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Original research
Characteristics and treatment for severe postpartum haemorrhage in different midwifery hospitals in one district of Beijing in China: an institution-based, retrospective cohort study
  1. Yike Yang1,2,
  2. Yu Shao3,
  3. Huan Chen4,
  4. Xiaoyue Guo1,
  5. Yingzhi Liang3,
  6. Yan Wang1,
  7. Yangyu Zhao1
  1. 1Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
  2. 2National Clinical Research Centre for Obstetrics and Gynecology, Beijing, China
  3. 3Haidian Maternal and Child Health Hospital, Beijing, Beijing, China
  4. 4Peking University Health Science Center, Beijing, Beijing, China
  1. Correspondence to Dr Yangyu Zhao; zhaoyangyu{at}bjmu.edu.cn; Professor Yan Wang; wjgqhn{at}263.net

Abstract

Objective To identify the characteristics and treatment approaches for patients with severe postpartum haemorrhage (SPPH) in various midwifery institutions in one district in Beijing, especially those without identifiable antenatal PPH high-risk factors, to improve regional SPPH rescue capacity.

Design Retrospective cohort study.

Setting This study was conducted at 9 tertiary-level hospitals and 10 secondary-level hospitals in Haidian district of Beijing from January 2019 to December 2022.

Participants The major inclusion criterion was SPPH with blood loss ≥1500 mL or needing a packed blood product transfusion ≥1000 mL within 24 hours after birth. A total of 324 mothers with SPPH were reported to the Regional Obstetric Quality Control Office from 19 midwifery hospitals.

Outcome measures The pregnancy characteristics collected included age at delivery, gestational weeks at delivery, height, parity, delivery mode, antenatal PPH high-risk factors, aetiology of PPH, bleeding amount, PPH complications, transfusion volume and PPH management. SPPH characteristics were compared between two levels of midwifery hospitals and their association with antenatal PPH high-risk factors was determined.

Results SPPH was observed in 324 mothers out of 106 697 mothers in the 4 years. There were 74.4% and 23.9% cases of SPPH without detectable antenatal PPH high-risk factors in secondary and tertiary midwifery hospitals, respectively. Primary uterine atony was the leading cause of SPPH in secondary midwifery hospitals, whereas placental-associated disorders were the leading causes in tertiary institutions. Rates of red blood cell transfusion over 10 units, unscheduled returns to the operating room and adverse PPH complications were higher in patients without antenatal PPH high-risk factors. Secondary hospitals had significantly higher rates of trauma compared with tertiary institutions.

Conclusion Examining SPPH cases at various institutional levels offers a more comprehensive view of regional SPPH management and enhances targeted training in this area.

  • China
  • health services administration & management
  • obstetrics
  • postpartum period

Data availability statement

Data are available in a public, open access repository. Extra data can be accessed via the Dryad data repository at http://datadryad.org/http://datadryad.org/http://datadryad.org/ with the doi: 10.5061/dryad.q2bvq83rp.

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Strengths and limitations of this study

  • This study comprised a large cohort of women as a representative sample from all midwifery institutions in Haidian, Beijing’s second most populous district.

  • The severe postpartum haemorrhage (SPPH) cases in this study represent the rescue capacity in highly urbanised and relatively developed regions of China, where a comprehensive transfer network system is established.

  • The data of SPPH were obtained from the Regional Obstetric Quality Control Office, which collects information of severe perinatal complication from regional midwifery hospitals.

  • Stratification analysis was carried out on the SPPH cases with/without antenatal postpartum haemorrhage high-risk factors in different levels of hospitals.

  • In this retrospective study, the limited availability of labour information and intraoperative data hindered accurate assessments pertaining to appropriate judgement and timing.

