe 87.0 247 87.1 85.4 91.4 0.66 88.7 82.2 91.3 0.32
a
The responses do not always total 252, because not all respondents answered every question.
b
Second-line pharmacological treatment. This treatment never includes ergometrine.
c
Time before administration of a second-line pharmacological treatment after the inefcacy of the rst treatment has been shown.
d
The test compares the maternity units according to their level (I, II, and III).
e
The test compares the maternity units according to their status (public, private, and academic).

Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 F. Vendittelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126
use of oxytocin for vaginal delivery is a common practice (92.8%
versus 84% in 2003) [13], as it is elsewhere [21] and is in line with
the best scientic evidence [22]. No evidence in the Cochrane
database covers the comparative benets and risks of intramus-
cular and intravenous oxytocin for the third stage of labour but the
practice in French maternity wards is to use intravenous oxytocin
for all deliveries (including caesareans) [23]. The scientic data do
not currently justify the recommendation of oxytocin both before
and after expulsion of the placenta [24]. Prophylactic use of
oxytocin has replaced that of ergot alkaloids in France, in view of
the latters adverse effects [22,25,26]. Misoprostol was not
recommended in the 2004 guidelines [14], and neither intramus-
cular prostaglandins nor misoprostol are preferable to conven-
tional injectable uterotonics as part of themanagement of the third
stage of labour [27].
A policy of controlled cord traction is found in only 30% of
maternity units, probably because touching the cord at placental
delivery was long considered poor practice because it was thought
to risk uterine inversion. Nonetheless, while the practice of
controlled cord traction has the advantage of reducing the risk of
manual removal of the placenta, it cannot reduce the risk of severe
PPH [28]. Moreover, there is no strong scientic evidence to prefer
fundal pressure at a controlled cord traction as part of the active
management of the third stage of labour [29]. Most respondents
(87%) reported that their policy calls for early cord clamping,
although a meta-analysis (of 15 trials, with 3911 women) found no
signicant differences between early and late cord clamping
groups for severe PPH, while stressing that delayed cord clamping
increases early haemoglobin concentrations and iron stores in
infants [30].
A third of the units reported using carbetocin for prevention of
bleeding in caesareans, but the cost-effectiveness of this substance
has not been demonstrated [31]. We noted a very high percentage
of manual delivery of the placenta after caesareans, although it has
declined (68.8% compared with 84.2% in 2003) [13]. A meta-
analysis has pointed out that manual removal of the placenta
compared with delivery of the placenta by cord traction at
caesarean delivery is associated with more endometritis, a lower
haematocrit after delivery, and a longer hospital stay [32].
Exteriorisation of the uterus is common practice in only one third
of the maternity units. However, there is not enough scientic
evidence to justify the choice of one type of repair for the uterine
incision over another (extra-abdominal or intra-abdominal) [33].
PPH diagnosis
PPH is most often dened for vaginal delivery (>500 ml) (82.5%
against 75.2% in 2003) [13]. More than half of maternity units now
have a denition of severe PPH (>1000 ml), compared with only
31.0% in 2003 [13]. Only 23.8% of respondents reported a denition
of PPH for caesarean deliveries (>1000 ml), and this percentage was
still lower for severe PPH for caesareans (>1500 ml) (13.1%). It is
possible that the threshold of 1000 ml is not that used for
caesareans and that units use a threshold of 500 ml, as for vaginal
births, or, on the contrary, 1500 ml. The 2004 guideline [14] did not
clearly specify the threshold of 500 ml for PPH, regardless of mode
of delivery, but the 2014 update now does so [11].
Blood loss for vaginal deliveries was reported to be estimated
clinically in 39.1% of cases (compared with 61% in 2003) [13]
(Table 2). The use of a collection bag after vaginal delivery has
increased quite markedly (90.8% versus 33% in 2003) [13]. After
caesareans, blood loss is most frequently estimated from the uid
collected in the suction canister (88.3%) combined with other
measurements (weight of swabs, dressings, etc.) (Table 3).
However, the use of a collection bag did not reduce the rate of
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
25
severe PPH compared with visual estimation of postpartum blood
loss in the EUPHRATES study [34].
