Secondary Logo

Institutional members access full text with Ovid®

Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using Video Analysis

Woiski, Mallory, MD, PhD; de Visser, Suzan, MD; van Vugt, Helena, MD; Dijkman, Anneke, MD, PhD; Schuitemaker, Nico, MD, PhD; van Meir, Claudia, MD, PhD; Middeldorp, Johanna, MD, PhD; Huisjes, Anjoke, MD, PhD; Mol, Ben W., MD, PhD; Molkenboer, Jan, MD, PhD; Moonen-Delarue, Desiree, MD; Oudijk, Martijn, MD, PhD; van Rheenen-Flach, Leonie, MD; Rijnders, Robert, MD, PhD; Pernet, Paula, MD, PhD; Porath, Martina, MD, PhD; de Wit, Sander, MD; Grol, Richard, MSc, PhD; Scheepers, Hubertina, MD, PhD; Hermens, Rosella, MSc, PhD

doi: 10.1097/AOG.0000000000002781
Contents: Maternal Morbidity and Mortality: Original Research

OBJECTIVE: To assess adherence to the national postpartum hemorrhage guideline and Managing Obstetric Emergencies and Trauma course instructions and its determinants in the Netherlands.

METHODS: A prospective observational multicenter study in 16 Dutch hospitals analyzing data from medical records of 398 women at high risk for postpartum hemorrhage, of which 293 were supplemented with data from prospective video recordings. Adherence to guideline-based quality indicators for prevention, management, and organization of postpartum hemorrhage care was measured. Indicators for prevention and management of postpartum hemorrhage were categorized according to the amount of blood loss (less than 500, greater than 500, greater than 1,000, and greater than 2,000 mL).

RESULTS: Overall, a lack of adherence was observed, particularly for the actions to be undertaken with blood loss greater than 1,000 mL (69 patients). Actions were not or only taken in a later stage when the blood loss had already increased to greater than 2,000 mL (21 patients). In almost 41% (n=119/293) of the deliveries, no active management was performed, and in almost 80% (n=89/112), vital signs were not monitored (blood loss greater than 500 mL) or monitored too late with respect to blood loss. The video recordings showed that in general the actual care given was considerably underreported in medical records. Postpartum hemorrhage care in the hospitals was well organized. Fifteen hospitals had a local postpartum hemorrhage protocol, and in 12 hospitals, team trainings were organized. Regarding the determinants, high-risk patient identification and type of hospital (university vs nonuniversity hospital) were mostly associated with better adherence.

CONCLUSION: This study showed low adherence to the guideline-based quality indicators, indicating a problem with Dutch quality care. The unique video observations provided additional, valuable information at which level improvement can be made. A tailor-made implementation strategy to improve quality of postpartum hemorrhage care has been developed.


Analysis of medical records supplemented with video analysis show low adherence to the guideline-based quality indicators for postpartum hemorrhage care in the Netherlands.

Departments of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, Reinier de Graaf Gasthuis, Delft, Diakonessenhuis, Utrecht, Groene Hart Ziekenhuis, Gouda, Gelre Ziekenhuizen, Apeldoorn, Academic Medical Centre, Amsterdam, Spaarne Ziekenhuis, Hoofddorp, Laurentius Ziekenhuis, Roermond, University Medical Centre Utrecht, Utrecht, Onze Lieve Vrouwe Gasthuis, Amsterdam, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, Spaarne Gasthuis, Haarlem, Maxima Medical Centre, Veldhoven, Pantein Maasziekenhuis, Boxmeer, and Maastricht University Medical Center, Maastricht, the Department of Obstetrics, Leiden University Medical Centre, Leiden, and the Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen, the Netherlands.

Corresponding author: Mallory Woiski, MD, PhD, Geert Grootplein 10, PO Box 9101, 6500 HB Nijmegen, the Netherlands; email:

Supported by the Netherlands Organization for Health Research and Development (ZonMw grant number No. 80-82315-98-09003).

Financial Disclosure Dr. Mol is supported by a National Health and Medical Research Council Practitioner Fellowship (GNT1082548) and has been a consultant for ObsEva, Merck, and Guerbet. The other authors did not report any potential conflicts of interest.

The authors thank Janine Liefers for the data management, Reinier Akkermans for his help with the multilevel analyses, and the participating hospitals, the FLUXIM study group, K. Deurloo, J. Roelofsen, the research nurses, and the employees of the Dutch Consortium for Healthcare Evaluation in Obstetrics and Gynaecology for their help with the data collection.

Each author has indicated that he or she has met the journal's requirements for authorship.

Received February 01, 2018

Received in revised form March 28, 2018

Accepted April 12, 2018

© 2018 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.