Introduction

Over the last three decades, China, particularly in Beijing, has witnessed a considerable decline in maternal mortality rates, bringing it up to par with other high-income countries.1 2 However, the country’s adoption of the two-child and three-child family policies has increased the number of pregnant women with high-risk factors, posing a significant challenge to midwifery institutions. Severe postpartum haemorrhage (SPPH)is the leading cause of maternal morbidity in high-income countries and accounts for over one-quarter of global maternal deaths.3 In China, SPPH is the leading cause of maternal mortality, accounting for about 25% of nationwide deaths, whereas, in Beijing, it is the third leading cause, accounting for about 10% of maternal deaths.4

The definition of SPPH varies and depends on the prevalence of severe blood loss in different regions and is also influenced by economic factors and available resources.5–7 A Delphi Steering Committee comprising experts from 13 countries, predominantly high-income nations, has proposed a definition of SPPH as postpartum blood loss exceeding 2000 mL or the need for transfusion of at least four units of red blood cells within 24 hours after the end of a pregnancy, in a pregnancy with at least 20 gestational weeks.8 It has been reported that typical signs and symptoms of PPH-induced hypovolaemia may not clinically appear until blood loss surpasses 25% of total blood volume (>1500 mL during late pregnancy).7 9In our region, severe PPH is defined as blood loss ≥1500 mL or needing a packed blood product transfusion ≥1000 mL within 24 hours post-birth.

In China, a classification of midwifery institutions has been developed to standardise a comprehensive and integrated framework for perinatal regionalisation and risk-appropriate maternal care. The National Health Commission (NHC) of China in 2017 proposed implementation of the ‘Five-Colour Management’ for women during pregnancy and 42-days post partum based on different pregnancy risk levels.10 11 The ‘Five-Colour Management’ requires that pregnant women be classified into five colours levels—green, yellow, orange, red and purple—according to their basic conditions and pregnancy complications. The specific classification of Five-Colour Management is shown in online supplemental table 1. Based on the Five-Colour Management and midwifery classification, the management department has outlined the following recommendations: primary midwifery hospitals are designated to offer fundamental midwifery care and admit pregnant women categorised as green grade. Secondary midwifery hospitals are equipped to provide midwifery techniques such as forceps delivery and caesarean section (CS), and exclusively admit pregnant women of orange grade or lower. Tertiary midwifery hospitals possess the capability to resuscitate both neonates and mothers and deliver intensive care. Referral centres encompass large-scale general hospitals entrusted with regional referral responsibilities. After establishing a hierarchical management structure across different midwifery institutions and creating a critical maternal treatment network, many pregnant women identified as having high antenatal PPH high-risk factors were relocated to transferal facilities. However, life-threatening complication still occurs frequently in women with no identifiable risk factors.12

Globally, several PPH quality improvement projects have been undertaken to standardise care and improve outcomes. In 2010, the California Maternal Quality Care Collaborative (CMQCC) developed and continues to update an obstetric haemorrhage toolkit that comprises a PPH risk assessment guide, instructions for preadmission testing and PPH management procedures.13 In Germany, GerOSS (German Obstetric Surveillance System) continues to generate deeper insights into relevant risk factors to enhance the identification and treatment of severe pregnancy complications.14 Joseph et al also outlined critical steps for implementing a standardised protocol for improved obstetric haemorrhage surveillance and management.15 However, most PPH safety bundles and guidelines are established by high-income countries and also used in low-income areas .

Prapawichar et al conducted a case–control study in Thailand to examine the risk factors for PPH across different hospital levels in various districts.16 The findings revealed a significant association of the presence of inadequate numbers of skilled nurse-midwives and insufficient availability of equipment supplies with the occurrence of high rates of PPH. Different SPPH treatment procedures and outcomes are seen across our region’s midwifery facilities. To improve regional hierarchical management and maternal treatment network establishment, we conducted a retrospective analysis of women to identify the characteristics and treatment approaches for patients with SPPH in different midwifery hospitals, especially those without detectable antenatal PPH high-risk factors.

Objectives

  1. We aimed to identify specific management issues and avenues for improving the PPH rescue capacity across various midwifery institutions in our region.

