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Optimizing Protocols in Obstetrics: Management of Obstetric Hemorrhage
Optimizing Protocols in Obstetrics: Management of Obstetric Hemorrhage
Optimizing Protocols in Obstetrics: Management of Obstetric Hemorrhage
SERIES 2
DIS TRIC T II
SERIES 2
OCTOBER 2012
Each institution is encouraged to review its existing hemorrhage protocols, and modify them if necessary to maximize safe patient care, or consider the creation of a policy to optimize the management of
obstetrical hemorrhage. Standardization of health care processes and reduced variation in practice has
been shown to improve outcomes and quality of care.
We extend our sincere appreciation to the committee of medical experts who offered their expertise
throughout the creation of this chapter. Their knowledge and dedication to this initiative is invaluable.
The District II PSQI Committee continues to develop additional chapters to be added to this resource.
If you have any questions regarding the enclosed materials, please contact Kelly Gilchrist, ACOG District II Patient Safety Manager, at 518-436-3461 or kgilchrist@ny.acog.org.
Sincerely,
SERIES 2
OCTOBER 2012
Index: Series 2
PAGE
4
4
5
6
NURSING INTERVENTIONS
Executive Summary
Core Elements for the Management of Obstetric Hemorrhage
Introduction & California Maternal Quality Care Collaborative
(CMQCC) Toolkit Overview
Recommendations to Optimize the Management of Obstetric Hemorrhage
ACOG PUBLICATIONS
8 ACOG Practice Bulletin # 76 Postpartum Hemorrhage
CMQCC RESOURCES
17 Obstetric Hemorrhage Care Guidelines Checklist
22 Summary Flowchart
23 Summary Table Chart
24 Training & Tools for Measurement of Blood Loss
SERIES 2
OCTOBER 2012
This document reflects emerging clinical, scientific and patient safety advances as of the date issued
and is subject to change. The information should not be construed as dictating an exclusive course of
treatment or procedure to be followed. While the components of a particular protocol and/or checklist
may be adapted to local resources, standardization of protocols and checklists within an institution is
strongly encouraged.
Executive
Summary
Twenty three hospitals throughout New York State responded to a request from ACOG District II to
submit their protocols regarding the diagnosis and management of obstetric hemorrhage. Although
many were well written policies and protocols, the committee did not identify a single protocol that
could meet the needs of all hospitals in New York State.
The work group used a number of resources, in addition to reviewing the submitted protocols, to select
the ideal requirements for a comprehensive approach to obstetrical hemorrhage. These included:
1. ACOG Practice Bulletin No. 76, Postpartum Hemorrhage
2. California Maternal Quality Care Collaborative (CMQCC), Improving Health
Care Response to Obstetric Hemorrhage Toolkit
Each hospital must take into account the resources available within its own institution and community
to design a protocol that will assist them in the optimal management of obstetrical hemorrhage. Each
institution is encouraged to review its existing policy and protocols, and modify them if necessary to
provide safe patient care, or consider the creation of a policy to optimize the management of obstetrical hemorrhage. The committee believes that all obstetric services must have a written hemorrhage
protocol in order to ensure the highest quality of patient care.
On reviewing the submitted protocols, it is noted that many contain excellent educational and instructional components. What most of them lack however, is the systematic approach required to ensure
an effective guideline or protocol. The inclusion of algorithms, charts, and checklists is helpful and the
following examples could be useful as hospitals strive to further improve their hemorrhage protocols.
Given the previous excellent work done in this area by the California Maternal Quality Care Collaborative (CMQCC) and the American Congress of Obstetricians and Gynecologists (ACOG), we encourage individuals to utilize these two extensive resources in the development of a hemorrhage protocol.
Core Elements
The following is a list of the components of any protocol that is created for the management of obstetrical hemorrhage. Hospitals should individualize their protocols based on an assessment of their own
resources.
