Early Identification of Risk Factors for Primary Postpartum Hemorrhage at Admission

Introduction

Postpartum hemorrhage (PPH) is the world‘s leading cause of maternal mortality, accounting for one-third of all maternal deaths worldwide. PPH causes up to 60% of all maternal deaths in developing countries. The majority of these deaths occur within 4 hours of delivery, indicating they are a consequence of events in the third stage of labor
(Murakami et al., 2015).

Postpartum hemorrhage remains an important cause of premature mortality of women worldwide; an estimated 500,000 women die from this cause every year with up to of quarter deaths occur due to hemorrhage. Post-Partum hemorrhage may occur in 1-5% of deliveries in developed as well as in developing countries and it is still most common cause of maternal morbidity and mortality
(Gul & Jabeen, 2018).

Postpartum hemorrhage is an obstetrical emergency that takes place following cesarean or vaginal delivery. Prevention can be achieved through timely diagnosis, provision of essential resources and equipment, and correct management of the third stage of labor. PPH can be classified into two categories: primary and secondary PPH. Primary PPH (early PPH) takes place within the first 24 hours following delivery, whereas secondary or delayed PPH transpires after 24 hours to 12 weeks following delivery (Jabbar, Perveen & Kumari, 2019).

Risk factors for postpartum hemorrhage include a prolonged third stage of labor, multiple delivery, episiotomy, fetal macrosomia, and history of postpartum hemorrhage. However, postpartum hemorrhage also occurs in women with no risk factors, so physicians must be prepared to manage this condition at every delivery. Strategies for minimizing the effects of postpartum hemorrhage include identifying and correcting anemia before delivery, being aware of the mother’s beliefs about blood transfusions, and eliminating routine episiotomy.

Reexamination of the patient’s vital signs and vaginal flow before leaving the delivery area may help detect slow, steady bleeding (Ononge et al., 2016).

Early assessment and aggressive treatment of PPH are important for reducing morbidity and mortality rates. A critical first step in managing persistent PPH is rapid recognition that clinically significant bleeding (unresponsive to initial measures) has occurred, with effective communication of the situation to the appropriate team members, both clinical and laboratory staff. Subsequent measures include immediate resuscitation with definitive action to arrest the bleeding (obstetric, surgical, and/or hematologic) and ongoing assessment and monitoring of the response to treatment. Persistent severe PPH requires early involvement of the most experienced members of the team (Nyfløt et al., 2017).

Nursing care during postpartum period is multifaceted requiring knowledge of normal physiologic process as well as potential risks. Anticipatory guidance during postpartum period can have a significant impact on postnatal outcomes. So, the nurse must work toward providing care and education that facilitate holistic family wellness. As well as complete assessment and obstetric history are very important, this might include medical history as; history of medical disease, routine medications and allergies, obstetric history as; gravid, parity, history of postpartum hemorrhage, history of complications during pregnancy, time and mode of delivery, presence of tears or lacerations during delivery, and anesthesia or medications, infant status as; breast or bottle feeding (Downey, Kruse, & Plonczynski, 2019).

Significance of the study

According to the study done by Mohamed, (2018) who investigated the maternity outcome of primary post-partum hemorrhage case in El-Minia maternity Hospital 2016- 2017: 2 years study  reported that the incidence of primary postpartum hemorrhage (PPH) was 1.88 % in 2016 and 189 cases (1.69%) in 2017 in El-Minia University Maternity Hospital.( Mohamed, 2018).

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and severe morbidity all over the world. The World Health Organization (WHO) estimates that, PPH is a cause of approximately 25% of maternal deaths recently; the industrialized countries have witnessed a slow but steady escalation in the incidence of PPH.  Developing countries experience a much higher burden of PPH; it is also a momentous cause of maternal death in the developed world. Death from PPH occurs in about 1 per 1000 deliveries in low-resource countries compared with 1 per 100,000 deliveries in high-resource countries. Globally, PPH causes 44,000 to 86,000 deaths per year considering it the leading cause of death in pregnancy (El Badawy, et al., 2017).

