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Hemorrhagia postpartum:  an implementation study on the NVOG guidelines and MOET instructions


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The most important cause of maternal morbidity in the Netherlands is Hemorrhagia post partum (HPP), with an incidence of 5% containing 10.000 women in the Netherlands a year. Introduction of an evidence-based guideline about HPP by the Dutch society of Obstetrics and Gynaecology (NVOG) and the course Management of Obstetrics Emergencies and Trauma (MOET course) did not lead to a reduction in HPP. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions.


Study design

To evaluate the implementation of the guideline and MOET instruction in the current care, measurement of the actual care will be performed  in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labor of 400 women with a high risk of HPP by using quality indicators extracted from the NVOG guideline and MOET instructions.

Barriers an facilitators for the guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients and a questionnaire among all Dutch gynaecologists and midwives.

In a feasibility study in 4 hospitals a tailor made strategy to implement the NVOG guideline and MOET instructions, based on the outcome of the two studies above, will be tested. In this feasibility study an effect-, process- and cost-evaluation will be performed


Study population

All women with a higher risk of HPP:

-HPP in previous delivery

-multiple pregnancy



-uterus myomatosis

 -grande multyparity

-long delivery

 -clotting disorders

 -thrombocytopenia (HELLP)


Outcome measures

Adherence to the quality indicators regarding the process , structure and outcome of care around childbirth (e.g. incidence of HPP)

Process-measures regarding the degree of making use of and experience with the various parts of the implementation strategy among professionals


Costs of the different parts of the implementation strategy


Power/data analysis

With an estimation of adherence to the guidelines of 50%, a precision of estimation of guideline adherence of 7.5% and an icc of 0.20, 320 women have to be included in the actual care study


Economic evaluation

Cost-evaluation of the different parts of the implementation strategy will be made


Time schedule

36 months, 6 months of preparation, 30 months inclusion, interviews,  feasibility study and analysis and report



Dr. H.C.J. Scheepers, UMC Maastricht

Dr. R.P.M.G. Hermens, Center of Quality of Care Research (IQ Healthcare) UMC st Radboud, Nijmegen



Drs. M.Woiski, UMC st Radboud, Nijmegen

Prof. dr. R. Grol, IQ Healthcare, Nijmegen

Prof. dr. F. Lotgering, UMC st Radboud Nijmegen

Dr. A. Middeldorp, LUMC

Prof. dr. J. Kremer, UMC st Radboud Nijmegen



ZonMW www.ZonMW.nl



Mallory Woiski, gynaecologist

Tel: 024-3614737

Email: fluxim@studies-obsgyn.nl