Health providers especially in Labor and Delivery (L&D) need to enhance their skills and competence in a dynamic teamwork situation given the erratic nature and various complications during labor. There is no knowing when emergency beckons and if the systems and processes can deliver quality health care.
Identification of problem or process to be changed
Bleeding after childbirth in excess of 500 ml blood (postpartum hemorrhage) can be life threatening if the intervention is not adequate or timely. PPH can be triggered from any of these reasons: the failure of uterus to contract after delivery, genital tract tears, or placental tissue retention.
Need for the change or enhancement, including driving forces such as: Regulatory, such as OSHA mandate
- Postpartum visits are documented as per protocol
- Use of written screening tools for postnatal depression scale screening
- Reports of laboratory tests, treatments and consultations are documented in the patient’s file
- Systems in place for timely delivery of lab test reports, blood, and drugs from pharmacy
California Maternity Quality Care Collaborative describes these stages for PPH patients:
- Zero Stage: normal - treated with fundal massage and oxytocin.
- Stage 1: Excess bleeding than normal - establish large-bore intravenous access, message personnel, increase oxytocin, methergine as an option, perform fundal massage, send for two units blood from the blood bank.
- Stage 2: bleeding continues despite intervention - check coagulation status, assemble response team, shift patient of OR, place intrauterine balloon, administer additional uterotonics (misoprostol, carboprost tromethamine), consider: uterine artery embolization, dilatation and curettage, and laparotomy with uterine compression stitches or hysterectomy.
- Stage 3: bleeding continues - activate massive transfusion protocol, mobilize additional personnel, recheck laboratory tests, perform laparotomy, consider hysterectomy.
- Have standardized protocol for PPH interventions
- Outline critical steps for managing massive hemorrhage
- Evaluate patient registrations
- Stock and timely release of blood
- Access to off-unit resources like senior obstetricians or experts
- Storage of emergency drugs
- Assemble competent team in the shortest time frame possible
- Running simulations drills
The patient satisfaction is based largely on the quality of interactions with physician, counseling, and nursing care. Patient counseling, written literature, and educational videos make the patient informed for better choices and nature of complexity of their case.
Life safety issue
Postpartum hemorrhage accounts of a quarter of all maternal mortality worldwide. So this is very high on the health care professionals involved in labor and delivery. Following fixed protocols in intervention at different stages increases patient’s odds through timely injection of drugs and interdisciplinary staff. Timeline
Severe cases of PPH occur in 11% of live birth (WHO, 2005) and so for a health centre this is not an everyday affair. But since this is mortal affliction it would be prudent for any health centre to improve in administering active intervention for such patients. A timeline of six months would be sufficient to improve the processes and improve response time.
The Labor & Delivery (L&D) for best for best teamwork practices must include comprehensive training to all staff working in the L&D unit. This must accompanied by personal one-on-one coaching both on technical and teamwork dimension – communication procedures, communication tools, emergency procedures, a comprehensive line of hierarchy, and whom to contact at what stage. Both the partners – nursing as well as physicians – must work as a team. These components are so vital that a facilitator is required as part of training especially when embarked on process improvements.
What change theorist and leadership style you would incorporate?
A genuine commitment from the hospital top management is absolutely necessary to signal a streamlining of systems and procedures. Even a committed physician, or departmental zeal in an environment of wanting to improve can lead to self-assessments and setting benchmarks of best practices and professional excellence. Task-Oriented leadership seems better suited to lead the change – focus of job delivery, clear work and role definition, have systems and structures in place.
Research literature to support proposed change process
Fiedler’s contingency theory state there is no particular way for managers to lead. The situation is dynamic and keeps evolving calling for different leadership styles. For routing tasks, which is intervention for PPH, a hands-on direct leadership would be preferable. A leader everyone can trust and be credible enough.
PDAC cycle, implementation strategies, and evaluation process
PDAC stands for Plan, Do, Check, and Act; it is a continuous cycle for process improvements. Planning entails collecting information and analyzing from past data of PPH cases. Do entails implementation of recommended changes. Check is to affirm whether the new changes bring out the desired goals and outcome. Act is the stage of seeking collaboration of the team from role clarity to process. An ideal preparation is to have a surprise drill and see how the team responds.
Postpartum Hemorrhage is a severe medical emergency and it needs the entire system to be in place, be responsive in readiness. There is a need for process improvements and implementations.
Guidelines for Immediate Action. Sapiens Publishing. Retrieved from http://www.sapienspublishing.com/pph_pdf/PPH-Guidelines.pdf
WHO recommendations for the prevention of Postpartum Hemorrhage. WHO. Retrieved from
Anderson, J & Etches, D (2007). Prevention and Management of Postpartum Hemorrhage. AAFP. [online] Retrieved from http://www.aafp.org/afp/2007/0315/p875.html
Standard Indicators. CABC [online] Retrieved from http://www.birthcenteraccreditation.org/images/CABC_Indicators.pdf
Burkman, R & Fennell, J (2011). A complication of pregnancy: are you prepared? Retrieved from http://www.femalepatient.com/PDF/036090045.pdf