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Table 2 Quality criteria for validation of 25 earlier developed quality indicators of PPH in primary midwifery care

From: Postpartum haemorrhage in midwifery care in the Netherlands: validation of quality indicators for midwifery guidelines

  Category, indicators Applicability Feasibility Amount of cases in adherence to indicator (%) Improvement potential Yes, No or NA (not applicable) If adherence to indicator is <90%
  n patients % of patients with missing values
If number of patients is >10 If availability of data is >70%   
  Prevention     
  Antenatally: identify 94 0   No
1. elevated- or high risk and agree on preventive strategies.    
  - No elevated- or high risk of PPH identified    85 (90)
  - Elevated- or high risk of PPH identified    9 (10)
  Referred to secondary care    9 (100)
  Not referred to secondary care    0 (0)
  high risk and agree (or adjust) on preventive strategies.    
2. At birth: identify elevated- or high risk 94 100 NA NA
3. If high risk is assessed: have birth occur in hospital supervised by the obstetrician. 94 100 NA NA
4.* Routinely administer uterotonics (at least 5 IU oxytocin intramuscular). 94 0   Yes
  - Yes, at least 5 IU oxytocin    54 (57)
- No    40 (43)
  In case of blood loss >500 mL, without signs of shock the midwife should;     
5. ** Objectify blood loss by weighing. 94 28   Yes
  - Yes    68 (72)
  - No/unknown    26 (28)
6. *** Homebirth: in case of retained placenta; refer to secondary care after 30 minutes. 35 0   Yes
  - Referral <35 minutes    13 (37)
  - Referral >35 minutes    22 (63)
7. *** Midwifery supervised hospital birth: in case of retained placenta; refer to secondary care after 30 minutes. 9/ No 11   NA
  - Referral <35 minutes    3 (33)
  - Referral >35 minutes    5 (56)
8. Home birth; if blood loss is not ceasing, refer to secondary care. 35 0   No
  - Timely referral    32 (91)
  - No timely referral    3 (9)
9. Midwifery supervised hospital birth if blood loss is not ceasing, refer to secondary care. 13 0   No
  - Timely referral    13 (100)
  - No timely referral    0 (0)
10. Treat PPH as uterine atony until proven otherwise. 94 0   Yes
  A Catheter    77 (82)
  B Uterine massage    66 (70)
  C Oxytocin    74 (79)
  D Combination of catheter, uterine massage and oxytocin    53 (56)
11. Post placental: if blood loss is not ceasing despite administration of uterotonics; examine for vaginal and perineal lesions 94 1 93 (99) No
  In case of PPH of >1000 mL and/or signs of shock, the midwife should;     
12. Inform the secondary caregiver (obstetrician). 94 0   No
- Yes    92 (98)  
  - No    2 (2)  
13. Start an intravenous line and supply with fluids, using 0,9% sodium chloride 94 1   No
A. Midwife    22 (23)  
  B. Ambulance personnel    47 (50)
  C. Hospital personnel (gynecologist or nurse)    21 (22)
  D. No intravenous line given    3 (3)
  E. Total given    91 (97)
14 Monitor vital signs frequently. 94 60   NA
β A Blood pressure    14 (15)
  B Pulse    1 (1)
  C Blood pressure &    23 (25)
  D pulse    
  E Total reported    38 (40)
15. Regardless of oxygen saturation, provide patient with 10–15 liter oxygen via non-rebreathing mask. 94 0   Yes
  - Yes    10 (11)
  - No    84 (89)
  In case of PPH of >1000 mL with signs of shock and/or >2000 mL blood loss the midwife should;     
16. In case of persisting hemorrhaging with signs of shock, perform uterine and/ or aortal compression.   94 100/No NA
17. Secure a second intravenous line (14 gauge). 3/ No 67   NA
  - Yes    0 (0)
  - No    1 (33)
18. If the patient has reduced consciousness due to hypovolemic shock, call for (paramedic) assistance in order to establish an open airway. 3/ No 100 NA NA
19. Immediately transfer patient to secondary care. 3/ No 0   NA
  - Yes    2 (67)
  - No    1 (33)
  Concerning cooperation, training and documentation     
20. Within every regional obstetric collaboration† a regional PPH protocol should be present, based on the national guidelines. 94 100 NA NA
21. A regional PPH protocol should be the basis of regular audits 94 100 NA NA
22. Every midwife should be aware that ambulance transportation in case of PPH or retained placenta is always of the highest urgency category (A1). 94 32   NA
  - A1 (arrival at patient    51 (54)
  - within 15 minutes)    
  - A2 (arrival at patient within 30 minutes)    13 (14)
23. After each PPH with >2000 mL blood loss, the multidisciplinary team should debrief the situation. 3/ No 100 NA NA
24. Within the regional obstetric collaboration† an annual training in obstetric emergencies should be provided. 94 100 NA NA
25. In a homebirth situation, anticipation on possible ambulance transport is necessary; make sure the patient is at an accessible place for (all) caregivers in time. 94 100 NA NA
  1. *Within 3 minutes after birth, at least 5 IU (international units) oxytocin intramuscular is given.
  2. **Estimated or measured blood loss before referring to secondary care.
  3. ***In case of retained placenta, the midwife called the obstetrician within 35 minutes after birth to refer and, in case of home birth, ambulance assistance is requested and on the way.
  4. βA single documentation of pulse and blood pressure would meet the requirements of this indicator.
  5. † Regional obstetric collaboration; a quarterly meeting with obstetricians and midwifery practices within a region in the Netherlands where policy, collaboration and practical agreements are discussed.
  6. NA, not applicable (Applicable and/or feasible indicators are in bold).