After Giving Birth
NR451 RN Capstone Course
Term and Year
After Giving Birth
Even though postpartum hemorrhage (PPH) is the leading cause of mortality after giving birth, most health care facilities do not have a standardized measures to assess blood volume loss and rely only on visual estimations for assessing and documenting blood loss. Consequently, blood loss below 250 mL tends to be overestimated, whereas blood loss above 2,000 mL tends to be underestimated (Bamberg et al., 2015). Inaccurate diagnosis of PPH delays treatment and increases mortality risk among intrapartum and postpartum women, so the purpose of the proposed nursing plan is to implement a standardized method that will be used to calculate maternal blood loss during childbirth. The intervention is expected to improve early detection of PPH and patient safety at this hospital’s Labor and Delivery Unit.
Change Model Overview
The John Hopkins Nursing Evidence-Based Practice Process (John Hopkins EBP) model is visually described in Figure 1. The model will be used as a guide to facilitate change because it offers a systematic way for implementing and testing EBPs using the following three steps: practice question, evidence, and translation. The practice question is developed by identifying the area for improvement, but the intervention needs to be grounded in evidence. The John Hopkins EBP process supports the use of research and non-research evidence for planning the intervention. However, before the evidence-based intervention is translated into practice, internal and external factors that can affect the implementation of the change have to be considered. Based on the analysis of those factors, if the change is considered feasible, it has to be implemented in three stages: pilot study, measurement of outcomes, and dissemination of findings.
Figure 1. John Hopkins EBP model.
Retrieved from “Johns Hopkins nursing evidence-based practice model and guidelines,” by R. P.. Newhouse, S. L. Dearholt, S. S. Poe, L. C. Pugh, and K. M. White, 2007. Copyright 2007 Sigma Theta Tau International.
Practice Question
Step 1: Recruit Interprofessional Team
The interprofessional team working on this project will include the director of nursing, the supervising physician of the obstetrics and gynecology department, the supervising nurse of the Labor and Delivery Unit, one senior executive of the Purchasing Department, one senior executive officer of the Human Resources (HR) department, and an external associate of the hospital in the role of an educator.
Step 2: Develop and Refine the EBP Question
The practice question this plan aims to address is: “In intrapartum and postpartum women, how do gravimetric methods and standardized visual estimations, compared to non-standardized visual measurement and estimation of blood loss, improve early detection of PPH and reduce maternal postpartum mortality?” The population in this question are intrapartum and postpartum women as their safety is at risk because of PPH. The proposed intervention is the standardization of QBL using gravimetric methods and standardized visual estimations because, in contrast with non-standardized measurement methods, they should improve the outcomes of childbirth. Specifically, the proposed intervention is expected to increase the likelihood of early detection in PPH cases and improve likelihood of survival among intrapartum and postpartum women.
Step 3: Define the Scope of the EBP
Even though the first efforts to quantify blood loss during childbirth were made during the late 19th century, PPH is still one of the leading causes of maternal death in the United States and the world (Schorn, 2010). In order to accurately measure the amount of blood lost during delivery, the staff can use under-buttock drapes, sucker bottles, or bedpans to collect fluids for accurate estimation and content analysis. However, non-standardized visual estimation is still often used because it is quick and convenient (Withanathantrige, Goonewardene, Dandeniya, Gunatilake, & Gamage, 2016). Underestimation of blood loss occurs is approximately 30% cases because visual estimations are not reliable, so it can be estimated that one third of women giving childbirth are at risk for mortality caused by preventable PPH (Al Kadri, Al Anazi, & Tamim, 2011).
Steps 4 and 5: Determine Responsibility of Team Members
The director of nursing needs to be involved in the project because the duties of nurses in those positions include ensuring that the nurses have the skills needed to implement the plan and that the nursing policy is updated accordingly to the results of the pilot study. A representative from the HR department also needs to be included in the planning and evaluation phase because the department will have to revise the hiring or training requirements for the staff in the Labor and Delivery Unit. The duty of the representative from the Purchasing Department is to allocate resources necessary to equip the hospital with the items needed to conduct the pilot study and ensure that the hospital is adequately stocked with those items if the intervention proves to be feasible for long-term implementation.
The role of the supervising physician and supervising nurse involved in the planning is to communicate the needs of the staff to the team working on the project, develop the data collection plan and communicate it to the staff, and collaborate with the Quality Improvement members who are sitting on the Women’s and Neonatal service line OB Practice Committee to develop a quantification of blood loss (QBL) protocol. Once the QBL protocol is prepared, an external associate in the role of an educator will be selected and assigned with the duty of educating the personnel working at the Labor and Delivery Unit (i.e., anesthesiologists, obstetricians, nurses, midwives, blood-bank personnel, and radiologists).
Evidence
Steps 6 and 7: Conduct Internal/ External Search for Evidence and Appraisal of Evidence
A total of five peer-reviewed articles were obtained for appraisal to assess the feasibility of the proposed intervention. Although systematic reviews and randomized controlled trials are considered to produce stronger evidence compared to other types of studies, only one study was designed as a secondary analysis of data from a randomized controlled trial. Three studies were quantitative prospective observational studies without controls. One article was a secondary source of evidence designed as a review of literature. Therefore, the overall quality of evidence used to evaluate the feasibility of the proposed project is considered to be moderate.
