Despite medical technology and research advances postpartum hemorrhages (PPH) continue to be a leading cause of morbidity and mortality for pregnant women, even in developed countries. One possible explanation for PPHs continuing to be a leading cause of maternal death is inconsistent recognition and timely treatment of women experiencing a PPH. This doctor of nursing practice project attempts to improve labor and delivery nurse knowledge through an educational intervention which will contribute to rapid identification and treatment of PPH. Knowledge change was demonstrated though change in pretest and posttest scores. The educational information and process was guided by adult learning theory and content was based on current research and evidence-based practice guidelines on PPH. Ninety six participants were assessed using a PPH pretest posttest design. The tests consisted of 15 questions. Correct scores were added and a percent correct score was calculated. The data demonstrated that 63% of the participants passed the pretest with an 80% or higher and 90% of the participants passed the posttest with an 80% or higher. The difference was statistically significant, indicating there was an increase in knowledge after the educational materials were presented. This DNP project contributes to social change by ensuring women receive excellent and timely PPH care by nurses who have a strong understanding of PPH and can apply that knowledge through rapid identification and treatment.

Postpartum hemorrhage is a leading cause of maternal death, yet many deaths related to hemorrhage might be prevented with early recognition and intervention. The birthing unit of a U.S. community hospital formed an interprofessional task force to plan and implement a postpartum hemorrhage protocol that would provide the obstetric team with the knowledge, skills, and tools needed for early identification and quick action when hemorrhage occurred. Lewin's model of change provided a framework for protocol implementation. The purpose of this doctoral project was to evaluate this quality improvement project. Secondary data internal to the organization were collected and analyzed to answer the practice-focused question, Is there a relationship between implementation of a postpartum hemorrhage protocol and the incidence of postpartum hemorrhage? To determine the incidence of postpartum hemorrhage, the number of hemorrhages with and without blood transfusion was divided by the number of deliveries and recorded monthly. The chi-square test was used to analyze the rates of hemorrhage pre- and post-implementation. A statistically significant decrease in hemorrhage was noted post-implementation, suggesting that there was a relationship between implementation of a protocol and the incidence of postpartum hemorrhage. This project supported the Walden University mission by working towards optimal health outcomes for women. Eliminating preventable harm related to hemorrhage benefits women, families, and communities. Lessons learned from the implementation and evaluation of this quality improvement project are expected to be utilized by nursing leaders to address other challenges identified in the obstetric setting.

No description available.

Hemorragia pós-parto (HPP) é tradicionalmente definida como perda sanguínea maior ou igual a 500 ml em partos vaginais e acima de 1000 ml em partos cesarianos e/ou queda de 10% do hematócrito comparado ao exame feito à admissão da parturiente e/ou sangramento importante que requeira hemotransfusão. Estima-se que 25 a 30% das mortes maternas são decorrentes da HPP. Além disso, este quadro pode causar impacto na qualidade de vida de mulheres e neonatos, devido às complicações, além da necessidade de intervenções. Objetivo: Estimar prevalência de HPP, efeito do tipo de parto e intervenções obstétricas sobre os valores hematimétricos (hematócrito e hemoglobina) em uma amostra de mulheres primíparas atendidas em hospital de ensino. Metodologia: A amostra constituiu-se de 100 primíparas, independente da via de parto. A coleta de dados foi realizada a partir de dados retrospectivos obtidos de prontuários (impresso e eletrônico), cartão de pré-natal, dentre outras fontes de consulta, respaldadas por formulário testado previamente em estudo piloto. Resultados: A prevalência de HPP na amostra de estudo foi de 16%. Através da análise simples (teste F), encontrou-se significância estatística para as seguintes variáveis: diabetes, síndromes hipertensivas, anemia