The Evidence-Based Evaluation And Practical Optimization Of Postpartum Hemorrhage Clinical Guideline

Objectives: A high quality guideline will be recommended as a basis on which a localized guideline can be developed through evaluating the quality of some guidelines for postpartum hemorrhage (PPH guideline) prevention and treatment over the world, and in combination of Gansu experience on diagnosis and treatment of postpartum hemorrhage so as to reduce postpartum hemorrhage maternal mortality in Gansu.Methods: The AGREE Ⅱ (Appraisal of Guidelines Research and Evaluation in Europe), which is internationally recognized as an excellent tool to evaluate Guidelines, was firstly used to assess the quality of some guidelines for prevention and treatment and consensus statements of postpartum hemorrhage. And then, a retrospective analysis on interventions of maternal postpartum hemorrhage and related influencing factors in Gansu was conducted. A survey plan was established by using Likert rating scale method and ranking method. Finally, Delphi Method was used to optimize the items of PPH practical guideline so as to recommend and confirm the entry of score more than50%listed in localized guideline of Gansu. On this basis, localization guideline was established.Results:There are6components in the course of AGREE Ⅱ evaluation including scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability and editorial independence. The evaluation results of9guidelines by use of AGREE Ⅱ showed:①there were7guidelines with standardized scores more than60%in "scope and purpose",2in "stakeholder involvement",3in "rigor of development",8in "clarity of presentation",2in "applicability" and1in "editorial independence". The comprehensive evaluation demonstrated that only1guideline was evaluated as grade A (scores of all the6specific components were higher than60%),7were grade B (with3-5specific components higher than60%),1was grade C (with2specific components higher than60%). According to recommendation standard of AGREE Ⅱ, guidelines reported by WHO in2012would be the best to be used as a basis to optimize localized guideline for maternal postpartum hemorrhage of Gansu.②Analysis results on monitoring data of clinical cases from2008to2012in Gansu showed that the maternal mortality rate ranged from28.17%to47.4%. Maternal death induced by obstetric hemorrhage accounted for30%. Maternal deaths induced by postpartum hemorrhage mainly occurred at home or in the county (district) hospitals, the proportion of unassisted home birth reduced year by year (about20%), while hospital birth in county (district) hospitals yearly increased (more than50%).Therefore, county (district) hospitals had become the main sites of postpartum hemorrhage deaths. Some factors exerted their impact on postpartum hemorrhage maternal deaths including knowledge and skills, attitudes, resources and management system of pregnant and lying-in women, home members, healthcare systems and related departments. The knowledge and skills of individual, and medical staff in county (district) hospital were the major factors that influenced postpartum hemorrhage maternal deaths, which accounted for41.4%and37.5%respectively; The Attitudes of individual and home members accounted for69.4%; Inadequate resources of individual and family accounted for65.2%, county (district) hospitals accounted for34.8%. In addition, the county (district) hospital accounted for92.3%, which was one of the most important factors to influence the management of hospital. The intervention to solve these problems would be selected as reference to optimized postpartum hemorrhage guideline.③According to32items proposed by WHO technical advisory committee and intervention experience over postpartum hemorrhage in Gansu, a survey plan was established by using Likert rating scale method and ranking method. Delphi was used to evaluate the entries of recommended guidelines and to rank the entries. At last we recommended the some items with score more than50%to enter into the guideline. The result showed that48items including WHO proposed32entries and16new entries were listed in guideline.Conclusions:The quality of postpartum hemorrhage guidelines of WHO (2012) based on evidence-based medicine was the highest among nine guidlines. Based on it, a practical guideline for postpartum hemorrhage of Gansu is established in combination of retrospect analysis on the intervention practice in the field of postpartum hemorrhage. Entries included in this optimized guidelines are more than WHO recommended entries including32items for intra-hospital which proposed by WHO (2012) and16extramural hospital items which proposed by experts.