Steps 8 and 9: Summarize the Evidence
Empirical evidence supports the need for standardizing QBL in Labor and Delivery departments. The Bland-Altman analysis performed by Larsson et al. (2006) demonstrates the lack of accuracy and precision of visual estimation, which tends to overestimate the quantity of blood loss by 114 m, whereas the actual amount of blood lost during delivery can vary by as much as 570 mL fewer or 342 mL compared to the estimated value. Al Kadari et al. (2011) and Bamberg et al. (2015) reported an increased incidence level of PPH after the implementation of standardized QBL protocols, which suggests that underdiagnosis of PPH used to be a significant threat to patients at their respective facilities. The findings of studies comparing standardized QBL methods and visual estimations of blood loss report either overestimation or underestimation of blood loss during delivery, so it can be concluded that visual estimation is not a reliable and may cause the labor and delivery care team to reach a high number of false positive and false negative diagnoses. The strongest sources of evidence included in this review recommend using a combined method (i.e., standardized direct measurement and a gravimetric measurement) because it was found to be the most accurate and have the highest rate of agreement (Schorn, 2010; Withanathantrige et al., 2016).
Step 10: Develop Recommendations for Change Based on Evidence
Based on the evidence from peer-reviewed literature, standardization of QBL during childbirth is essential for improving patient safety. Because the hospital does not implement standardized measures of blood loss at the moment, it is expected that the intrapartum and postpartum patients are at an unnecessarily high risk of preventable PPH. The implementation of standardized measurements for QBL during delivery is recommended to improve patient safety and quality of care. The combined method for estimating blood loss is recommended as it is supported by the strongest evidence reviewed.
Translation
Steps 11, 12, and 13, 14: Action Plan
The following items will be purchased or designed and placed in every delivery room for easy access to the personnel: (a) weighing scales for gravimetric measurement, graduated/calibrated under-buttock drapes, and (c) laminated lists of items used during delivery and their weight. The staff will be instructed to use the combination method for intrapartum and postpartum QBL according to the procedures developed by the interdisciplinary members working on the plan. The timeline for the plan is one month do obtain the materials and clearly define the procedures staff will follow during the pilot study, which will be conducted over a period of three months. The pilot study will be designed as a pre-/post-test observational study without a control group. The incidence of PPH and severe PPH will be the primary outcomes for evaluation.
Steps 16 and 16: Evaluating Outcomes and Reporting Outcomes
The purpose of the intervention is to improve the accuracy of PPH and severe PPH diagnosis. If the incidence of PPH changes significantly during the study compared to the previous period, that will be a clear indication that standardized measures are needed to prevent either overdiagnosis of PPH or adverse outcomes of preventable PPH. The key stakeholders need to receive a written report that contains the results and interpretations of the pilot study, as well as an oral presentation that provides a rationale for improving care quality by standardizing the QBL procedures at the Labor and Delivery Unit.
Steps 17: Identify Next Steps
The standardization of blood loss measurement for the prevention of PPH is specifically designed for the Labor and Delivery Unit because that condition does not occur in other hospital departments. The implementation needs to be made permanent in the Labor and Delivery Unit using three strategies. First, the institution needs to standardize the QBL protocol at unit-level to clarify the roles of staff in monitoring PPH. Second, staff adherence rates have to be maintained by adjusting the work environment to ensure that the staff has easy access to the required materials. Third, the procedures must be revised in accordance to feedback from the staff based on their observations and experience from practice.
Step 18: Disseminate Findings
The findings will first be communicated to all employees of the hospital who need to be aware of the standard procedures Labor and Delivery Unit and implement those procedures in practice. Disseminating the findings outside of the organization can be done by preparing an article for publication or presentation at a conference on the topic of maternal health care.
Conclusion
Overdiagnosis of PPH leads to high and unnecessary health care costs, whereas preventable PPH also leads to high costs of care because of delayed treatments, as well as increased rates of preventable postpartum mortality. The current evidence from research suggests that visual estimates, which are currently used at the hospital’s Labor and Delivery Unit, are inferior to standardized QBL methods because they tend to overestimate or underestimate PPH rates. Therefore, the practice question of this intervention will benefit women receiving intrapartum and postpartum care, who are at risk for PPH. In accordance with the John Hopkins EBP model, the recommendation for using the combined QBL method is based on evidence from empirical research evidence and non-research evidence from practical experience obtained at the Labor and Delivery Unit. The plan for translating the proposed intervention into practice has been developed to ensure that the intervention is necessary to improve quality of care before standardizing the procedures used and disseminating the findings.
References
Al Kadri, H., Al Anazi, B., & Tamim, H. (2011). Visual estimation versus gravimetric measurement of postpartum blood loss: a prospective cohort study. Archives of Gynecology & Obstetrics, 283(6), 1207-1213. doi:10.1007/s00404-010-1522-1
Bamberg, C., Niepraschk-von Dollen, K., Mickley, L., Henkelmann, A., Hinkson, L., Kaufner, L., & Pauly, F. (2016). Evaluation of measured postpartum blood loss after vaginal delivery using a collector bag in relation to postpartum hemorrhage management strategies: a prospective observational study. Journal of Perinatal Medicine, 44(4), 433-439. doi:10.1515/jpm-2015-0200
Larsson, C., Saltvedt, S., Wiklund, I., Pahlen, S., & Andolf, E. (2006). Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstetricia Et Gynecologica Scandinavica, 85(12), 1448-1452. doi:10.1080/00016340600985032
Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M. (2007). Johns Hopkins nursing evidence-based practice model and guidelines. Indianapolis, IN: Sigma Theta Tau International.
Schorn, M. N. (2010). Measurement of blood loss: review of the literature. Journal of Midwifery & Women’s Health, 55(1), 20-27. doi:10.1016/j.jmwh.2009.02.014
Withanathantrige, M., Goonewardene, M., Dandeniya, R., Gunatilake, P., & Gamage, S. (2016). Comparison of four methods of blood loss estimation after cesarean delivery. International Journal of Gynecology & Obstetrics, 135(1), 51-55. doi:10.1016/j.ijgo.2016.03.036