diagnosticada durante a gestação, analgesia, tipo de parto e peso do recém-nascido. Porém através da regressão linear múltipla, observou-se significância apenas para as variáveis: diabetes e analgesia. Mulheres portadoras de diabetes apresentaram maiores perdas hemáticas; enquanto que mulheres que realizaram analgesia durante o trabalho de parto, apresentaram menores perdas. Dentre as complicações mais frequentes no período compreendido do puerpério imediato à alta hospitalar detectou-se: necessidade de ocitócito terapêutico adicional (20 UI); nível de hemoglobina < 9 mg/dl; lipotímia; necessidade de suplementação com sulfato ferroso (em dose terapêutica); 22 mulheres apresentaram algum tipo de sintoma (fraqueza, desânimo, entre outros); 62 mulheres apresentaram anemia no período puerperal. Houve correlação positiva (0,89) entre os níveis de queda do hematócrito e da hemoglobina, sendo que para queda de hematócrito >= 10%, a queda de hemoglobina foi de 2,99 mg/dl. Não foram constatadas outras associações significativas. Considerações finais: Acreditamos que a dosagem de hemoglobina e hematócrito 48 horas pós-parto é uma importante ferramenta para auxiliar no diagnóstico precoce e mais fidedigno dos quadros, devendo esta prática ser adotada como rotina nas instituições. Ressaltamos mais uma vez que análise laboratorial não exime o profissional de avaliação clínica rigorosa e minuciosa. Assim, esta prática vem complementar a assistência clínica no puerpério e em hipótese alguma se deve substituí-la. Dada a magnitude do problema e a escassez de estudos sobre a temática acreditamos que todos os trabalhos sobre a questão são louváveis e podem contribuir para a melhoria da assistência ao ciclo gravídico-puerperal. / Postpartum hemorrhage (PPH) is traditionally defined as blood loss greater than or equal to 500 ml in vaginal parturition and over 1000 ml in cesarean sections and/or 10% drop in hematocrit compared to examination by the admission of the mother and/or major bleeding requiring blood transfusion. It is estimated that 25-30% of maternal deaths are due to PPH. Moreover, this framework can impact quality of life of women, newborns, due to its complications, and the need for interventions. Objective: To estimate the prevalence of PPH and effect of type of delivery and obstetric interventions on the hematological values (hemoglobin and hematocrit) in a sample of primiparous women attended at a teaching hospital. Methodology: The sample consisted of 100 primiparous, regardless of mode of delivery. Data collection was performed with retrospective data obtained from medical records, pregnancy card, among other sources of information, backed-up by a form previously tested in a pilot study. Results: The prevalence of PPH in the study sample was 16%. Through simple analysis (F test), statistical significance was found for the following variables: diabetes, hypertensive disorders, anemia diagnosed during pregnancy, analgesia, mode of delivery and weight of the newborn. But through multiple linear regression, we found significance only for the variables: diabetes and analgesia. Women with diabetes had higher blood loss, whereas women who underwent analgesia during labor, showed smaller losses. The following complications were identified: need for additional oxytocin therapy (20UI), hemoglobin < 9 mg/dl, syncope, need for supplementation with iron (terapheutic dose), 22 women had some type of symptoms (weakness, prostration, etc), 62 women had anemia in the postpartum period. A positive correlation (0.89) between the levels of low hematocrit and hemoglobin, while those for the fall of hematocrit >= 10%, the drop in hemoglobin was 2.99 mg/dl. No association with other variables was found. Final considerations: We believe that dosage of hemoglobin and hematocrit 48 hours after delivery is an important tool for early diagnosis and the most reliable for detection of the frameworks, so, should this practice be adopted as routine in institutions. We emphasize once again that laboratoring testing does not relieve the professional of a rigorous and thorough clinical evaluation. Thus, this practice come to complement the clinical care in puerperium and in no way should replace it. Given the magnitude of the problem and the scarcity of studies on the subject believe that all study on the issue is commendable and may contribute to the improvement of care in pregnancy and childbirth.

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 4 uppsatser.

