Learning from adverse clinical outcomes: major obstetric haemorrhage in Scotland, 2003-05.
OBJECTIVE
To describe a system for learning from cases of major obstetric haemorrhage.


METHODS
Prospective critical incident audit.


METHODS
All consultant-led maternity units in Scotland, between 1 January 2003 and 31 December 2005.


METHODS
Women suffering from major obstetric haemorrhage (estimated blood loss > or = 2500 ml or transfused > or = 5 units of blood or received treatment for coagulopathy during the acute event).


METHODS
Hospital clinical risk management teams reviewed local cases using a standard, national assessment pro forma.


METHODS
Standard of care provided and learning points identified.


RESULTS
Rate of major haemorrhage was 3.7 (3.4-4.0) per 1000 births. Pro formas returned for 517 of 581 reported cases (89%); 41% were delivered by emergency caesarean section (compared with 15% of all Scottish births). Uterine atony was the most common cause (250 women, 48%); 32% had multiple causes. A consultant obstetrician gave hands-on care to 368 (71%) and a consultant anaesthetist to 262 (50%). Placenta praevia as a cause was independently associated with consultant presence. Central venous pressure monitoring was used in 164 (31%) women, and 108 (21%) women were admitted to intensive care. Parity, blood loss, and placenta praevia as a cause were independently associated with peripartum hysterectomy (performed in 62 women, 12%). Balloon tamponade and haemostatic uterine suturing were successful in 92 of 116 women (79%). Most cases were assessed as well managed, with 'major suboptimal' care identified in only 14 cases (3%).


CONCLUSIONS
It is feasible to identify and assess cases of major obstetric haemorrhage prospectively on a national basis. Most women received appropriate care, but many learning points and action plans were identified.
Brace
V
V
Department of Obstetrics and Gynaecology, Aberdeen Maternity Hospital, Aberdeen, UK. v.brace@abdn.ac.uk
Kernaghan
D
D
Penney
G
G
D000293:Adolescent; D000328:Adult; D021721:Balloon Occlusion; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002404:Catheterization / Q000706:statistics & numerical data; D002585:Cesarean Section / Q000706:statistics & numerical data; D005240:Feasibility Studies; D005260:Female; D006470:Hemorrhage / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008485:Medical Audit; D008875:Middle Aged; D009774:Obstetrics / Q000706:statistics & numerical data; D010923:Placenta Previa / Q000209:etiology; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000517:prevention & control*; D011364:Professional Practice / Q000706:statistics & numerical data; D011446:Prospective Studies; D012151:Resuscitation / Q000706:statistics & numerical data; D012308:Risk Management; D012606:Scotland / Q000453:epidemiology; D014593:Uterine Inertia / Q000209:etiology