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Military Health System

DHA implements standard practices to improve maternal outcomes

Image of Military health personnel wearing face mask during medical training. William Beaumont Army Medical Center medical personnel prepare for treatment of a simulated postpartum hemorrhage using WBAMC’s new simulation system which provides cutting-edge scenarios for training to medical staff. The new simulation system at the Fort Bliss facility aims to increase communication and improve interdisciplinary and clinical performance of staff when treating obstetric emergencies (Photo by: Marcy Sanchez, William Beaumont Army Medical).

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The Defense Health Agency's Women and Infant Clinical Community has recently implemented standardized practices to improve maternal outcomes in all its military medical treatment facilities around the world.

The new DHA-Procedural Instruction (DHA-PI) 6025.35, Guidance for Implementation of the Postpartum Hemorrhage (PPH) Bundle, provides instruction for implementation of the postpartum hemorrhage bundle at all MTFs providing obstetrical care.

Prior to issuing the DHA-PI in January 2021, the Military Health System had many different methodologies, but not an enterprise standard for the process to evaluate risk assessment and resources to promptly treat PPH to prevent maternal complications, said U.S. Public Health Service Capt. Anne McMillan, PPH Bundle Campaign co-lead and interim lead for the DHA Women's Health Clinical Management Team (WHCMT).

Considering PPH accounted for 10.7% of all maternal deaths in the United States between 2014 and 2017, according to the Center for Disease Control - Prevention's Pregnant Mortality Surveillance System, the effort is an important step in standardizing clinical practices and processes in obstetric care to reduce maternal morbidity and mortality across the MHS.

"The PPH campaign implements leading practices drawn from research and national and international organizations," said McMillan. "It provides a universal set of recommendations to standardize the clinical processes and resources that have been shown to help prevent and treat PPH."

The Navy Bureau of Medicine and Surgery adapted the hemorrhage safety bundle and implemented it across its medical facilities in 2016, according to McMillan. Building upon the lessons learned between 2017 and 2019, the Defense Health Agency conducted a PPH bundle pilot program at five military medical treatment facilities (MTFs). This pilot program further defines the standardized processes and develop a DHA PPH procedural instruction that would provide implementation guidance across the MHS, focusing on specific equipment, resources, and procedures required to enhance a system-level response.

As part of the bundle, each MTF must have a six-drawer purple cart with supplies, equipment, and medications specific to standard PPH treatment, allowing for immediate access to resources, explained McMillan. Additionally, each MTF must provide consistent assessments of a mother's risk factors throughout the course of perinatal care, before and after birth.

"Standardization of the review of a patient's risk factors or medical conditions is built into the medical record, with corresponding actions to support moderate and high-risk mothers," she said.

"The bundle components are designed to address specific steps to identify, prevent, and/or respond to a PPH event, and efforts are underway to update training, supplies, equipment, and resources and develop closer collaborations to decrease adverse outcomes for mothers and their families," explained McMillan. "Well prepared health care teams and informed patients comprise the best teams to prevent complications and improve outcomes for mothers and their families."

Additionally, the PPH bundle implementation campaign is one of DHA's strategic priorities for fiscal 2021. WICC started the implementation project in October 2020 in 12 MTFs with inpatient obstetrical units, focusing on readiness, recognition/prevention, response and reporting.

"Implementation of the PPH bundle is one of many clinical strategies being implemented to further support military readiness and quality of care for all beneficiaries and their families," said McMillan.

What is PPH?

PPH is a leading cause of maternal deaths globally, contributing to a quarter of deaths annually, according to a study published by the National Institutes of Health in 2016. It is one of a group of severe maternal morbidity (SMM) conditions that include unexpected outcomes from labor and delivery with significant consequences on a woman's health, explained Theresa Hart, senior nurse consultant, co-lead of the PPH Bundle Campaign, and WICC program manager.

According to the CDC, SMM has increased steadily in recent years, affecting more than 50,000 women in the United States in 2014, the last year for which this data is available. The report details that the cause of why SMM is on the rise is still not entirely clear. The report purports that changes in the overall health of the population of women giving birth - such as increases in maternal age, pre-pregnancy obesity, pre-existing chronic medical conditions, and cesarean delivery - may contribute to increases in complications.

Military health personnel wearing face mask performing an assessment on a new born baby
Navy Hospitalman Haleigh Turney (left) and Navy Hospital Corpsman 3rd Class Tamarra Francois perform a life assessment on a newborn at the Naval Medical Center San Diego’s labor and delivery ward on July 29, 2020 (Photo by: Navy Mass Communication Specialist Seaman Luke). 

And although some vaginal bleeding is normal and expected after a woman has a baby, it is important to know the difference between normal and excessive bleeding, expanded Hart. "This blood mainly comes from the area in your uterus where the placenta was attached, but it may also come from any cuts and tears that happened during delivery."

Bleeding is usually heaviest just after birth and gradually decreases as days progress, over about two weeks, while the uterus heals, she added. In contrast, PPH is excessive bleeding from the uterus after having a baby.

The 2016 NIH study defines PPH as blood loss from the genital tract of 500 mL or more following a normal vaginal delivery, or 1,000 mL or more following a cesarean section within 24 hours of birth.

"Excessive bleeding is the soaking of a sanitary pad in less than an hour, passing a clot or clots bigger than the size of a chicken egg, or any concerns related to changes in bleeding," said Hart.

Women experiencing any increased bleeding, especially bright red bleeding that lasts longer than a few days after delivery, should call their provider," she added. "However, postpartum bleeding that is evaluated and treated early may never become a (primary) postpartum hemorrhage (event)."

Common symptoms of PPH include feeling a sense of bleeding or noticing more blood, "perhaps with some blood clots when a woman stands on her feet after sitting or lying down," said Hart. "If the bleeding is very extensive, the mother may feel faint and/or lightheaded and should call for help, whether in the hospital or at home.

"The mother needs to be aware of her body, monitor her postpartum bleeding and how she is feeling, and communicate this with her health care team quickly to obtain prompt action and treatment," she said.

Hart highlighted that although PPH is not necessarily preventable, there are some factors that can increase the possibility of PPH. These include having had multiple pregnancies, caesarian sections, or uterine surgeries; the number of babies (twins or more) carried in a pregnancy; the duration of the labor or the length of time spent pushing; and any maternal infections or blood clotting issues.

"Knowing your medical and pregnancy history and communicating this with your health care team is very important and can help everyone be prepared to respond quickly," she said.

The most important and effective strategy to prevent complications during labor and delivery is to have a collaborative relationship between the mother and her health care team. This includes a full history, review, and subsequent updating of ongoing or historic risk factors, readily available resources, a trained team, and practice or simulation of emergency situations - precisely the components of the standard PPH bundle being implemented across the MHS.

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Last Updated: December 13, 2021
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