Hemorragia pós-parto (HPP) é tradicionalmente definida como perda sanguínea maior ou igual a 500 ml em partos vaginais e acima de 1000 ml em partos cesarianos e/ou queda de 10% do hematócrito comparado ao exame feito à admissão da parturiente e/ou sangramento importante que requeira hemotransfusão. Estima-se que 25 a 30% das mortes maternas são decorrentes da HPP. Além disso, este quadro pode causar impacto na qualidade de vida de mulheres e neonatos, devido às complicações, além da necessidade de intervenções. Objetivo: Estimar prevalência de HPP, efeito do tipo de parto e intervenções obstétricas sobre os valores hematimétricos (hematócrito e hemoglobina) em uma amostra de mulheres primíparas atendidas em hospital de ensino. Metodologia: A amostra constituiu-se de 100 primíparas, independente da via de parto. A coleta de dados foi realizada a partir de dados retrospectivos obtidos de prontuários (impresso e eletrônico), cartão de pré-natal, dentre outras fontes de consulta, respaldadas por formulário testado previamente em estudo piloto. Resultados: A prevalência de HPP na amostra de estudo foi de 16%. Através da análise simples (teste F), encontrou-se significância estatística para as seguintes variáveis: diabetes, síndromes hipertensivas, anemia diagnosticada durante a gestação, analgesia, tipo de parto e peso do recém-nascido. Porém através da regressão linear múltipla, observou-se significância apenas para as variáveis: diabetes e analgesia. Mulheres portadoras de diabetes apresentaram maiores perdas hemáticas; enquanto que mulheres que realizaram analgesia durante o trabalho de parto, apresentaram menores perdas. Dentre as complicações mais frequentes no período compreendido do puerpério imediato à alta hospitalar detectou-se: necessidade de ocitócito terapêutico adicional (20 UI); nível de hemoglobina < 9 mg/dl; lipotímia; necessidade de suplementação com sulfato ferroso (em dose terapêutica); 22 mulheres apresentaram algum tipo de sintoma (fraqueza, desânimo, entre outros); 62 mulheres apresentaram anemia no período puerperal. Houve correlação positiva (0,89) entre os níveis de queda do hematócrito e da hemoglobina, sendo que para queda de hematócrito >= 10%, a queda de hemoglobina foi de 2,99 mg/dl. Não foram constatadas outras associações significativas. Considerações finais: Acreditamos que a dosagem de hemoglobina e hematócrito 48 horas pós-parto é uma importante ferramenta para auxiliar no diagnóstico precoce e mais fidedigno dos quadros, devendo esta prática ser adotada como rotina nas instituições. Ressaltamos mais uma vez que análise laboratorial não exime o profissional de avaliação clínica rigorosa e minuciosa. Assim, esta prática vem complementar a assistência clínica no puerpério e em hipótese alguma se deve substituí-la. Dada a magnitude do problema e a escassez de estudos sobre a temática acreditamos que todos os trabalhos sobre a questão são louváveis e podem contribuir para a melhoria da assistência ao ciclo gravídico-puerperal. / Postpartum hemorrhage (PPH) is traditionally defined as blood loss greater than or equal to 500 ml in vaginal parturition and over 1000 ml in cesarean sections and/or 10% drop in hematocrit compared to examination by the admission of the mother and/or major bleeding requiring blood transfusion. It is estimated that 25-30% of maternal deaths are due to PPH. Moreover, this framework can impact quality of life of women, newborns, due to its complications, and the need for interventions. Objective: To estimate the prevalence of PPH and effect of type of delivery and obstetric interventions on the hematological values (hemoglobin and hematocrit) in a sample of primiparous women attended at a teaching hospital. Methodology: The sample consisted of 100 primiparous, regardless of mode of delivery. Data collection was performed with retrospective data obtained from medical records, pregnancy card, among other sources of information, backed-up by a form previously tested in a pilot study. Results: The prevalence of PPH in the study sample was 16%. Through simple analysis (F test), statistical significance was found for the following variables: diabetes, hypertensive disorders, anemia diagnosed during pregnancy, analgesia, mode of delivery and weight of the newborn. But through multiple linear regression, we found significance only for the variables: diabetes and analgesia. Women with diabetes had higher blood loss, whereas women who underwent analgesia during labor, showed smaller losses. The following complications were identified: need for additional oxytocin therapy (20UI), hemoglobin < 9 mg/dl, syncope, need for supplementation with iron (terapheutic dose), 22 women had some type of symptoms (weakness, prostration, etc), 62 women had anemia in the postpartum period. A positive correlation (0.89) between the levels of low hematocrit and hemoglobin, while those for the fall of hematocrit >= 10%, the drop in hemoglobin was 2.99 mg/dl. No association with other variables was found. Final considerations: We believe that dosage of hemoglobin and hematocrit 48 hours after delivery is an important tool for early diagnosis and the most reliable for detection of the frameworks, so, should this practice be adopted as routine in institutions. We emphasize once again that laboratoring testing does not relieve the professional of a rigorous and thorough clinical evaluation. Thus, this practice come to complement the clinical care in puerperium and in no way should replace it. Given the magnitude of the problem and the scarcity of studies on the subject believe that all study on the issue is commendable and may contribute to the improvement of care in pregnancy and childbirth.