  2. First, through stratificational analysis of antenatal PPH high-risk factors, our aim was to improve hierarchical referral management.

  3. Second, by focusing on patients with SPPH without antenatal PPH high-risk factors, we aimed to recognise the aetiology and improve the treatment of SPPH.

  4. Third, by analysing the treatment approaches in different midwifery hospitals, we aimed to identify the disparity between lower-level hospitals and higher-level hospitals to carry out target training.

Methodology

Study area

Haidian district is 431 sq km in area, accounting for about 2.6% of Beijing’s landmass. At the end of 2021, the district had 3.130 million permanent residents, making it the second most populous in Beijing. The district has 19 midwifery institutions, 9 tertiary facilities (three serving as regional transferal centres) and 10 secondary facilities. Primary midwifery institutions are mostly distributed in rural areas, and there are no primary midwifery institutions in this region.

Study design and time frame

A retrospective cohort study was conducted from January 2019 to December 2022.

Participants

The Beijing maternal management policy requires all midwifery institutions to prepare and submit monthly reports about severe perinatal complications to the Regional Obstetric Quality Control Office (ROQCO). Such complications include eclampsia, cyanosis, oliguria or anuria, coagulation disorders, and shock, lower oxygenation index, thrombocytopaenia, abnormal liver, and renal functions and provision of specialised care (use of vasoactive agents, mechanical ventilation, haemofiltration, massive transfusion and unplanned hysterectomy).

Information on SPPH cases reported to ROQCO were collected for the purpose of this study. The SPPH was defined as blood loss ≥1500 mL or the need for a packed blood product transfusion ≥1000 mL within 24 hours after childbirth and gestational periods >20 weeks. Figure 1 shows the flowchart of the selection process.

Figure 1

Flowchart showing the selection process of 324 mothers with SPPH in different midwifery institutions. PPH, postpartum haemorrhage; SPPH, severe postpartum haemorrhage.

Data collection

Data were collected and abstracted from case summaries submitted by 19 midwifery institutions to ROQCO in Beijing’s Haidian district. These summaries provide comprehensive information on cases of PPH, including detailed demographics, pregnancy history, delivery outcomes and emergency interventions. In detail, pregnancy variables such as age at delivery, gestational weeks, height, parity, delivery mode, antenatal PPH high-risk factors, aetiology of PPH, bleeding amount, SPPH complications like coagulation disorders and shock, transfusion volume and PPH management were obtained. The word count ranges from 2000 to 4000 Chinese characters.

Antenatal PPH high-risk factors

Antenatal PPH high-risk factors considered were as outlined in global PPH guidelines and studies.5 7 17 18 The classification of these risks was based on the aetiology of PPH or assessments conducted during admission, labour or perinatal period. The most important antenatal high-risk factors were summarised as follows: (1) placenta previa/placenta accreta; (2) previous surgical procedures (more than two CS surgeries or myomectomy); (3) intramural fibroid (≥5 cm); (4) multiple pregnancies; (5) macrosomia; (6) history of PPH; (7) anticoagulant medication/coagulation disorders (Fib/platelet reduction); (8) severe pre-eclampsia/HELLP syndrome; (9) anaemia (Hb ≤9.0 g/dL).

Aetiology of PPH

The SPPH aetiologies are divided as four ‘Ts’. Tone—atonic uterus; Tissue—retained placental tissue and placenta accreta spectrum (PAS) disorders; Trauma—soft birth canal injury, that is, perineal laceration, haematoma of perineum and vaginal wall, cervical tears, rupture of uterus, inversion of uterus and intraoperative vascular injury, and so on. Thrombin—coagulation disorder dysfunction, can be divided into inherited, such as von Willebrand diseases, haemophilia and acquired, such as the use of anticoagulant therapy and disseminated intravascular coagulopathy after placental abruption, pre-eclampsia with severe features or amniotic fluid embolism.

