(764) Effect of improved uterotonic availability on postpartum hemorrhage and maternal morbidity after vaginal delivery

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 PPH rates and a gradual increase in SMM-H after 2020, with the majority of PPH after vaginal deliveries (VD) occurring in those deemed low-risk. Consequently, we implemented a strategy to improve the availability of 2nd-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 VD.

Study Design:

Prior to 7/2024, misoprostol was available in all delivery rooms. Methylergonovine and carboprost, considered more effective, were not in the room at delivery unless requested by the provider. After 7/2024, all 3 uterotonics were made available in the room at initiation of 2^nd stage labor.  We reviewed all deliveries from the 10 months before and after this change (10/2023-7/2024, 9/2024-6/2025). Deliveries from 8/2024 were excluded to allow for washout. We investigated differences in PPH and SMM-H rates in VD pre- and post-intervention. Chi-square was used to determine statistical significance.

Results:

There was no difference in VD PPH pre- vs post-intervention (6.09% vs 5.92%, p = 0.78). Similarly, there was no significant change in VD SMM-H (22.35% vs 19.80%, p=0.51). The rates of PPH and SMM-H in low-risk VD patients were 5.4% and 17.8% pre- compared to 5.4% and 15.7% post-intervention. These differences were not statistically significant. Low-risk patients comprised 57.31% of VD with PPH after the intervention. Of VD requiring 2nd-line uterotonics, misoprostol was the most common first agent prior to the intervention (60%) vs methylergonovine after (46%) which was statistically different from prior (p < 0.0001).  

Conclusion:

Improving 2nd-line uterotonic availability in the delivery room did not improve VD PPH rates or SMM-H but did change 2nd-line uterotonic choice. PPH risk stratification may not alter PPH rates or morbidity but may improve timeliness of blood product administration.