PPH management
Only 2.8% of maternity units lacked a written protocol for PPH
(compared with 16% in 2003) [13] (Table 4). A survey in 2003 in
Australia and New Zealand found that 41.2% of maternity units had
no written protocol for PPH [17]. The existence of a protocol is
thought to improve the identication of severe PPH [35] and even
to induce a shift toward earlier resolution of maternal bleeding and
the use of fewer blood products [36].
In the case of recognised PPH, the rst-line pharmacological
treatment was oxytocin in 96.3% of maternity units (versus 80.5%
in 2003) [13]; these results show excellent adherence to the
2004 guidelines [14]. In accordance with other ndings, miso-
prostol was rarely used (0.8% of maternity units versus 15.1% in
2003) [13,37] (Table 4).
Time to administration of a second-line pharmacological
treatment, once the inefcacy of the rst was shown, was not
dened for 14.3% of the maternity units (compared with 16.7% in
2003) [13]. Most of the maternity units set this period at 30 min,
corresponding to the national recommendation in 2004 (82.9%
versus 73.7% in 2003) [13] (Table 4). Nonetheless this time period
varies across Europe [38].
Sulprostone was the second-line treatment for PPH for 97.5% of
respondents (compared with 49.9% in 2003) [13] (Table 4).
Misoprostol was rarely used, in accordance with the French
guidelines, which did not recommend it [14].
Association with maternity-unit level and status
Level III maternity units had a denition for PPH more often.
Moreover, for caesareans, they used manual removal of the
placenta less often (Table 3) and measured blood loss objectively,
from the suction canister (Table 3), more often. These ndings may
be explained by the fact that these are most often very large and/or
academic public maternity units, both factors that increase the
need for standardized protocols and the probability that profes-
sionals will adhere strongly to the national guidelines.
Conclusion
Although unit policies continue to differ in some ways from the
2004 French guidelines, management, especially for use of
oxytocin for the third stage of labour, has improved since the
2003 European survey. We also observe that these practices
differed relatively little between levels of care. We noted, in
comparison to the EUPRATES study [13], an improvement of the
practices observed, which is likely to be associated with the
decrease in maternal mortality in France due to haemorrhage
from uterine atony during the interval between these two studies
[18].
It is nonetheless necessary to provide better support for these
French perinatal professionals in their adoption of these guide-
lines. It would also be interesting to analyse whether the maternity
units that followed the 2004 guidelines most closely had fewer
maternal complications associated with PPH.
Conict of interest
None of the authors has any conict of interest concerning the
topic or contents of this article.
26 F. Vendittelli et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 205 (2016) 2126
Funding
This study was supported by a grant from the French Ministry of
Health (PHRCN 2009 No. 05-05).
Ethics
Study ethics approval was obtained on November, 2009 (CECIC
Rhnes-Alpes-Auvergne, Grenoble, IRB 5044).
Authors contributions
FV, MHBC, and BB designed the study. FV, BP, and CB conducted
the analysis. FV wrote the rst draft of the manuscript. FV and DL
obtained the funding for the study. All the authors supervised the
interpretation of the analysis, and helped in revising the
manuscript.
Acknowledgement
None.
References
[1] Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum
haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynecol
2008;22:9991012.
[2] European perinatal health report. Health and care of pregnant women and
babies in Europe in 2010. . http://www.europeristat.com/reports/european-
perinatal-health-report-2010.html.
[3] Khan KS, Wojdyla D, Say L. WHO systematic review of causes of maternal
deaths. Lancet 2006;367:106674.
[4] Wilman K, Bouvier-Colle MH, the MOMS group. Maternal mortality as an
indicator of obstetric care in Europe. BJOG 2004;111:1649.
[5] Hoveyda F, MacKenzie IZ. Secondary postpartum haemorrhage: incidence,
morbidity and current management. BJOG 2001;108:92730.
[6] Saucedo M, Deneux-Tharaux C, Bouvier-Colle MH, French National Experts
Committed on Maternal Mortality. Ten years of condential inquiries into
maternal deaths in France, 19882007. Obstet Gynecol 2013;122:75260.
