Table 1 Final set of quality indicators for the measurement of PPH-care in primary care

For prevention of PPH, the midwife should;

1

Antenatally: identify elevated- or high risk of PPH and agree on preventive strategies*.^†

8.5 (12)

100

2

At birth: identify elevated- or high risk of PPH and agree (or adjust) preventive strategies*.^†

8 (12)

100

3

If high risk of PPH is assessed: have birth occur in hospital supervised by the obstetrician. ^†

8.5 (12)

100

4

Routinely administer uterotonics (at least 5 IU oxytocin intramuscular). ^†

9 (12)

83,3

In case of blood loss >500 mL, without signs of shock the midwife should;

5

Measuring blood loss by weighing. ^†

9 (12)

91,6

6

Homebirth: in case of retained placenta; refer to secondary care after 30 minutes

9 (13)

92,3

7

Midwifery supervised hospital birth: in case of retained placenta; refer to secondary care after 30 minutes

9 (13)

75

8

Homebirth: if blood loss is not ceasing, refer to secondary care. ^†

9 (12)

83,4

9

Midwifery supervised hospital birth: if blood loss is not ceasing, refer to secondary care. ^†

9 (12)

83,3

10

Treat PPH as uterine atony (and apply bladder catheterization, uterine massage and oxytocin) until proven otherwise.

9 (13)

100

11

Post placental: if blood loss is not ceasing despite administration of uterotonics, examine for vaginal and perineal lesions. ^†

7 (12)

75

In case of PPH of >1000 mL and/or signs of shock, the midwife should;

12

Inform the secondary caregiver (obstetrician).

9 (13)

100

13

Start an intravenous line and supply with fluids, using 0, 9% sodium chloride.

8 (13)

100

14

Monitor vital signs frequently (pulse, blood pressure, respiratory frequency).

8 (13)

92,4

15

Regardless of oxygen saturation, provide patient with 10–15 litre oxygen via non-rebreathing mask.

9 (13)

84,6

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 haemorrhage with signs of shock, perform uterine and/ or aortal compression. ^†

8 (12)

83,3

17

Secure a second intravenous line (14 gauge).

9 (13)

79,9

18

If the patient has reduced consciousness due to hypovolemic shock, call for (paramedic) assistance in order to establish an open airway.

9 (13)

83,4

19

Immediately transfer patient to secondary care. ^†

(12) Added in second round

100

Concerning cooperation and training;

20

Within every regional obstetric collaboration^£ a regional PPH protocol should be present, based on national guidelines.

9 (13)

91,7

21

A regional PPH protocol should be the basis of regular audits.

9 (13)

83,3

22

The midwife is aware that ambulance transportation in case of PPH or retained placenta is always of the highest urgency category.

9 (13)

91,7

23

After each PPH with >2000 mL blood loss, the multidisciplinary team should debrief the situation.

8 (13)

83,4

24

Within the regional obstetric collaboration^£ an annual training in obstetric emergencies should be provided.

9 (13)

100

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.

9 (13)

100