Early       identifying maternal risks for postpartum hemorrhage is still an important and useful key point in daily practice because a high risk pregnancy can then be closely monitored by a special                team        to modify their risk factors. As a result,           this may lead to a reduction of maternal morbidity and mortality (Lertbunnaphong, et al., 2010).

Aim of the study

Early identification of risk factors for primary postpartum hemorrhages and measure the association between these factors and the occurrence of primary PPH at admission.

 Research Question

• What are the levels of women risk factors for primary postpartum hemorrhage at admission?

Subjects and Methods

Research Design

A descriptive cross-sectional research design was utilized to fulfill the aim of this study.

Research setting

This study was conducted at Minia university hospital for maternity and child at antenatal care department, delivery room and immediate post-partum room.

Subjects:

 The target population included all women in last trimester of pregnancy were admitted to hospital for vaginal or cesarean section (CS) delivery during a period of six month.

Sample included two groups study group who are at risk of PPH, which control group         not suffer from PPH during labor.         

Inclusion Criteria:                                             

• Females showing the clinical diagnosis of primary PPH .
• Age (20:45 years)
• Females who were admitted to antenatal unit at MUHOP.
• Women have blood loss 500ml or more for vaginal delivery, 1000 ml or more for cesarean section.

Exclusion Criteria:  

• Prenatal chronic disease.
• Females with pregnancy induced diseases (gestational diabetes and preeclampsia and those taking anti-coagulant drugs during pregnancy).
• Women were diagnosed with secondary PPH.
• Preterm labor and gestational age less than 36 weeks.
• Home delivery.

Control group:

Females who were admitted to hospital for vaginal or cesarean section delivery in last trimester of pregnancy of any age and parity and not suffered from primary PPH during labor. 

Tools of the study

To achieve the goal of the study, data was collected through using the following

Tools:

Tool I: Socio-demographic characteristics including (age, residence, educational level, occupation and income).

Tool II: Risk factors assessment tool  designed by (The Association of Women’s Health, Obstetric and Neonatal Nurses, 2015.) to determine level of risk  factor of primary postpartum hemorrhage at admission  for PPH divided into three parts, to assess low risk factors (5) included (no previous uterine incision, singleton pregnancy, ≤4- previous vaginal births,,,etc.) moderate risk factor (11) included  (induction of labor (with oxytocin) or cervical ripening,  multiple gestation, >4 - previous vaginal births, prior cesarean birth or prior uterine incision, large uterine fibroids, history of one previous PP.. etc) and high-risk factors (8) included (Active bleeding more than “bloody show, has 2 or more moderate symptoms of risk factor, suspected placenta accrete or percreta, Known coagulopathy, History of more than one previous PPH,,,etc.) (The Association of Women’s Health, Obstetric and Neonatal Nurses, 2015).

Procedure:

 An official letter was requested from the Dean of the faculty of Nursing at Minia University to director of Minia university hospital for maternity and child, asking for permission to collect data. Meeting with selected hospital manager to explain the objectives and aim of the study who helped to gain their cooperation and to allow interviewing women during minimal workload activities.

The investigator was attending to selected hospital to collect the datafrom 9.00 AM to 1.00 PM in two days each week (Sunday and Monday) for six months. The investigator was collected data from antenatal care department, delivery room and immediate post-partum room for six months. The investigator was collect data from 3-6 women each week.

All women were informed that their participation is voluntary and reassurance was given to the women about the confidentiality of their responses. The investigator explained the aim and nature of study briefly through direct personal communication that it was take time from 40-50 minutes with the participants. Oral consent was obtained from the participants before inclusion in the study.

