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.