[7] Brace V, Penney G, Hall M. Quantifying severe maternal morbidity: a Scottish
population study. BJOG 2004;111:4814.
[8] Zhang WH, Alexander S, Bouvier-Colle MH, Macfarlane A, the Moms-B group.
Incidence of severe pre-eclampsia, postpartum haemorrhage and sepsis as a
surrogate marker for severe maternal morbidity in a European population-
based study: the MOMS-B survey. BJOG 2005;112:8996.
[9] Zwart JJ, Richters JM, Ory F, de Vries JIP, Bloemenkamp KWM, van Roosmalen J.
Severe maternal morbidity during pregnancy, delivery and puerperium in the
Netherlands: a nationwide population-based study of 371 000 pregnancies.
BJOG 2008;115:84250.
[10] Rath WH. Postpartum hemorrhageupdate on problems of denitions and
diagnosis. Acta Obstet Gynecol Scand 2011;90:4218.
[11] Sentilhes L, Vayssire C, Deneux-Tharaux C, et al. Postpartum hemorrhage:
guidelines for clinical practice from the French College of Gynaecologists and
Obstetricians (CNGOF) in collaboration with the French Society of Anesthesi-
ology and Intensive Care (SFAR). Eur J Obstet Gynecol Reprod Biol
2016;198:1221.
[12] Winter C, Macfarlane A, Deneux-Tharaux C, et al. Variations in policies for
management of the third stage of labour and the immediate management of
postpartum haemorrhage in Europe. BJOG 2007;114:84554.
[13] Deneux-Tharaux C, Dreyfus M, Gofnet F, et al. Prevention and early
management of immediate postpartum haemorrhage: policies in six perinatal
networks in France. J Gynecol Obstet Biol Reprod 2008;37:23745.
[14] Gofnet F, Mercier F, Teyssier V, et al. Postpartum haemorrhage: recom-
mendations for clinical practice by the CNGOF (December 2004). Gynecol
Obstet Fertil 2005;33:26874.
[15] Omedo B, Miranda E, Cordon O, Petteker CM, Funai EF. Improving maternal
health and safety through adherence to postpartum haemorrhage protocol in
Latin America. Int J Gynecol Obstet 2014;125:1625.
Downloaded for Mahasiswa FK UKDW 01 (mhsfkdw01@gmail.com) at Universitas Kristen Duta Wacana from ClinicalKey.com by Elsevier on September 06, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
[16] Nadisauskiene RJ, Kliucinskas M, Dobozinskas P, Kaceraushiene J. The impact
of postpartum haemorrhage management guidelines implemented in clinical
practice: a systematic review of the literature. Eur J Obstet Gynecol Biol
2014;178:216.
[17] Fowler SJ. Provision for major obstetric haemorrhage: an Australian and New
Zealand survey and review. Anaesth Intensive Care 2005;33:78493.
[18] Saucedo M, Deneux-Tharaux C, Bouvier-Colle MH. Epidmiologie de la
mortalit maternelle en France, 20072009. J Gynecol Obstet Biol Reprod
2013;42:61327.
[19] Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. Active versus expectant
management for women in the third stage of labour. Cochrane Database Syst
Rev 20153:, doi:http://dx.doi.org/10.1002/14651858.CD007412.pub4 [Art. No.:
CD007412].
[20] International Confederation of Midwives, International Federation of Gyne-
cology and Obstetrics. International joint policy statement No. 136. Manage-
ment of the third stage of labor to prevent postpartum haemorrhage. J Obstet
Gynaecol Can 2003;25:9523.
[21] Roberts CL, Lain SJ, Morris JM. Variation in adherence to recommendations for
management of the third stage of labor. Int J Gynecol Obstet 2008;103:17284.
[22] Westhoff G, Cotter AM, Tolosa JE. Prophylactic oxytocin for the third stage of
labour to prevent postpartum haemorrhage. Cochrane Database Syst Rev 2013
(10), doi:http://dx.doi.org/10.1002/14651858.cd001808.pub2 [Art. No.:
CD001808].
[23] Oladapo OT, Okusanya BO, Abalos E. Intramuscular versus intravenous
prophylactic oxytocin for the third stage of labour. Cochrane Database Syst
Rev 2012(2), doi:http://dx.doi.org/10.1002/14651858.cd009332.pub2 [Art.