Statistical analysis

All statistical analyses were performed using GraphPad Prism V.9 (GraphPad Software, San Diego, California, USA). The SPPH characteristics were expressed as means, SD, number (n) and percentage (%). χ2 test, Fisher’s exact test or an Unpaired t-test were used when appropriate. The p value<0.05 was considered statistically significant.

Results

Between January 2019 and December 2022, a total of 324 cases of SPPH were reviewed and observed, accounting for 0.30% of the overall population of 106 697 mothers across 19 midwifery institutions (online supplemental table 2). SPPH occurred in different midwifery institutions including 86 patients from 10 secondary midwifery hospitals and 238 patients from 9 tertiary midwifery hospitals. Clinical information and treatment were obtained from the cases reported to ROQCO and analysed. Mothers with severe antenatal PPH were then divided into those without (n=121) and with (n=203) antenatal PPH high risk factors (figure 1). Clinical data were subsequently analysed and compared between these two groups. In the present study, we targeted the group of patients without antenatal PPH high-risks factors.

Comparison between different midwifery institutions

Table 1 compares clinical information and treatment outcomes of patients with SPPH from different midwifery institutions. The results show significant differences in delivery age, gestational weeks, parity and delivery mode. The patients with SPPH at tertiary midwifery institutions were older, with earlier gestational weeks and longer delivery histories. Most patients with SPPH in tertiary midwifery hospitals (75.6%) delivered through CS. Furthermore, most of them (76.1%) had antenatal PPH high-risk factors associated with placental-related disorders. On the other hand, patients in secondary midwifery hospitals had significantly lower CS rates of 55.8% and antenatal PPH high-risk factors of 25.6%. Placental-related complications (58.4%) were identified as the major cause of SPPH in tertiary hospitals, whereas uterine atony without associated retention of placental tissues (54.7%) was the primary cause of SPPH in secondary hospitals. Additionally, trauma was identified in 16.3% of SPPH cases in secondary midwifery institutions, considerably higher than the 4.6% in tertiary hospitals (figure 2A, B).

Figure 2

SPPH aetiologies (A, B) in different midwifery hospitals; (C, D) in patients without/with antenatal PPH high-risk factors. The SPPH aetiologies are divided into four ‘Ts’. Tone—atonic uterus; Tissue—retained placental tissue and placenta accreta spectrum disorders; Trauma—soft birth canal injury, that is, perineal laceration, haematoma of perineum and vaginal wall, cervical tears, rupture of uterus, inversion of uterus and intraoperative vascular injury, and so on. Thrombin—coagulation disorder dysfunction, can be divided into inherited, such as von Willebrand diseases, haemophilia and acquired, such as the use of anticoagulant therapy and the occurrence of disseminated intravascular coagulopathy after placental abruption, pre-eclampsia with severe features or amniotic fluid embolism. PPH, postpartum haemorrhage; SPPH, severe postpartum haemorrhage.

Table 1

Information of SPPH cases in different midwifery institutions

There was no difference in blood loss among patients with SPPH across different midwifery institutions. However, blood loss exceeding 4000 mL after CS delivery was significantly higher in secondary facilities than in tertiary facilities. Conversely, there was no difference in vaginal deliveries. Furthermore, PPH complications like coagulation disorders and shock were greater in secondary hospital patients than in tertiary hospital patients.

To compare treatment outcomes across the two levels of hospitals, we also looked at the PPH management approaches used in our region. In nearly all the reported cases of SPPH, first-line and second-line uterotonics and haemostatics were used. Unfortunately, specific drug delivery timing and dose information could not be obtained. Plasma transfusion was higher in secondary hospital patients with PPH than in tertiary hospital patients with PPH, but there was no difference in RBC transfusion volume. Because of differences in blood loss during CS deliveries across various hospitals, we examined intraoperative approaches and discovered that the hysterectomy rate was significantly higher in tertiary hospitals. Secondary hospitals preferred uterine packing during CS deliveries. Additionally, unscheduled returns to the operating room (OR) remained higher in secondary midwifery hospitals. The difference in transarterial embolisation between the two levels of hospitals could be explained.

