Study design, training programme, and population
This retrospective cohort study was conducted at the Kagoshima City Hospital and Kagoshima University Hospital. Both hospitals serve as tertiary referral centres in the Kagoshima Prefecture, especially in the Satsuma Peninsula. Both hospitals are located in Kagoshima City, the capital of the Kagoshima Prefecture. Almost all severe cases of PPH in the Satsuma Peninsula are transferred to these two hospitals. In the Satsuma Peninsula, there are approximately 10,000 deliveries per year that are performed in 23 private clinics and five hospitals.
In September 2017, the J-MELS programme was distributed to all private clinics and hospitals performing deliveries. As a result, all the 28 clinics and hospitals in the region were involved in the programme with at least one provider in each institution having complete the programme by 2019. Overall, 229 participants (64 obstetricians and 165 midwives and nurses) attended the programme during this period. The J-MELS programme, emphasised the importance of (1) monitoring patients’ vital signs (blood pressure, heart rate, SI, saturation of percutaneous oxygen [SpO2], respiratory rate, and consciousness) during and after delivery to allow earlier recognition of PPH, (2) administering a high concentration of oxygen in PPH, and (3) using more than two routes for intravenous (IV) injection lines ≥20 gauge in PPH and stating clearly the standardised protocol for deciding maternal transfer: once maternal vital signs worsened to (1) SI > 1.0 with continuous haemorrhage, (2) SI > 1.5, (3) SpO2 < 95% (room air), (4) tachypnoea or forced breathing, and (5) disturbance of consciousness. One goal of this programme was to achieve earlier awareness of PPH and earlier maternal transfer to tertiary hospitals, which can lead to earlier advanced treatment at a referral hospital, before the collapse of circulation and disseminated intravascular coagulation (DIC), and ultimately prevent maternal death.
We screened patients who were transferred to either the Kagoshima City Hospital or Kagoshima University Hospital for PPH from January 2015 to December 2020. Because no patient opted out from the study, all patients were included.