No.: CD009332].
[24] Soltani H, Hutchon DR, Poulose TA. Timing of prophylactic uterotonics for the
third stage of labour after vaginal birth. Cochrane Database Syst Rev 2010(8),
doi:http://dx.doi.org/10.1002/14651858.cd006173.pub2 [Art. No.: CD006173].
[25] Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam QM. Prophylactic use of
ergot alkaloids in the thirs stage of labour. Cochrane Database Syst Rev 2007
(2), doi:http://dx.doi.org/10.1002/14651858.CD005456.pub2 [Art. No.:
CD005456].
[26] McDonald SJ, Abbott JM. Prophylactic ergometrine-oxytocin for the third stage
of labour. Cochrane Database Syst Rev 2014(1), doi:http://dx.doi.org/10.1002/
14651858.CD000201.pub2 [Art. No.: CD00020].
[27] Tunalp , Hofmeyr GJ, Glmezoglu AM. Prostaglandins for preventing
postpartum haemorrhage. Database Syst Rev 2012(8), doi:http://dx.doi.org/
10.1002/14651858.CD000494.pub4 [Art. No.: CD000494].
[28] Hofmeyr GJ, Mshweshwe NT, Glmezoglu AM. Controlled cord traction for the
third stage of labour. Cochrane Database Syst Rev 2015(1), doi:http://dx.doi.
org/10.1002/14651858.cd008020.pub2 [Art. No.: CD008020].
[29] Pea-Mart GE, Comunin-Carrasco G. Fundal pressure versus controlled cord
traction as part of the active management of the third stage of labour.
Cochrane Database Syst Rev 2007(4), doi:http://dx.doi.org/10.1002/14651858.
cd005462.pub2 [Art. No.: CD005462].
[30] McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical
cord clamping of term infants on maternal and neonatal outcomes. Cochrane
Database Syst Rev 2013(7), doi:http://dx.doi.org/10.1002/14651858.
CD004074.pub3 [Art. No.: CD004074].
[31] Su LL, Chong YS, Samuel M. Carbetocin for preventing postpartum
haemorrhage. Cochrane Database Syst Rev 2012(4), doi:http://dx.doi.org/
10.1002/14651858.CD005457.pub4 [Art. No.: CD005457].
[32] Anorlu RI, Maholwana B, Hofmeyr GJ. Methods of delivering the placenta at
caesarean section. Cochrane Database Syst Rev 2008(3), doi:http://dx.doi.org/
10.1002/14651858.cd004737.pub2 [Art. No.: CD004737].
[33] JacobsJokhan D, Hofmeyr GJ. Extra-abdominal versus intra-abdominal repair
of the uterine incision at caesarean section. Cochrane Database Syst Rev 2004
(4), doi:http://dx.doi.org/10.1002/14651858.CD000085.pub2 [Art. No.:
CD000085].
[34] Zhang WH, Deneux-Tharaux C, Brocklehurst P, et al. Effect of a collector bag for
measurement of postpartum blood loss after vaginal delivery: cluster
randomized trial in 13 European countries. BMJ 2010;340:c293, doi:http://
dx.doi.org/10.1136/bmj.c293.
[35] Batra P, Suda D, Markovic D, Gutkin R. The effect of an obstetric hemorrhage
protocol on outcomes in postpartum hemorrhage. Obstet Gynecol 2014;123
(S1):136S.
[36] Shields LE, Smalarz K, Refgee L, Mugg S, Burdumy TJ, Propst M.
Comprehensive maternal haemorrhage protocols improve patient safety
and reduce utilization of blood products. Am J Obstet Gynecol 2011;205:368
e18.
[37] Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alrevic Z. Treatment for
primary postpartum haemorrhage. Cochrane Database Syst Rev 2014(2), doi:
http://dx.doi.org/10.1002/14651858.CD000201.pub2 [Art. No.: CD000201].
[38] Deneux-Tharaux C, Macfarlane A, Winter C, et al. Policies for manual removal
of placenta at vaginal delivery: variations in timing within Europe. BJOG
2009;116:11924.