Definition
Risk Factors/Etiology
Initial Interventions
Medical Treatment
Surgical Treatment
Defined Care Team and Escalation Role Clarity
Checklist Algorithm
Transfusion Policy
Drills
Obstetric hemorrhage continues to cause maternal morbidity and mortality in New York and across the
United States. Most of these cases occur in spite of women delivering in hospitals staffed by physicians,
nurses, and support personnel who are knowledgeable, highly motivated, and well trained. Often these
cases occur in hospitals that have very well written obstetric hemorrhage protocols in place. The nature of
obstetric hemorrhage management is that it is a time and team dependent performance that requires precision choreography. Having a good protocol that has never been practiced as a drill or dry run is similar
to a football team that studies its plays but never works through the timing on the practice field, or a dance
troupe that never rehearses before opening night.
The Hemorrhage Protocol Work Group has been assigned the task of helping to prevent serious harm associated with obstetric hemorrhage. To that end, this committee has evaluated and chosen resources that
can be used to design very good hemorrhage protocols. However, to be effective, your protocol must have
two things that our work group cannot provide:
1. Each hemorrhage protocol must be designed and/or approved by the people who will execute it
(and they must be given time and resources and permission needed to produce or thoroughly
study the written protocol that will work specifically in the institution where it is designed).
2. Each hemorrhage protocol must be tested for feasibility within the institution and taught and
rehearsed through dry runs or drills to improve its quality and the precision team work necessary
to effectively manage obstetric hemorrhage.
CMQCC
Toolkit
Overview
The toolkit begins with a section on, How To Use This Toolkit (pages 1-2) followed by a compendium of
evidence-based, best practices related to obstetric hemorrhage. Obstetric hemorrhage care guidelines are
presented in three forms starting with the most comprehensive Checklist followed by a Table chart and
finally the most streamlined version the Flowchart. The comprehensive Checklist delineates all topics
the workgroup thought should be included in a protocol except for simulation/drills topic. A comprehensive document exists within the tool kit related to obstetric hemorrhage drills and simulations. This document includes multiple detailed, ready to use scenarios which focus on both the technical management of
obstetric hemorrhage, and team function, communication, and role clarity. The document finishes with a
Hospital Level Implementation Guide (pages 95-109) which addresses practical planning for implementation of new evidence-based protocols and guidelines for quality improvement.
We believe a successful protocol should contain the following core elements. Links to examples from the
CMQCC Toolkit are included.
SERIES 2
OCTOBER 2012
Provide continuing medical education on hemorrhage for your entire medical team.
Ensure all hospital staff, including physicians, nurses, laboratory personnel and others are
aware of the protocol related to dealing with maternal hemorrhage. Incorporate this protocol
into your hospitals mandatory annual educational programs and ensure all new staff is
oriented to its content.
Findings from obstetrical quality improvement initiatives should be incorporated on an
on-going basis into improvements of the hemorrhage protocol.
ACOG
PRACTICE
BULLETIN
CLINICAL MANAGEMENT GUIDELINES FOR
OBSTETRICIANGYNECOLOGISTS
NUMBER 76, OCTOBER 2006
(Replaces Committee Opinion Number 266, January 2002)
Postpartum Hemorrhage
This Practice Bulletin was
developed by the ACOG Committee on Practice Bulletins
Obstetrics with the assistance
of William N. P. Herbert, MD,
and Carolyn M. Zelop, MD.
The information is designed to
aid practitioners in making
decisions about appropriate
obstetric and gynecologic care.
These guidelines should not be
construed as dictating an exclusive course of treatment or procedure. Variations in practice
may be warranted based on the
needs of the individual patient,
resources, and limitations
unique to the institution or type
of practice.
Severe bleeding is the single most significant cause of maternal death worldwide. More than half of all maternal deaths occur within 24 hours of delivery,
most commonly from excessive bleeding. It is estimated that, worldwide,
140,000 women die of postpartum hemorrhage each yearone every 4 minutes
(1). In addition to death, serious morbidity may follow postpartum hemorrhage.
Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss
of fertility, and pituitary necrosis (Sheehan syndrome).
Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. All obstetric units and practitioners
must have the facilities, personnel, and equipment in place to manage this
emergency properly. Clinical drills to enhance the management of maternal
hemorrhage have been recommended by the Joint Commission on Accreditation
of Healthcare Organizations (2). The purpose of this bulletin is to review the
etiology, evaluation, and management of postpartum hemorrhage.
Background
The physiologic changes over the course of pregnancy, including a plasma volume increase of approximately 40% and a red cell mass increase of approximately 25%, occur in anticipation of the blood loss that will occur at delivery
(3). There is no single, satisfactory definition of postpartum hemorrhage. An
estimated blood loss in excess of 500 mL following a vaginal birth or a loss of
greater than 1,000 mL following cesarean birth often has been used for the
diagnosis, but the average volume of blood lost at delivery can approach these
amounts (4, 5). Estimates of blood loss at delivery are notoriously inaccurate,
with significant underreporting being the rule. Limited instruction on estimating blood loss has been shown to improve the accuracy of such estimates (6).
Also, a decline in hematocrit levels of 10% has been used to define postpartum
hemorrhage, but determinations of hemoglobin or hematocrit concentrations
may not reflect the current hematologic status (7). Hypotension, dizziness, pal-
1039
1040
Postpartum Hemorrhage
lor, and oliguria do not occur until blood loss is substantial10% or more of total blood volume (8).
Postpartum hemorrhage generally is classified as
primary or secondary, with primary hemorrhage occurring within the first 24 hours of delivery and secondary
hemorrhage occurring between 24 hours and 612 weeks
postpartum. Primary postpartum hemorrhage, which
occurs in 46% of pregnancies, is caused by uterine
atony in 80% or more of cases (7). Other etiologies are
shown in the box Etiology of Postpartum Hemorrhage,
with risk factors for excessive bleeding listed in the box
Risk Factors for Postpartum Hemorrhage.
If excessive blood loss is ongoing, concurrent evaluation and management are necessary. A number of general medical supportive measures may be instituted,
including provision of ample intravenous access; crystalloid infusion; blood bank notification that blood products
may be necessary; prompt communication with anesthesiology, nursing, and obstetriciangynecologists; and
blood collection for baseline laboratory determinations.
When treating postpartum hemorrhage, it is necessary to balance the use of conservative management techniques with the need to control the bleeding and achieve
hemostasis. A multidisciplinary approach often is
required. In the decision-making process, less-invasive
methods should be tried initially if possible, but if unsuccessful, preservation of life may require hysterectomy.
Management of postpartum hemorrhage may vary greatly among patients, depending on etiology of the bleeding,
available treatment options, and a patients desire for
What should be considered in the initial evaluation of a patient with excessive bleeding in
the immediate puerperium?
Postpartum Hemorrhage
1041
Dose/Route
Frequency
Comment
Oxytocin (Pitocin)
Continuous
Methylergonovine
(Methergine)
IM: 0.2 mg
Every 24 h
15-methyl PGF2
(Carboprost)
(Hemabate)
IM: 0.25 mg
Dinoprostone
(Prostin E2)
Suppository: vaginal
or rectal
20 mg
Every 2 h
Misoprostol
(Cytotec, PGE1)
When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after vaginal
delivery, tamponade of the uterus can be effective in
decreasing hemorrhage secondary to uterine atony (Table
2). Such approaches can be particularly useful as a temporizing measure, but if a prompt response is not seen,
preparations should be made for exploratory laparotomy.
Packing with gauze requires careful layering of the
material back and forth from one cornu to the other using
a sponge stick, packing back and forth, and ending with
extension of the gauze through the cervical os. The same
effect often can be derived more easily using a Foley
catheter, Sengstaken-Blakemore tube, or, more recently,
the SOS Bakri tamponade balloon (16), specifically tailored for tamponade within the uterine cavity in cases of
postpartum hemorrhage secondary to uterine atony.
