Effect of improved uterotonic availability on postpartum hemorrhage and maternal morbidity after vaginal delivery, review of a single-center quality-improvement initiative.

Abstract

Introduction: After implementation of a hemorrhage risk stratification system and management bundle in 2019, our hospital demonstrated a reduction in hemorrhage-related severe maternal morbidity (SMM-H). We then noted a plateau in postpartum hemorrhage (PPH) rates and a gradual increase in SMM-H after 2020, with the majority of PPH after vaginal deliveries (VDs) occurring in those deemed low-risk. Consequently, we implemented a strategy to improve the availability of second-line uterotonics in the delivery room regardless of PPH risk. The objective of this study is to evaluate the effect of this intervention on rates of PPH and SMM-H after VDs.

Methods:  Through this quality improvement (QI) initiative, we aimed to improve injectable uterotonic availability and use at time of delivery. Our primary outcome measures were rate of PPH and SMM-H in VD. We reviewed all deliveries from the 16 months before and after this intervention (April 2023-July 2024, September 2024-December 2025). Deliveries from August 2024 were excluded to allow for washout. Chi-square was used to determine statistical significance.

Results: There were 5365 VDs included in the pre-intervention group with 63.6% designated low-risk for PPH and 4768 included in the post-intervention group with 62.4% designated low-risk. There was no difference in VD PPH pre- versus post-intervention (6.33% vs. 6.61%, p = 0.61). Similarly, there was no significant change in VD SMM-H (22.9% vs. 25.6%, p = 0.40). The rates of PPH and SMM-H in low-risk VD patients were 5.7% and 18.6% pre-intervention compared to 6.1% and 18.8% post-intervention. These differences were not statistically significant. Low-risk patients comprised 57.5% of VDs with PPH after the intervention. Of VDs requiring second-line uterotonics, misoprostol was the most common first agent prior to the intervention (60%) versus methylergonovine after (45%), which was statistically different from prior (p < 0.0001).

Conclusion: Improving second-line uterotonic availability in the delivery room did not improve VD PPH rates or SMM-H but did change second-line uterotonic choice.