After that the investigator was distribute all questionnaires to women who participated in the study and asked them to fulfill them and the investigator spend this time with women during fulfilling the questionnaires. The investigator was reminding women to answer all questions that present in questionnaires. Duration of data collection was started from middle July 2019 to the middle of December 2019. At the end of data collection the investigator gave women advices and instructions about risk factor for primary post-partum hemorrhage.

Validity and Reliability

To establish validity,   The questionnaire was be piloted on panel  of five experts in the field of obstetric and gynecological staff  and Nursing professors who reviewed the instruments for clarity ,relevance, comprehensive understanding ,applicability and easiness ,To establish reliability, statistically done alpha Cronbach way to check the stability of the internal consistency of instrument was 0.651

Ethical consideration:

 A written initial approval was obtained from the dean of the faculty of nursing and from the research ethical committee of the faculty of nursing, Minia University, and approval to conduct the study was obtained from the dean of the faculty of nursing, Minia University.

Oral informed consent was obtained from women who participated in this study after explaining the nature and purpose of the study. Participants were informed that their participation in the study was completely voluntary and acceptance of participants was obtained.

Pilot study:

 It was carried out on 10% of the total study sample (10 women). It was clarity of the tools, assessment of feasibility of fieldwork & to detect any possible obstacles that might face the investigator with interfere with data collection. Necessary modifications were done based on contents for more simplicity, and clarity. The subjects were included to the actual sample.

Statistical design

 Data entry was done using compatible personal computer. Statistical analysis done by using statistical package of social science (SPSS, IBM version 25) and excel for figures. The content of each tool was analyzed, categorized and then coded. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations for quantitative variables. Statistical significance used at P value <0.05. Odd's Ratio (OR) and their 95% confidence intervals (95% CI) were calculated to compare risk factors for PPH in both groups.

Results

Table (1): Distribution of the study sample regarding their socio-demographic characteristics (n= 120).

Table 1: shows that, 43.3% of study group and 48.3% of control group aged between 31 – 35 years with mean age   25.9 ± 14.1 and 25.4 ± 13.8 years respectively.

Regarding residence, 55.0% of study group and 58.3% of control group lived in urban area, 26.7% of study group and 20.0% of control group have basic education level.

Concerning occupation, 76.7% of study group and 66.7% of control group were housewives and 81.7% vs 68.3 of them had low income level respectively.

There were no statistically significance differences between study and control groups regarding their socio-demographic characteristics

Table (2): Distribution of the study sample regarding their low risk factors of primary post-partum hemorrhage  (n= 120)

**significant at P value < 0 .01

Table (2): presents that, study group had low risk for current PPH in previous uterine incision, and known bleeding disorder by less than one folds (OR= .145, and .123 respectively) and history of PPH by more than one folds (OR= 1.107) with statistically significance differences with P – value ≤ .0001, .0001, and .02 respectively.

Table (3):  Distribution of the study sample regarding their moderate factors of primary post-partum hemorrhage among study sample (n= 120).

                        **significant at P value < 0 .01                      *significant at P value < 0 .05

Table (3): shows that, study group had moderate risk for current PPH in  multiple gestation by more than  ten folds (OR= 10.412), large uterine fibroids by more than  nine folds (OR= 9.667),  prior cesarean birth or prior uterine incision, polyhydramnios by more than seven folds (OR= 7.231& 7.500 respectively), and chorioamnionitis by four folds (OR= 4.0) with statistically significance differences.

Table (4): Distribution of the study sample regarding their high factors of primary post-partum hemorrhage among study sample (n= 120).

                        **significant at P value < 0 .01                      *significant at P value < 0 .05

Table (4): result of presents table show that, study group had high risk for current PPH in women had two or more moderate symptoms of risk factors  by more than  one hundred  folds (OR= 196),  platelets <100,000/mm³ by more than fifty folds (OR= 58.00), hematocrit <30  by more than twenty folds (OR= 20.429), placenta previa and suspected placenta accretes by more than ten folds (OR= 11.769& 10.231 respectively), with statistically significance differences.