Effect of improved uterotonic availability on postpartum hemorrhage and maternal morbidity after vaginal delivery, review of a single‐center quality‐improvement initiative
Danielle L. Chirumbole, Towana Sims, Stacie Denning, Sheena Glover, Lauren Shubert, Michael Jochum, Celeste Green, Courtney Thompson, Adewunmi Babalola, Tara Barrick, Sharon Burks, Manisha Gandhi, Christina DavidsonAbstract
Introduction
After implementation of a hemorrhage risk stratification system and management bundle in 2019, our hospital demonstrated a reduction in hemorrhage‐related severe maternal morbidity (SMM‐H). We then noted a plateau in postpartum hemorrhage (PPH) rates and a gradual increase in SMM‐H after 2020, with the majority of PPH after vaginal deliveries (VDs) occurring in those deemed low‐risk. Consequently, we implemented a strategy to improve the availability of second‐line uterotonics in the delivery room regardless of PPH risk. The objective of this study is to evaluate the effect of this intervention on rates of PPH and SMM‐H after VDs.
Methods
Through this quality improvement (QI) initiative, we aimed to improve injectable uterotonic availability and use at time of delivery. Our primary outcome measures were rate of PPH and SMM‐H in VD. We reviewed all deliveries from the 16 months before and after this intervention (April 2023–July 2024, September 2024–December 2025). Deliveries from August 2024 were excluded to allow for washout. Chi‐square was used to determine statistical significance.
Results
There were 5365 VDs included in the pre‐intervention group with 63.6% designated low‐risk for PPH and 4768 included in the post‐intervention group with 62.4% designated low‐risk. There was no difference in VD PPH pre‐ versus post‐intervention (6.33% vs. 6.61%, p = 0.61). Similarly, there was no significant change in VD SMM‐H (22.9% vs. 25.6%, p = 0.40). The rates of PPH and SMM‐H in low‐risk VD patients were 5.7% and 18.6% pre‐intervention compared to 6.1% and 18.8% post‐intervention. These differences were not statistically significant. Low‐risk patients comprised 57.5% of VDs with PPH after the intervention. Of VDs requiring second‐line uterotonics, misoprostol was the most common first agent prior to the intervention (60%) versus methylergonovine after (45%), which was statistically different from prior ( p < 0.0001).
Conclusion
Improving second‐line uterotonic availability in the delivery room did not improve VD PPH rates or SMM‐H but did change second‐line uterotonic choice.