1042
Postpartum Hemorrhage
Comment
Uterine tamponade
Packing
Foley catheter
SengstakenBlakemore tube
SOS Bakri tamponade balloon
Comment
Uterine curettage
Uterine artery ligation
B-Lynch suture
Hypogastric artery ligation
Repair of rupture
Hysterectomy
(28). In the multicenter study cited previously, hysterectomy was required in 0.7% for the first cesarean delivery
and increased with each cesarean delivery up to 9% for
patients with their sixth or greater cesarean delivery.
In the presence of previa or a history of cesarean
delivery, the obstetric care provider must have a high
clinical suspicion for placenta accreta and take appropriate precautions. Ultrasonography may be helpful in
establishing the diagnosis in the antepartum period.
Color Doppler technology may be an additional adjunctive tool for suspected accreta (29). Despite advances in
imaging techniques, no diagnostic technique affords the
clinician complete assurance of the presence or absence
of placenta accreta.
If the diagnosis or a strong suspicion is formed
before delivery, a number of measures should be taken:
Postpartum Hemorrhage
1043
Rupture can occur at the site of a previous cesarean delivery or other surgical procedure involving the uterine wall
from intrauterine manipulation or trauma or from congenital malformation (small uterine horn), or it can occur
spontaneously. Abnormal labor, operative delivery, and
placenta accreta can lead to rupture. Surgical repair is
required, with the specific approach tailored to reconstruct the uterus, if possible. Care depends on the extent
and site of rupture, the patients current clinical condition, and her desire for future childbearing. Rupture of a
previous cesarean delivery scar often can be managed by
revision of the edges of the prior incision followed by
primary closure. In addition to the myometrial disruption, consideration must be given to neighboring structures, such as the broad ligament, parametrial vessels,
ureters, and bladder. Regardless of the patients wishes
for the avoidance of hysterectomy, this procedure may
be necessary in a life-threatening situation.
rates vary between 0.4% and 1.6% (30). Clinical judgment is an important determinant, given that estimates of
blood loss often are inaccurate, determination of hematocrit or hemoglobin concentrations may not accurately
reflect the current hematologic status, and symptoms and
signs of hemorrhage may not occur until blood loss
exceeds 15% (8). The purpose of transfusion of blood
products is to replace coagulation factors and red cells for
oxygen-carrying capacity, not for volume replacement.
To avoid dilutional coagulopathy, concurrent replacement with coagulation factors and platelets may be necessary. Table 4 lists blood components, indications for
transfusion, and hematologic effects.
Autologous transfusion (donation, storage, retransfusion) has been shown to be safe in pregnancy (31, 32).
However, it requires anticipation of the need for transfusion, as well as a minimal hematocrit concentration often
above that of a pregnant woman. Autologous transfusion
generally is reserved for situations with a high chance of
transfusion in a patient with rare antibodies, where the
likelihood of identifying compatible volunteer-provided
blood is very low. Blood donated by directed donors has
not been shown to be safer than blood from unknown,
volunteer donors. Cell saver technology has been used
successfully in patients undergoing cesarean delivery. In
a multicenter study of 139 patients using such devices, no
untoward outcomes were noted when compared with
control patients (33).
Volume (mL)
Contents
240
50
250
40
Modified from Martin SR, Strong TH Jr. Transfusion of blood components and derivatives in the obstetric intensive care
patient. In: Foley MR, Strong TH Jr, Garite TJ, editors. Obstetric intensive care manual. 2nd ed. New York (NY): McGraw-Hill;
2004. Produced with permission of The McGraw-Hill Companies.
1044
Postpartum Hemorrhage
Regardless of the cause of postpartum hemorrhage, subsequent replacement of the red cell mass is important.
Along with a prenatal vitamin and mineral capsule daily
(which contains about 60 mg of elemental iron and
1 mg folate), two additional iron tablets (ferrous sulfate,
300 mg, each yielding about 60 mg of elemental iron) will
maximize red cell production and restoration. Erythropoietin can hasten red cell production in postpartum anemic patients to some extent, but it is not approved by the
U.S. Food and Drug Administration for postoperative anemia, and it can be costly (40). Postpartum hemorrhage in
a subsequent pregnancy occurs in approximately 10% of
patients (8).