Comparison between mothers with and without antenatal PPH high-risk factors

Based on antenatal PPH high-risk factors, patients with SPPH were divided into two groups: with and without antenatal PPH high-risk factors (table 2). Mothers with antenatal PPH high-risk factors were older, had lower gestational age and higher CS rates. The primary cause of SPPH in women with antenatal PPH high-risk factors was placental-related complications. In contrast, the identified major cause of SPPH in patients without antenatal PPH high-risk factors was uterine atony without associated retention of placental tissues. Trauma was seen in 17.4% and 2% of SPPH women without and with antenatal PPH high-risk factors, respectively (p<0.01) (figure 2C, D). Although there was no considerable difference in blood loss between the two groups, PPH-related problems (like coagulation disorders and shock) and the need for RBC transfusion exceeding 10 units were significantly higher in patients without antenatal PPH high-risk factors.

Table 2

Information of SPPH in patients with or without antenatal PPH high-risk factors

Patients with antenatal PPH high-risk factors, especially those with PAS disorders, had notably higher hysterectomy rates, especially in tertiary hospitals. On the other hand, patients without antenatal high-risk factors, especially those in secondary hospitals (10 out of 14 cases), showed higher rates of uterine packing during CS, often due to atony. The uterine balloon tamponade was the most prevalent packing technique used in patients without antenatal high-risk factors, of which nearly half (40%) of the cases reported having used a balloon 2 hours after delivery. Similarly, the rates of unscheduled returns to the OR and intensive care unit (ICU) admissions were higher in patients without antenatal PPH high-risk factors.

Comparison in SPPH mothers without antenatal PPH high-risk factors who gave birth in secondary and tertiary hospitals

As per the Pregnancy Risk Management requirements, women with specified PPH risk factors should be moved to tertiary transferal centres. Only pregnant women without severe antenatal PPH concerns should deliver in secondary midwifery hospitals. Our results showed that patients with SPPH suffered more blood loss during CS delivery in secondary hospitals. Moreover, secondary hospitals observed more complications in pregnant women without antenatal PPH high-risk factors.

There was no difference in age, parity, gestational weeks, delivery mode and PPH aetiology of patients with SPPH without antenatal PPH high-risk factors between secondary and tertiary midwifery hospitals (table 3). On the other hand, total blood loss and blood loss in vaginal delivery cases were comparable between the two hospital levels. However, although not statistically different (p=0.06), the incidence of blood loss exceeding 4000 mL during CS procedures performed at secondary facilities was significantly higher compared with tertiary maternal facilities.

Table 3

Information of SPPH in patients without antenatal PPH high-risk factors in different midwifery institutions

Among the patients without antenatal PPH high-risk factors, there were eight cases (27.6%) of CS delivery patients with blood loss exceeding 4000 mL in second-class hospitals, whereas only one case (3.8%) was reported in tertiary midwifery facilities. The case at the tertiary hospital was a 39+ weeks, uniparous patient with an intrapartum fever that necessitated a CS delivery. During the procedure, chorioamnionitis-induced uterine atony was observed, and intrauterine packing was conducted. However, the treatment escalated to an unscheduled hysterectomy due to severe vaginal bleeding after abdominal closure. The eight cases in secondary hospitals were comparable with the above-described case. Most of these women were term and were scheduled for vaginal delivery. However, they underwent an unplanned CS and an exploratory laparotomy due to placenta abruption, chorioamnionitis, amniotic fluid embolism and intraperitoneal haemorrhage. Most of these patients had PPH complications like coagulation disorders, shock, kidney damage and cardiopulmonary disorders.

Discussion

Principal findings

In this study, we identified the clinical characteristics of severe PPH across different levels of midwifery institutions in a district of Beijing, China. We found that the aetiology of severe PPH across different hospital levels varied significantly. Primary uterine atony was the leading cause of severe PPH in secondary midwifery hospitals. In contrast, placental-associated disorders were the major cause in tertiary institutions, accounting for over 50% of all SPPH cases.

