title: Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.
abstract: BACKGROUND
  The objective of this prospective cohort study was to assess whether the 45-minute prehospital limit for ambulance transfer is met in case of postpartum hemorrhage (PPH) after midwifery-supervised home birth in The Netherlands and evaluate the process of ambulance transfer, maternal condition during transfer, and outcomes in relation to whether this limit was met.
  
  
  METHODS
  Using ambulance report forms and medical charts, ambulance intervals, urgency coding, clinical condition (using the lowest Revised Trauma Score, [RTS]), and maternal outcomes were collected. From April 2008 to April 2010, midwives reported 72 cases of PPH. Associations between duration of the ambulance transfer, maternal condition during ambulance transfer and outcomes were analyzed. The main outcome measures were duration of ambulance transfer, RTS, blood loss, surgical procedures, and blood transfusions.
  
  
  RESULTS
  Seventy-two cases were reported, 18 (25%) were excluded: 54 cases were analyzed. In 63 percent, the 45-minute prehospital limit was met, 75.9 percent received a RTS of 12, indicating optimal Glasgow Coma Scale, systolic blood pressure, and respiratory frequency. In 24.1 percent a decrease in systolic blood pressure was found (RTS 10 or 11). We found no difference in outcomes between women with different RTS or in whom the 45-minute prehospital limit was or was not met.
  
  
  CONCLUSIONS
  We found no relation between the duration of ambulance transfer and maternal condition or outcomes. All women fully recovered. The low-risk profile of women in primary care, well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.
authors.affiliation: Department of Obstetrics and Gynaecology, Reinier de Graaf Groep, Delft, The Netherlands.
authors.forename: Ineke
authors.initials: I
authors.lastname: Stolp
authors.affiliation: Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Marrit
authors.initials: M
authors.lastname: Smit
authors.affiliation: Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Sanne
authors.initials: S
authors.lastname: Luxemburg
authors.affiliation: Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Thomas
authors.initials: T
authors.lastname: van den Akker
authors.affiliation: Regional Ambulance Services, Leiden, The Netherlands.
authors.forename: Jan
authors.initials: J
authors.lastname: de Waard
authors.affiliation: Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, The Netherlands.|Department of Medical Humanities, EMGO Institute VU University Medical Centre, Amsterdam, The Netherlands.
authors.forename: Jos
authors.initials: J
authors.lastname: van Roosmalen
authors.affiliation: Center for Evidence Based Education, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Rien
authors.initials: R
authors.lastname: de Vos
mesh_terms: D000328:Adult; D000552:Ambulances; D005260:Female; D006700:Home Childbirth / Q000009:adverse effects*; D006801:Humans; D008880:Midwifery; D009426:Netherlands; D006473:Postpartum Hemorrhage / Q000628:therapy*; D011247:Pregnancy; D011320:Primary Health Care / Q000458:organization & administration*; D011446:Prospective Studies; D014187:Transportation of Patients / Q000592:standards*; D055815:Young Adult
keywords: midwifery; postpartum hemorrhage; primary care