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Improving practice and reducing significant postpartum haemorrhage through audit

02 January 2018
10 min read
Volume 26 · Issue 1



In 2012, there was a concern about the incidence of postpartum haemorrhage (PPH) and the prevalence of physiological third stage management at a midwife-led birthing unit.


To determine whether midwives considered risk factors for PPH and provided informed choice when planning third stage management, and whether there was any relationship between third stage management and PPH.


A cohort of 57 women who experienced a PPH >500mL was identified, and their records audited. Findings were shared with the midwifery team, who generated solutions. These were implemented in 2013/14 and a re-audit was conducted in 2015.


The re-audit showed that the incidence of PPH >1000mL had decreased. As a result of improvements in risk assessment and informed consent surrounding third stage management, no women were inappropriately managed physiologically during the third stage. Using an agreed pathway and PPH boxes was associated with an improvement in the quality and speed of treatment.


The audit cycle was used effectively to review practice. It identified deficiencies and helped the midwifery team to generate solutions, which resulted in improved outcomes for women.

The midwife-led birthing unit (MLBU) at Norfolk and Norwich University NHS Foundation Trust provides care for approximately 1000 healthy, low-risk women annually. Evidence has indicated that these women were more likely to experience normal birth with fewer interventions in a MLBU rather than in a consultant-led unit, with no changes as to the safety of mothers or babies (Brocklehurst et al, 2011). A risk assessment tool (Appendix 1), based on the best available evidence, is applied on admission to identify women as low-risk and to ensure that choices can be supported.

The MLBU philosophy is to support women's birth choices, focusing on normal physiological processes and avoiding unnecessary medical interventions. In 2012, 41% of women who gave birth at an MLBU experienced a physiological third stage of labour. The third stage lasts from the birth of the baby to the expulsion of the placenta and membranes (National Institute for Health and Care Excellence (NICE), 2014). ‘Physiological management’ awaits spontaneous separation and expulsion of the placenta: no drugs are routinely administered, the umbilical cord is not clamped or cut before the placenta has separated from the uterus and the placenta is birthed by maternal effort (NICE, 2014). Embracing physiology avoids disturbing initial mother-infant interactions important in bonding (Buckley, 2011) and allows physiological transfusion of blood to the neonate, reducing neonatal anaemia caused by under-transfusion (Harris, 2001; Mercer, 2001; Fry 2007, Andersson et al, 2012).

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