Most pregnant women with antenatal PPH high-risk factors were identified and relocated to transferal centres. There were 74.4% and 23.9% cases of severe PPH without identifiable antenatal PPH high-risk factors in secondary and tertiary maternal hospitals, respectively. Although there was no difference in blood loss between the two groups, PPH complications such as RBC transfusion >10 units, unscheduled returns to the OR, and ICU admissions were significantly higher in patients without antenatal PPH high-risk factors,

Additionally, trauma was the second leading aetiology of SPPH in lower-level midwifery facilities, particularly in patients without detectable antenatal PPH high-risk factors. Furthermore, secondary facilities had higher bleeding rates >4000 mL in CS and other adverse PPH complications.

Results and clinical and research implications

Although SPPH may develop without a known cause, several studies have investigated the specific high-risk factors for PPH. Liu et al19 conducted a retrospective cohort study comprising 532 SPPH cases in 34 178 mothers and reported several SPPH risk factors, including age <18 years, history of PPH, previous CS deliveries, predelivery anaemia, stillbirth, prolonged labour, placenta previa, placental abruption, PAS20 and macrosomia. Nyfløt et al also reported a history of SPPH, anticoagulant medications in pregnancy, anaemia, severe pre-eclampsia or HELLP syndrome, uterine fibromas and multiple pregnancies as the strongest risk factors of SPPH.21 The antenatal PPH high-risk factors listed in this study were consistent with the above-mentioned factors. Räisänen et al also provide an unique perspective on abnormal umbilical cords as specific risks for PPH, which may not be detected prenatally.22

In tertiary hospitals, over 75% of patients with SPPH had antenatal PPH high-risk factors, particularly PAS, which is associated with a higher risk of overall maternal and surgical morbidities.23 PAS, first reported in 1927 with an incidence of only 0.12 in 1000 women,24 has risen about 13-fold due to a rapidly increasing rate of CS deliveries,25 and it may increase to 1 in 200 women by 2025.26 With the widespread use of prenatal ultrasound examinations, most cases of PAS were recognised and referred to higher-level hospitals. In our study, retained placental tissue or PAS disorders were the leading cause of SPPH, accounting for over 50% of cases in tertiary institutions. In contrast, the primary cause was uterine atony in secondary hospitals. These results provide important insights that can guide the preparation of PPH rescue resources and development of simulation drills for different levels of midwiferies.

Many risk assessment tools27 28 have been claimed to be capable of identifying 60%–85% of patients who could experience significant obstetric haemorrhage.29 However, a validation study30 in a retrospective cohort of over 10 000 women showed that approximately 1% of mothers in the low-risk group developed a SPPH. In this study, over one-third of SPPH cases lacked detectable antenatal PPH high-risk factors. Furthermore, the bleeding amount in these low-risk mothers was comparable to that of the high-risk groups, whereas their PPH complication rates were significantly higher. There were no significant differences in bleeding volume, transfusion volume and PPH complications between the two hospital levels in this study. Consequently, there is a need for all obstetricians, midwives and nurses in different midwifery institutions to recognise and effectively handle SPPH, which is difficult, especially in low-risk cases.

Although trauma accounts for only 7.7% (25/324) of all cases of SPPH, it ranks as second most common aetiology in lower-level midwifery facilities, particularly among patients lacking detectable antenatal high-risk factors. On reviewing the 25 cases of SPPH resulting from trauma, it was observed that 18 cases were delivered vaginally while 7 cases underwent CS. The traumatic incidents encompassed perineal lacerations, haematoma formation in the perineum and vaginal wall, cervical tears, uterine rupture, uterine inversion, intraoperative vascular injuries and more. Improved midwifery techniques and enhanced operative skills play a pivotal role in mitigating the incidence of trauma.

