10/5/2016

Obstetric Hemorrhage:
Intervening Safely and Expeditiously

Disclaimer: The following material is an example only

and not meant to be prescriptive. ACOG accepts no
liability for the content or for the consequences of any
actions taken on the basis of the information provided.

We have no financial interest or other relationships with

the industry relative to the topics being discussed.

CONFLICT OF INTEREST
DISCLOSURE STATEMENT

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OBSTETRIC HEMORRHAGE: KEY ELEMENTS

• RECOGNITION & PREVENTION • RESPONSE (every hemorrhage)

(every patient)
• Risk assessment
• Universal active management of
3rd stage of labor
• REPORTING / SYSTEMS
• READINESS (every unit)
• Blood bank (massive transfusion
protocol)
• Cart & medication kit
• Hemorrhage team with education &
drills for all stakeholders
• Checklist
• Support for patients/families/staff
for all significant hemorrhages
LEARNING (every unit)
• Culture of huddles & debrief
• Multidisciplinary review of serious
hemorrhages
• Monitor outcomes & processes
metrics

Risk Assessment
• Prenatal
• Pre-pregnancy BMI >50
• Clinically significant
bleeding disorder
• Other significant
medical/surgical risk*
• *Special considerations
• Placenta
accreta/percreta/increta
• Patients refusing blood
transfusion
• Admission for labor
• Medium/High risk
(Type & screen/Type &
cross)
• Intrapartum
• Medium risk:
• Chorioamnionitis
• Oxytocin > 24 hours
• Prolonged 2nd stage
• Magnesium sulfate
• High risk:
• New active bleeding
• 2 or more medium risk
factors

UNIVERSAL ACTIVE MANAGEMENT OF 3RD STAGE OF LABOR

• Increase IV Oxytocin rate, 500mL/hour of 10-40 units/500-

1000mL solution
• Titrate infusion rate to uterine tone, up to 500mL as needed

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BLOOD BANK: MASSIVE TRANSFUSION PROTOCOL

1.In order to provide safe obstetric care institutions must:

• Have a functioning Massive Transfusion Protocol (MTP)

• Have a functioning Emergency Release Protocol (a minimum of 4
units of O-negative/uncrossmatched RBCs)*
• Have the ability to obtain 6 units PRBCs and 4 units FFP
(compatible or type specific) for a bleeding patient
• Have a mechanism in place to obtain platelets and additional
products in a timely fashion

Blood transfusion or crossmatching should not be used as a negative quality marker &
is warranted for certain obstetric events.

STATEMENT ON THE USE OF BLOOD PRODUCTS

Blood transfusion or crossmatching should not be used as a negative quality marker

and is warranted for certain obstetric events. In cases of severe obstetric
hemorrhage, ≥4 units of blood products may be necessary to save the life of a
maternity patient.
Hospitals are encouraged to coordinate efforts with their laboratories, blood banks,
and quality improvement departments to determine the appropriateness of
transfusion and quantity of blood products necessary for these patients.

HEMORRHAGE CART: RECOMMENDED INSTRUMENTS

Vaginal Cesarean/Laparotomy
[ ] Vaginal retractors; long
[ ] Hysterectomy tray
weighted speculum
[ ] #1 chromic or plain catgut
[ ] Long instruments
suture & reloadable straight
(needle holder, scissors, needle for B-Lynch sutures
Kelly clamps, sponge forceps)
[ ] Intrauterine balloon
[ ] Intrauterine balloon
[ ] Procedural instructions
[ ] Banjo curette (balloon, B-Lynch, arterial
[ ] Bright task light ligations)
[ ] Procedural instructions
(balloon)

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RECOMMENDED INSTRUMENTS MEDICATION KIT

(for rapid access to medications)
[ ] Oxytocin (Pitocin)
10-40 units per 500-1000mL solution 2 pre-mixed bags
[ ] Oxytocin (Pitocin)
10 units 2 vials
[ ] 15-methyl PGF2α (Hemabate)
250 micrograms/milliliters 1 ampule *
[ ] Misoprostol (Cytotec)
200 microgram tablets 5 tabs
[ ] Methylergonovine (Methergine)
0.2 milligrams/milliliters 1 ampule *