Summary of
Recommendations and
Conclusions
In the presence of conditions known to be associated with placenta accreta, the obstetric care provider
must have a high clinical suspicion and take appropriate precautions.
Proposed Performance
Measure
If hysterectomy is performed for uterine atony, there
should be documentation of other therapy attempts.
References
1. AbouZahr C. Global burden of maternal death and disability. Br Med Bull 2003;67:111. (Level III)
2. Preventing infant death and injury during delivery.
Sentinel Event ALERT No. 30. Joint Commission on
Accreditation of Healthcare Organizations. Available at:
http://www.jointcommission.org/SentinelEvents/Sentinel
EventAlert/sea_30.htm. Retrieved June 12, 2006. (Level
III)
3. Chesley LC. Plasma and red cell volumes during pregnancy. Am J Obstet Gynecol 1972;112:44050. (Level III)
4. Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM.
Blood volume changes in pregnancy and the puerperium.
Am J Obstet Gyencol 1962;84:127182. (Level III)
5. Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH.
Emergency hysterectomy for obstetric hemorrhage.
Obstet Gynecol 1984;64:37680. (Level III)
6. Dildy GA 3, Paine AR, George NC, Velasco C. Estimating
blood loss: can teaching significantly improve visual estimation? Obstet Gynecol 2004;104:6016. (Level III)
7. Combs CA, Murphy EL, Laros RK Jr. Factors associated
with postpartum hemorrhage with vaginal birth. Obstet
Gynecol 1991;77:6976. (Level II-2)
Postpartum Hemorrhage
1045
10. Poe MF. Clot observation test for clinical diagnosis of clotting defects. Anesthesiology 1959;20:8259. (Level III)
27. Silver RM, Landon MB, Rouse DT, Leveno KJ, Song CY,
Thom EA, et al. Maternal morbidity associated with multiple repeat cesarean delivery. Obstet Gynecol 2006;107:
122632. (Level II-2)
28. Zaki ZM, Bahar AM, Ali ME, Albar HA, Gerais MA. Risk
factors and morbidity in patients with placenta previa accreta compared to placenta previa non-accreta. Acta
Obstet Gynecol Scand 1998;77:3914. (Level II-3)
1046
Postpartum Hemorrhage
12345/09876
Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:
103947.
Evidence obtained from at least one properly designed randomized controlled trial.
II-1 Evidence obtained from well-designed controlled
trials without randomization.
II-2 Evidence obtained from well-designed cohort or
casecontrol analytic studies, preferably from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this
type of evidence.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the
following categories:
Level ARecommendations are based on good and consistent scientific evidence.
Level BRecommendations are based on limited or inconsistent scientific evidence.
Level CRecommendations are based primarily on consensus and expert opinion.
Postpartum Hemorrhage
1047
version 1.4
Ongoing Risk
Assessment
If: Cumulative Blood Loss >500ml vaginal birth or >1000ml C/S -ORVital signs >15% change or HR 110, BP 85/45, O2 sat <95% -ORIncreased bleeding during recovery or postpartum,
proceed to STAGE 1
Page 1 of 4
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal Child and Adolescent Health Division
STAGE 1: OB Hemorrhage
Cumulative Blood Loss >500ml vaginal birth or >1000ml C/S -ORVital signs >15% change or HR 110, BP 85/45, O2 sat <95% -ORIncreased bleeding during recovery or postpartum
MOBILIZE
ACT
THINK
Primary nurse:
Establish IV access if not present, at least 18 gauge
Increase IV fluids rates (Lactated Ringers preferred) and increase Oxytocin
rate (500 mL/hour of 10-40 units/1000mL solution); Titrate Oxytocin infusion
rate to uterine tone
Continue vigorous fundal massage
Administer Methergine 0.2 mg IM per protocol (if not hypertensive); give once,
if no response, move to alternate agent; if good response, may give additional
doses q 2 hr
Vital Signs, including O2 sat & level of consciousness (LOC) q 5 minutes
Weigh materials, calculate and record cumulative blood loss q 5-15 minutes
Administer oxygen to maintain O2 sats at >95%
Empty bladder: straight cath or place Foley with urimeter
Type and Crossmatch for 2 units Red Blood Cells STAT (if not already done)
Keep patient warm
Physician or midwife:
Rule out retained Products of Conception, laceration, hematoma
Surgeon (if cesarean birth and still open)
Inspect for uncontrolled bleeding at all levels, esp. broad ligament, posterior
uterus, and retained placenta
If: Continued bleeding or Continued Vital Sign instability, and <1500 mL cumulative blood loss
proceed to STAGE 2
Dose
Pitocin
(Oxytocin)
10 units/ml
Methergine
(Methylergonivine)
Side Effects
Contraindications
Storage
Continuous
Usually none
Nausea, vomiting, hyponatremia (water
intoxication) with prolonged IV admin.