Objective Postpartum hemorrhage (PPH) is a major cause of maternal mortality world-wide; misoprostol is a relatively cheap, easily administered, and an efficient medication to be given after the delivery of the baby to prevent PPH, thus posing it as a first choice in resource-poor communities. The aim of this study is to answer questions regarding the most appropriate dose (400 µg versus 600 µg), effect of labour settings (community or clinical), and management of labour on misoprostol effectiveness and safety in preventing PPH. Methods We developed a search strategy and conducted a search within five key databases. Two reviewers screened the articles for predefined inclusion/exclusion criteria, quality, and performed data extraction. Discrepancy was dealt with by reaching consensus. In article 1, we only included randomized controlled trials, we performed a random-effects Bayesian network meta-analysis comparing 400 µg to 600 µg misoprostol over five outcomes of interest: blood loss ≥500 ml, blood loss ≥1000 ml, using additional uterotonics, shivering, and pyrexia. In article 2, we included any experimental trial, we performed a random effects model meta-analysis, pooling the incidence of PPH from each misoprostol arm. Subsequently, a meta-regression model was performed on identified potential effect-modifiers, including clinical settings and labour management. Results Of 444 identified records, 46 trials met the inclusion/exclusion criteria in article 1, and 56 trials in article 2. The odds ratio (OR) of misoprostol 400 µg vs. 600 µg for bleeding ≥ 500 ml is 0.86 [95% Credible Intervals: 0.46 − 1.54], for bleeding ≥ 1000 ml the OR is 0.83 [95% CrI 0.54 – 1.26], for additional uterotonics is 0.75 [95% CrI 0.40 – 1.40], for pyrexia and shivering an OR of 0.57 [95% CrI 0.15 – 2.18] and 0.63 [95% CrI 0.29 – 1.31] respectively. The overall incidence of PPH was 6.62 per 100 pregnancies (95%CI 4.71 per 100 – 8.53 per 100). Labour settings and other aspects of active management of labour had no statistically significant effect on the incidence of post-partum hemorrhage. Conclusion We found no difference between the administration of misoprostol 400 µg or 600 µg for the prevention of PPH and side effects of misoprostol, as well as no effect of labour settings and management of labour on misoprostol effectiveness.

Postpartum hemorrhage (PPH) is the leading direct cause of maternal mortality worldwide, with the majority of deaths taking place in the least developed countries of the world. Low- and middle-income countries (LMICs) have increased rates of PPH due to lack of access to healthcare, inadequate number of care providers and availability of interventions and resources needed. PPH has four main etiologies: uterine atony, trauma, retained placenta and coagulopathy. The most common and challenging to treat is uterine atony, where a lack of uterine contractility leads to massive hemorrhage postpartum. Specific risk factors have been identified that increase a woman’s risk of developing PPH. Risk factors of PPH can be categorized as biological, demographical and social risk factors. Many people in LMICs experience a lot of the social risk factors like lack of providers, skilled facilities and resources available to them in case of an obstetric emergency. Home births are also a common practice in many LMICs, placing a woman further from any resources she may have had access to if she was at a health facility. PPH can also occur in women without risk factors and requires that providers always be prepared to treat it. Interventions to treat PPH are well known and encompass both pharmacological and non-pharmacological interventions that are usually tried in a least to most invasive order. The first line of intervention is often to administer a uterotonic drug, preferably oxytocin. This poses a challenge to LMICs because oxytocin requires a cold-chain storage, which many LMICs countries lack. Therefore, uterotonics and non-pharmacologic interventions have increasingly been used in these regions. The final and ultimate life saving measure to stop bleeding is a hysterectomy, which is often not available in these rural places where home births take place, and has led to higher mortality rates. Prevention measures of PPH include increasing antenatal care (ANC) use and practicing active management of the third stage of labor (AMTSL) with all pregnancies. Use of ANC and ultrasound technology can help identify the biological risk factors that make a woman more likely to experience PPH. Solutions to lowering the occurrence of PPH in LMICs involve increasing resources and access to healthcare. An important part to increasing access is increasing the number of skilled health facilities and health providers. Community health workers (CHW) and skilled birth attendants (SBA) are vital to increasing the amount and acceptability of care in these regions. These workers are trusted members of the community that can help educate and bring resources to women, as well as women to the resources. Solutions to stopping PPH need to consider the affordability, acceptability and accessibility in order to reach people in remote areas with limited resources. Both immediate short-term interventions and long-term, longitudinal healthcare reform are necessary to save mothers in LMICs.

