| Objective:This research conducted a Meta-analysis to screen effective early warning tools of postpartum hemorrhage(PPH);further,a prospective observation of assessment indicators of PPH was conducted to screen significant parameters in order to guide the practice of midwives and nurses,since there was a lack of relative comprehensive evidence regarding maternal assessment.Then the assessment strategy of PPH was formulated.Through the process of a systematic review on present guidelines and Meta-analysis relevant to PPH,quality judgement of each evidence and a selection of high quality recommendations,a draft of warning assessment and early intervention program of PPH in vaginal delivery population was built up,combined with assessment strategy,to go over a two-round Delphi consult for a final program.As a theoretical foundation,the goal was to design a scientific warning assessment and early intervention program of postpartum hemorrhage oriented to the nursing staffs,which could adapt to our domestic conditions.Methods:1.The formulation of assessment strategy of PPH: A systematic review was conducted on PPH warning scores as an important tool to identify antepartum high risk populations.All relative articles were systematically searched and evaluated,and a Meta-analysis was done to compare the differences of predictive values.Then,a prospective longitudinal observation study was implemented to determine primary assessment indicators.A self-designed buttock drape was used to collect blood after baby birth.Meanwhile,the assessment indicators were recorded on a defined time schedule,including temperature,blood pressure,mean arterial pressure,pulse,shock index,respiratory rate,arterial oxygen saturation,urine amount,contraction of uterus,height of fundus,symptoms of hemorrhagic shock,as well as laboratory parameters(pre and post red blood cell account,hemoglobin,hematocrit,platelet account,and pre prothrombin time,activated partial prothrombin time,international normalized ratio,D-dimer).Subjects were divided into PPH group and non-PPH group according to the total amount of blood loss.The general lineal model of repeated measurement analysis and generalized estimating equations were conducted in SPSS 21.0 software.For those selected as primary,MedCalc was further adopted to draw ROC curves,and time points of those AUC>0.7 were considered to have better prediction.Based on above,assessment strategy of PPH was formulated.2.The construction of warning assessment and early intervention program of PPH in vaginal delivery: With the methodology of evidence based nursing,guidelines were systematically searched on multiple databases and professional websites within recent 5 years.A quality judgement was conducted for each paper included and relevant recommendations were preserved as the framework of the program.A draft was built up based on the above results combined with assessment strategy,which then was sent to experts for a two-round consult.In this Delphi method,the authority of experts and importance of the items were analized under the following criteria: agreement rate>70%,mean score of significance>3.50,and a coefficient of variation<0.25.The program was finally formed on the basis of the results of each round.Results:1.(1)The systematic review of early warning scores on PPH kept 6 tools of 9 articles,and the Meta-analysis of three which adopted the tool by National PPH Prevention and Treatment Group showed an accumulated SEN of 40%,SPE of 94% and DOR 13.39.(2)A total sample of 150 were included in the longitudinal study,with 71 turned out to be in the PPH group and 79 non-PPH;9 were found to have severe postpartum hemorrhage,with the incidence of 6%.(1)Differences within both group of pulse was significant(P<0.05),and so was it between groups(P<0.01);differences within both group of shock index and temperature were not significant(P>0.05),but otherwise between groups(P<0.01);there were diversities in pre-and post-red blood cell account,hemoglobin,hematocrit both between and within groups(P<0.05).However,changes in other parameters like blood pressure,et al.showed no significant difference either within or between groups(P>0.05).(2)At 15 min postpartum,pulse showed a result of AUC>0.7,and the cut-off value was 89;shock index and temperature at 30 min and 1 h showed AUC>0.7,and cut-off values 0.72 and 0.68,36.5 and 36.6,respectively.2.(1)Evidence synthesis: 19 websites were systematically searched for guidelines with methodology of ADAPTE.Through a rigid screen and evaluation,13 guidelines were included with 6 rated as “highly recommended”,5 “recommended” and 2 “not recommended”.Recommendations were summarized,with a total of 76 items.Based on these recommendations and the study results of the first part,a draft framework was formulated,including 3 first-level dimensions and 17 second-level dimensions.(2)14 experts participated in the process of Delphi consult.The positivity coefficient was 0.933 for the 1st round and 1.000 for the 2nd,and the authority coefficient was 0.875.After a two-round consult and revise of the draft,the final program was formulated,including interventions part and goals part.The former contains 3 primary entries,17 aspects interventions with a total item of 93,and the latter contains 35 items.Conclusions:The Modified Warning Scores of PPH and High Risks Scoring System of Postpartum Hemorrhage were identified to have best prediction.A further prospective longitudinal observation study on maternal assessment indicators and routines provided reference for the formulation of assessment strategy.Over the course of systematic review and quality judgement of clinical evidence on PPH,scientific and authoritative recommendations were selected from guidelines as the basis of program construction,integrating the previous study results.The program draft went through a two-round Delphi consult to demonstrate its practicality.Consequently,a final program was set with nearly consistent agreement.Formulated program is scientific and practical,which can provide direction for clinical practice. |
PDF Full Text Request