BP and HR with high doses, esp IV push
Hypersensitivity to drug
Room temp
Refrigerate
Protect from
light
IM
(not given IV)
250 mcg
IM or intramyometrial
(not given IV)
-Q 15-90 min
-Not to exceed 8 doses/24
hrs
-If no response after 3
doses, it is unlikely that
additional doses will be of
benefit.
Refrigerate
800-1000mcg
Per rectum
(PR)
One time
Rare
Known allergy to prostaglandin
Hypersensitivity to drug
Room temp
0.2 mg
250mcg/ml
Cytotec
(Misoprostol)
IV infusion
Frequency
-Q 2-4 hours
-If no response after first
dose, it is unlikely that
additional doses will be of
benefit
0.2mg/ml
Hemabate
(15-methyl PG F2a)
Route
Nausea, vomiting
Severe hypertension, esp. with rapid
administration or in patients with HTN or PIH
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal Child and Adolescent Health Division
STAGE 2: OB Hemorrhage
Continued bleeding or Vital Sign instability, and <1500 mL cumulative blood loss
MOBILIZE
ACT
THINK
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal Child and Adolescent Health Division
STAGE 3: OB Hemorrhage
Cumulative blood loss >1500ml, >2 units PRBCs given, VS unstable or suspicion for DIC
MOBILIZE
Nurse or Physician:
Activate Massive Hemorrhage
Protocol
PHONE #:_________________
Charge Nurse or designee:
Notify advanced Gyn surgeon
(e.g. Gyn Oncologist)
Notify adult intensivist
Call-in second anesthesiologist
Call-in OR staff
Reassign staff as needed
Call-in supervisor, CNS, or
manager
Continue OB Hemorrhage Record
(In OR, anesthesiologist will assess
and document VS)
If transfer considered, notify ICU
Blood Bank:
Prepare to issue additional blood
products as needed stay ahead
ACT
THINK
For Resuscitation:
Aggressively Transfuse
Based on Vital Signs, Blood Loss
KEY: HIGH RATIO of FFP to RBC
Either: 6:4:1 PRBCs: FFP: Platelets
Or: 4:4:1 PRBCs: FFP: Platelets
Unresponsive Coagulopathy:
After 8-10 units PRBCs and
coagulation factor replacement may
consider risk/benefit of rFactor VIIa
Once Stabilized: Modified Postpartum
Management; consider ICU
BLOOD PRODUCTS
Packed Red Blood Cells (PRBC)
(approx. 35-40 min. for crossmatchassuming no sample is
in the lab and assuming no antibodies are present)
Transfuse O Negative blood if you cannot wait
Fresh Frozen Plasma (FFP)
(approx. 35-45 min. to thaw for release)
Platelets (PLTS)
Local variation in time to release (may need to come from
regional blood bank)
Cryoprecipitate (CRYO)
(approx. 35-45 min. to thaw for release)
Page 4 of 4
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal Child and Adolescent Health Division
SERIES 2
OCTOBER 2012
21
Time of
admission
Stage 0
All Births
Blood Loss:
>500 ml Vaginal
>1000 ml CS
Stage 1
Activate
Hemorrhage
Protocol
Blood Loss:
1000-1500 ml
Stage 2
Sequentially
Advance through
Medications &
Procedures
Blood Loss:
>1500 ml
Stage 3
Activate
Massive
Hemorrhage
Protocol
Unresponsive Coagulopathy:
After 10 Units PBRCs and full
coagulation factor replacement,
may consider rFactor VIIa
Standard Postpartum
Management
Fundal Massage
NO
INCREASED BLEEDING
YES
PreAdmission
v 1.4 5/7/2010
YES
CALL FOR EXTRA HELP
