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

From: The development of quality indicators for the prevention and management of postpartum haemorrhage in primary midwifery care in the Netherlands

   Median (n) Agreement (% of panellists with score of 7, 8 or 9)
  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
  1. * Preventative strategies imply consultation with an obstetrician to determine policy regarding PPH prevention e.g. birth supervised by obstetrician, or birth supervised by midwife, but in hospital with intravenous access prior to birth.
  2. £ 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.
  3. The ambulance paramedic did not rate these items; it was not within his field of expertise and stated these as ‘not assessable’.