A recurring theme in the literature is that simulation is a positive teaching strategy when compared to other methods of instruction and produces positive student outcomes (Jefferies, 2016). Simulation provides educators a way to reproduce a clinical teaching experience in a safe, supportive learning environment. The purpose of this quantitative research study was to determine whether an obstetrical simulation educational experience is an effective strategy for educating undergraduate nursing students in the management of a postpartum hemorrhage. A quasi-experimental study using a pre-test and post-test design was employed in a Women’s Health Course and Pediatrics course over one semester. A single convenience sample (N=81) of junior baccalaureate nursing students was used for this study. There were 41 students in the control group and 40 in the experimental group. Both the control and experimental groups received the traditional didactic session, case study, skills lab instruction, and clinical. In addition, the experimental group received the postpartum simulation. This simulation study tested the differences in knowledge, satisfaction, and confidence level between junior nursing students who did and did not participate in the simulation. There were three instruments used during this study; a pre-test/post-test for knowledge acquisition, the National League for Nursing (NLN) (2005) student satisfaction and confidence level survey, and the Creighton Competency Evaluation Instrument (C-CEI) (Todd, Manz, Hawkins, Parsons, & Hercinger, 2008). The pre-test/post-test measured the knowledge acquisition obtained from the didactic session. NLN (2005) student satisfaction and confidence level survey measured students’ satisfaction and confidence level from either the interactive skills lab sessions or the simulation. The C-CEI tool measured the students’ performance during the simulation. There were four categories: assessment, communication, clinical judgment, and patient safety that the researcher measured the students’ performance during the simulation. Data for the knowledge acquisition, revealed both the experimental and control groups significantly increased between the pre-test and the post-test. The post-test showed statistically significant differences between groups, with the control group outperforming the experimental group. As such, the data demonstrate that the simulation did not have a significant effect on knowledge. Data from the NLN (2005) student satisfaction and confidence level survey were analyzed using a two group MANOVA. Although the results of the MANOVA were not significant, as a follow up analysis, the individual questions were used as the dependent variables in a MANOVA. When the individual questions were used as the dependent variables in a MANOVA, the experimental group performed significantly better in two out of the five questions on student satisfaction and five out of the nine questions on student self-confidence. There was a strong positive correlation between satisfaction with current learning and self–confidence. Data for the students’ performance were analyzed using the C-CEI tool. A perfect score on the C-CEI instrument was 14 points, 100%. The overall group average was 8.1 points or 58%. Of the four sections in the C-CEI tool, the lowest mean was Communication (0.5185), followed by Patient Safety (mean = 0.5333). Although student groups were able to communicate with the patient effectively 67% of the time, none of the simulation groups provided an organized report to the healthcare provider with minimal prompting. During the postpartum simulation, 33% of the students administered medications safely. The wrong dosage and incorrect technique were seen in 67% of the simulations. Communication and safe medication practice are essential to ensuring patient safety; it is important that faculty prepare nursing graduates to provide safe care. Even though there were limitations to this study, a convenience sample at one public university, the findings are informative and have implications for future teaching and learning strategies. The results of this study add to the body of knowledge that supports the use of simulation as a teaching strategy in undergraduate nursing education. / Educational Leadership