Give Meds: Hemabate 250 mcg IM -orMisoprostol 800-1000 mcg PR
Transfuse 2 Units PRBCs per clinical
signs
Do not wait for lab values
Consider thawing 2 Units FFP
Conservative Surgery
YES
NO
B-Lynch Suture/Intrauterine Balloon
Fertility Strongly
Uterine Artery Ligation
Desired
Hypogastric Ligation (experienced surgeon only)
Consider IR (if available & adequate experience) HEMORRHAGE CONTINUES
Increased
Postpartum
Surveillance
NO
Increased
Postpartum
Surveillance
NO
Consider ICU
Care; Increased
Postpartum
Surveillance
Definitive Surgery
Hysterectomy
CONTROLLED
California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This project was supported by Title V funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division
Assessments
Stage 0
Stage 0 focuses
on risk
assessment and
active
management of
the third stage.
Stage 1
Stage 1 is short:
activate
hemorrhage
protocol, initiate
preparations and
give Methergine
IM.
Stage 2
Stage 2 is
focused on
sequentially
advancing
through
medications and
procedures,
mobilizing help
and Blood Bank
support, and
keeping ahead
with volume and
blood products.
Stage 3
Stage 3 is
focused on the
Massive
Transfusion
protocol and
invasive surgical
approaches for
control of
bleeding.
Meds/Procedures
version 1.4
Blood Bank
Active Management
If Medium Risk:T&Scr
3rd Stage:
If High Risk: T&C 2 U
Oxytocin IV infusion or
If Positive Antibody
10u IM
Screen (prenatal or
Fundal Massagecurrent, exclude low level
vigorous, 15 seconds min. anti-D from
RhoGam):T&C 2 U
PR
Bring 2 Units PRBCs to
2nd IV Access (at least
bedside, transfuse per
18gauge)
clinical signs do not
Bimanual massage
wait for lab values
Vaginal Birth: (typical order) Use blood warmer for
Move to OR
transfusion
Repair any tears
Consider thawing 2 FFP
D&C: r/o retained placenta
(takes 35+min), use if
Place intrauterine balloon
transfusing >2u PRBCs
Selective Embolization
Determine availability of
(Interventional Radiology)
additional RBCs and
Cesarean Birth: (still intra-op) other Coag products
(typical order)
Inspect broad lig, posterior
uterus and retained
placenta
B-Lynch Suture
Place intrauterine balloon
California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details
This Project was supported by Title V funds received from the State of California, Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division
OB HEMORRHAGE TOOLKIT
APPENDIX E.3. METHODS FOR DEVELOPING TRAINING AND TOOLS FOR QUANTITATIVE MEASUREMENT OF BLOOD
LOSS
Recommended methods for ongoing quantitative measurement of blood
loss:
1. Formally estimate blood loss by recording percent (%) saturation of
blood soaked items with the use of visual cues such as pictures/posters
to determine blood volume equivalence of saturated/blood soaked
pads, chux, etc.
2. Formally measure blood loss by weighing blood soaked pads/chux
3. Formally measure blood loss by collecting blood in graduated
measurement containers
Quantifying blood loss by weighing (see images at right and below)
Establish dry weights of common items
Standardize use of pads
Build weighing of pads into routine practice
Develop worksheet for calculations
126