title: Evaluation of compliance and outcomes of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in Pakistan.
abstract: BACKGROUND
  Massive postpartum hemorrhage is a life threatening obstetric emergency. In order to prevent the complications associated with this condition, an organized and step-wise management protocol should be immediately initiated.
  
  
  METHODS
  An evidence based management protocol for massive postpartum hemorrhage was implemented at Aga Khan University Hospital, Karachi, Pakistan after an audit in 2005. We sought to evaluate the compliance and outcomes associated with this management protocol 3 years after its implementation. A review of all deliveries with massive primary postpartum hemorrhage (blood loss ≥ 1500 ml) between January, 2008 to December, 2008 was carried out. Information regarding mortality, mode of delivery, possible cause of postpartum hemorrhage and medical or surgical intervention was collected. The estimation of blood loss was made via subjective and objective assessment.
  
  
  RESULTS
  During 2008, massive postpartum hemorrhage occurred in 0.64% cases (26/4,052). No deaths were reported. The mean blood loss was 2431 ± 1817 ml (range: 1500-9000 ml). Emergency cesarean section was the most common mode of delivery (13/26; 50%) while uterine atony was the most common cause of massive postpartum hemorrhage (14/26; 54%). B-lynch suture (24%) and balloon tamponade (60%) were used more commonly as compared to our previously reported experience. Cesarean hysterectomy was performed in 3 cases (12%) for control of massive postpartum hemorrhage. More than 80% compliance was observed in 8 out of 10 steps of the management protocol. Initiation of blood transfusion at 1500 ml blood loss (89%) and overall documentation of management (92%) were favorably observed in most cases.
  
  
  CONCLUSIONS
  This report details our experience with the practical implementation of a management protocol for massive postpartum hemorrhage at a tertiary care hospital in a developing country. With the exception of arterial embolization, relatively newer, simpler and potentially safer techniques are now being employed for the management of massive postpartum hemorrhage at our institution. Particular attention should be paid to the documentation of the management steps while ensuring a stricter adherence to the formulated protocols and guidelines in order to further ameliorate patient outcomes in emergency obstetrical practice. More audits like the one we performed are important to recognize and rectify any deficiencies in obstetrical practice in developing countries. Dissemination of the same is pivotal to enable an open discourse on the improvement of existing obstetrical strategies.
authors.affiliation: Department of Gynecology and Obstetrics, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
authors.forename: Lumaan
authors.initials: L
authors.lastname: Sheikh
authors.forename: Nida
authors.initials: N
authors.lastname: Najmi
authors.forename: Umair
authors.initials: U
authors.lastname: Khalid
authors.forename: Taimur
authors.initials: T
authors.lastname: Saleem
mesh_terms: D002985:Clinical Protocols; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006785:Hospitals, University; D006801:Humans; D010154:Pakistan; D006473:Postpartum Hemorrhage / Q000209:etiology / Q000628:therapy*; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D012189:Retrospective Studies; D016896:Treatment Outcome; D014593:Uterine Inertia / Q000628:therapy