This comparison of SPPH outcomes between the two hospital levels revealed no difference in total blood loss and bleeding amount during vaginal deliveries. However, blood loss >4000 mL after CS was significantly higher in secondary hospitals than in tertiary maternity hospitals. In the tertiary hospital cases, the majority of CS indications were due to PAS disorders, whereas in secondary hospitals, over half of the patients without antenatal PPH high-risk factors underwent CS following vaginal labour. This suggests that differences in operational expertise and rescue management capabilities between the two hospital levels may have contributed to this discrepancy. Meanwhile, the absence of transarterial embolisation in many secondary hospitals due to equipment and technological requirements results in a disparity between the two levels of hospitals. Identification of PPH complications in lower-level hospitals suggested existence of management problems. Several guidelines on the prevention and treatment of PPH have been published globally. However, decisions on handling measures and when to resort to invasive procedures remains a difficulty.

Strengths and limitations

The main strength of this study was the large cohort of women which ensured a representative sample from all midwifery institutions in Haidian, Beijing’s second most populous district. By comparing the characteristics of SPPH cases between different levels of midwifery institutions, we learnt more about the disparity in aetiology, management, and outcomes of SPPH. Furthermore, understanding the disparities between different levels of midwifery institutions helps in finding breakthroughs for training programmes.

The limitations of our study are as follows: first, it is important to note that primary midwifery institutions are primarily located in rural areas, and there are no such facilities in this specific region. As a result, this study may not fully represent the overall situation in China. Second, it is worth highlighting that this is a retrospective study, focusing exclusively on cases with a blood loss of ≥1500 mL or those requiring a packed blood product transfusion of ≥1000 mL within the first 24 hours postbirth. To compare proportions of SPPH between groups, it is necessary to include all deliveries, including those without SPPH. However, obtaining information on non-PPH cases from all midwifery hospitals poses a challenge. Finally, the labour information was incomplete, and a majority of cases lacking antenatal high-risk factors for PPH exhibited a likelihood of experiencing additional labour complications and persisting postpartum risk factors. Despite the wealth of detailed information available in the reported cases, essential aspects such as management options, timing of drug administration and interventions could not be obtained without a thorough review of the original case files. This is particularly crucial for surgical cases where intraoperative approaches require accurate judgement and precise timing. The implementation of a case discussion system is helpful to identify the gap between two levels of hospitals, which could be attributed to disparities in operational skills and rescue management.

Conclusion

Our results revealed significant differences in the characteristics of SPPH between secondary and tertiary midwifery hospitals. It was encouraging to observe that placental-related disorders were recognised as discernable antenatal PPH high-risk factors and transferred to tertiary midwifery institutions in this region. However, due to the prevalence of unpredictable PPH during labour, secondary midwifery institutions encountered problems like trauma, and deficiencies in operational skill and rescue management, especially for patients without detectable antenatal PPH high-risk factors. Therefore, reviewing SPPH cases across different hospital levels provides a broad perspective on SPPH research and helps in discovering breakthroughs for SPPH targeted training.

Data availability statement

Data are available in a public, open access repository. Extra data can be accessed via the Dryad data repository at http://datadryad.org/http://datadryad.org/http://datadryad.org/ with the doi: 10.5061/dryad.q2bvq83rp.

Ethics statements

Patient consent for publication

Ethics approval

The study was approved by the medical research ethics committee of the Peking University Third Hospital. The need for informed consent was waived due to the retrospective nature of this study. All information obtained from the patients’ medical records was anonymised and deidentified prior to analysis.

References

Footnotes

  • YY and YS contributed equally.

  • Contributors YY wrote the main manuscript text, YS provided analysis of the data, HC assisted to prepare tables, XG aided in data analysis and YL prepared the original dataset. All authors reviewed and approved the manuscript. Y W is responsible for the overall content as guarantor.

  • Funding The project was funded by the National Key Research and Development Program of China (2021YFC2701500, 2021YFC2701505).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.