Global Health Nurse Leader

Reducing obstetric hemorrhage to improve

maternal health

Matthew Medina, RNC-OB, C-EFM, BS

UN Millennium Development Goals (MDG’s)

The Millennium Development Goals are a set of broad benchmarks to be realized by 2015. They were adopted by the United Nations in 2000 8 focus areas International framework Both globally and locally driven

UN Millennium Development Goals (MDG’s)

UN Millennium Development Goals (MDG’s)

Focusing on

•Reducing the global maternal mortality rate by 75%

•Universal access to reproductive healthcare by 2015

UN Millennium Development Goals (MDG’s)

“Women in low-resource countries are well aware of the risks associated with childbearing. Nigerian women describe pregnancy and birth as ‘journeys of uncertain outcomes’, ‘risky businesses’, ‘hazardous jobs’” (Callister & Edwards, 2010, p.590).

Obstetric Hemorrhage

Obstetric hemorrhage is a global problem and a leading cause of maternal morbidity and mortality Causes of obstetric hemorrhage include

Uterine Atony Genital Tract Trauma (Lacerations to the vagina and/or

perineum, episiotomy Retained placenta, membranes, and/or blood clots Abnormal placentation (accreta, previa) Coagulopathies

In general, a blood loss of >500 ml in a vaginal delivery or >1000 ml in a Cesarean delivery

https://www.cia.gov/library/publications/the-world-actbook/rankorder/2223rank.html

Obstetric Hemorrhage

Maternal mortality rates per 100,000 live births (2010) South Sudan: 2050 maternal deaths Ghana: 350 maternal deaths India: 200 maternal deaths Dominican Republic: 150 maternal death United States: 21 maternal deaths Canada: 12 maternal deaths Ireland: 6 maternal deaths Greece: 3 maternal deaths

Obstetric Hemorrhage

In 2010, the WHO ranked the United States 50th for maternal mortality (Bingham, 2010, p.529). In 2007 that ranking was 25th.

Given that the US spends more per capita on healthcare, shouldn’t we have more impressive statistics?

Discussion Question: What are some reasons our numbers are so appalling?

Obstetric Hemorrhage

How can we begin to fix our own maternal mortality statistics and become a leader among developing nations?

Accurate Measurements

Accurate quantification of blood loss in the delivery room and in the immediate postpartum period is the most effective way to recognize developing problems

AWHONN's QBL video is an excellent overview

Accurate Measurements

According to a study cited in Gabel & Weber (2014), visual estimates of blood loss by nurses and physicians is underestimated by about 30 % (p. 553). This often results in late recognition and delayed treatment.

In their article, Gabel & Weber highlight a theme that nurses believe quantifying blood loss leads to earlier intervention and improved outcomes

Teams Training and Drills

Simulation based training allows clinicians to polish and practice skills that will translate to excellent care delivery in routine and emergency situations

Reccommended drills include: Maternal Code Blue Neonatal Resucitation (NRP) Shoulder Dystocia Primary Postpartum Hemorrhage

(PPH)

Teams Training and Drills

As highlighted in Chichester et al., (2015), the optimal learning opportunity… Challenges decision-making skills Contains tension and timing that is realistic to

practice Environment consistent with practice setting

Postpartum Hemorrhage Noelle Simulation

The WOMAN Trial

World Maternal Antifibrinolytic Trial- London On going randomized double blind placebo

controlled trial Tranexamic acid (TXA) is an anti-fibrinolytic

drug being studied to determine if utilizing TXA will reduce maternal mortality with a PPH

It is hypothesized that TXA will also significantly reduce the need for gravid hysterectomy, puerperal anemia, and blood transfusions.

STAY TUNED!!!

Bingham, D. (2012). Eliminating Preventable, Hemorrhage-Related Maternal Mortality

and Morbidity. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(4), 529-530. doi:10.1111/j.1552-6909.2012.01371.x Bingham, D., & Jones, R. (2012). Maternal Death from Obstetric Hemorrhage. JOGNN:

Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(4), 531-539. doi: 10.1111/j.1552-6909.2012.01372.x Callister, L., & Edwards, J. (2010). Achieving Millennium Development Goal 5, the

improvement of maternal health. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 39(5), 590-599. doi:10.1111/j.1552-6909.2010.01161.x Chichester, M., Hall, N. J., Wyatt, T. L., & Pomilla, R. (2014). A cost-effective approach

to simulation-based team training in obstetrics. Nursing For Women's Health, 18(6), 500-507. doi:10.1111/1751-486X.12162 Edwards, J. E., & Hanke, J. C. (2013). An update on maternal mortality and morbidity in

the United States. Nursing For Women's Health, 17(5), 376-388. doi: 10.1111/1751-486X.12061 

Gabel, K. T., & Weeber, T. A. (2012). Measuring and Communicating Blood Loss

During Obstetric Hemorrhage. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(4), 551-558. doi:10.1111/j.1552-6909.2012.01375.x Oyelese, Y., & Ananth, C. V. (2010). Postpartum hemorrhage: epidemiology, risk

factors, and causes. Clinical Obstetrics And Gynecology, 53(1), 147-156. doi: 10.1097GRF.0b013e3181cc406d Shakur, H., Elbourne, D., Gülmezoglu, M., Alfirevic, Z., Ronsmans, C., Allen, E., & Roberts, I. (2010). The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials, 1140. doi: 10.1186/1745-6215-11-40