Thesis (MCur)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Background: Misoprostol, a prostaglandin E1 analogue with its uterotonic properties has entered as an integral part of management of the third stage of labour, helping to prevent postpartum haemorrhage (PPH). Objective: To assess evidence on the effectiveness of misoprostol compared to a placebo for the prevention and treatment of postpartum haemorrhage. Methods: Databases searched included; MEDLINE, Google Scholar and Cochrane Central Register of Controlled Trials (CENTRAL). Other sources were also searched. All articles were screened for methodological quality by two reviewers independently by standardized instrument. Data was entered in Review Manger 5.1 software for analysis. Results: Three Misoprostol studies were included (2346 participants), Oral (2 trials) and sublingual (1 trial). Misoprostol has shown not to be effective in reducing PPH (RR 0.65: 95% CI 0.40-1.06). Only one trial reported on need for blood transfusion (RR 0.14; 95% CI 0.02-1.15). Misoprostol use is associated with significant increases in shivering (RR 2.75; 95% CI 2.26-3.34) and pyrexia (RR 5.34; 95% CI 2.86-9.96) than with placebo. No maternal deaths were reported in included trials. Compared to placebo, misoprostol was coupled with less hysterectomies and additional used of uterotonics (RR 0.45; 95%CI 0.21-0.96) compared to placebo. Conclusion: Results of this review shows that the use of misoprostol in combination with some components of active management was not associated with any significant reduction in incidence of PPH. However oral administration showed a significant reduction in incidence of PPH. For its use for treatment of postpartum haemorrhage, there is a need for research focus in optimal dose and route of administration for a clinically significant effect and acceptable side effects. / AFRIKAANSE OPSOMMING: Agtergrond: Misoprostol, 'n prostaglandien E1 analoog met sy uterotonic eienskappe het ingeskryf as' n integrale deel van die bestuur van die derde stadium van kraam, help postpartum bloeding (PPH) te voorkom. Doelwit: Om bewyse oor die effektiwiteit van Misoprostol in vergelyking met 'n placebo vir die voorkoming en behandeling van postpartum bloeding te evalueer. Metodes: Databases gesoek ingesluit, Medline, CINHAL, Google Scholar en Cochrane Sentrale Register van gecontroleerde studies (Sentraal). Ander bronne is ook deursoek. Alle artikels is gekeur vir die metodologiese kwaliteit deur twee beoordelaars onafhanklik deur die gestandaardiseerde instrument. Data is opgeneem in Review Manger 5.1 sagteware vir ontleding. Hoof Resultate: Drie Misoprostol studies were ingesluit (2346 deelnemers). Mondeling (2 proe) en sublinguale (1 verhoor). Misoprostol het getoon nie doeltreffend te wees in die vermindering van PPH (RR 0,65: 95% CI 0,40-1,06). Slegs een verhoor berig oor die noodsaaklikheid vir 'n bloedoortapping (RR 0,14, 95% CI 0,02-1,15). Misoprostol gebruik word geassosieer met 'n aansienlike toename in bewing (RR 2,75, 95% CI 2,26- 3,34) en koors (RR 5,34, 95% CI 2,86-9,96) as met' n placebo. Geen moederlike sterftes is aangemeld in proewe. In vergelyking met placebo, was Misoprostol tesame met minder hysterectomies en addisionele gebruik van uterotonics (RR 0,45, 95% CI,21-,96) in vergelyking met placebo. Gevolgtrekking: Resultate van hierdie studie toon dat die gebruik van Misoprostol in kombinasie met 'n paar komponente van aktiewe bestuur is wat nie verband hou met' n beduidende afname in die voorkoms van PPH. Vir die gebruik vir die behandeling van postpartum bloeding, daar is 'n behoefte vir navorsing fokus in die optimale dosis en die roete van administrasie vir' n klinies beduidende uitwerking en aanvaarbare neweeffekte.