* Needs refrigeration

CHECKLIST: STAGE 1
Blood loss >500 mL vaginal OR blood loss >1000 mL cesarean
WITH NORMAL VITAL SIGNS and LAB VALUES
Oxytocin (Pitocin)
INITIAL STEPS 10-40 units per 500-1000mL solution
 Ensure 16G or 18G IV access Methylergonovine (Methergine)
 Increase IV fluid (crystalloid without
oxytocin) 0.2 milligrams IM (may repeat)
 Insert indwelling urinary catheter 15-methyl PGF2α (Hemabate, Carboprost)
 Fundal massage 250 micrograms IM (may repeat in q15
MEDICATIONS minutes, maximum 8 doses)
 Increase oxytocin, additional
uterotonics Misoprostol (Cytotec)
BLOOD BANK 800-1000 micrograms PR
 Type & crossmatch 2 units RBCs 600 micrograms PO or 800 micrograms SL
ACTION
 Determine etiology & treat Tone (i.e., atony)
 Prepare OR, if clinically indicated Trauma (i.e., laceration)
(optimize visualization/examination) Tissue (i.e., retained products)
Thrombin (i.e., coagulation dysfunction)

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CHECKLIST: STAGE 2
Continued bleeding EBL up to 1500 mL OR
>2 uterotonics WITH NORMAL VITAL SIGNS and LAB VALUES

INITIAL STEPS
 Mobilize additional help
 Place 2nd IV (16-18G)
 Draw STAT labs (CBC, coags, fibrinogen)
 Prepare OR
MEDICATIONS
 Continue Stage 1 medications
BLOOD BANK
 Obtain 2 units RBCs (DO NOT wait for labs. Transfuse per clinical signs/symptoms)
 Thaw 2 units FFP
ACTION
 Escalate therapy with goal of hemostasis
Huddle and move to Stage 3 if continued blood loss and/or abnormal VS

CHECKLIST: STAGE 3
Continued bleeding with EBL >1500 mL OR >2 units RBCs given
OR Patient at risk for occult bleeding/coagulopathy OR
any patient with abnormal vital signs/labs/oliguria
INITIAL STEPS
 Mobilize additional help Oxytocin (Pitocin)
10-40 units per 500-1000mL solution
 Move to OR
Methylergonovine (Methergine)
 Announce clinical status 0.2 milligrams IM (may repeat)
(vital signs, cumulative blood loss, etiology) 15-methyl PGF2α (Hemabate, Carbopros
 Outline & communicate plan t)
250 micrograms IM (may repeat in q15
MEDICATIONS minutes, maximum 8 doses)
 Continue Stage 1 medications
Misoprostol (Cytotec)
BLOOD BANK 800-1000 micrograms PR
 Initiate massive transfusion protocol 600 micrograms PO or 800 micrograms SL

(If clinical coagulopathy: add cryoprecipitate, consult for additional agents)

ACTION
 Achieve hemostasis, interventions based on etiology

CHECKLIST: STAGE 4
Cardiovascular Collapse (massive hemorrhage, profound hypovolemic shock or
amniotic fluid embolism)
INITIAL STEPS
 Mobilize additional resources

MEDICATIONS
 ACLS

BLOOD BANK
 Simultaneous aggressive massive transfusion

ACTION
 Immediate surgical intervention to ensure hemostasis (hysterectomy)

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EXAMPLE
25

CHECKLIST: POST-HEMORRHAGE MANAGEMENT

 Determine disposition of patient (whether ICU required)

 Debrief with the whole obstetric care team

 Debrief with patient and family

 Document

REPORTING / SYSTEMS LEARNING

(every unit)
• Establish a culture of huddles for high-risk patients and
post-event debriefs
• Conduct a multidisciplinary review of serious
hemorrhages for systems issues
• Monitor outcomes and processes metrics

TECHNIQUES TO OPTIMIZE
OUTCOMES
Non-surgical & Surgical interventions
Quantifying blood loss (QBL)

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INTRAUTERINE BALLOON TECHNIQUE

• Insert under ultrasound guidance
• Inflate to 500 cc with sterile water or NaCl
• Use vaginal packing (iodoform or antibiotic soaked gauze) 
to maintain correct placement and maximize tamponade
• Gentle traction — secure to patient’s leg or attach weight  < 
than 500 g

INTRAUTERINE BALLOON TECHNIQUE

• Transabdominal placement (via incision)

• Connect to fluid collection bag to monitor hemostasis
• Continuous monitoring of vital signs and signs of increased
bleeding
• May need to flush clots with sterile isotonic saline
• Maximum time balloon can remain in place is 24 hours
• To deflate:
– Remove tension from shaft
– Remove packing
– Aspirate fluid
– Remove catheters gently

SURGICAL MANAGEMENT
• Uterine curettage
• Placental bed suture
• Uterine artery ligation
• Uteroovarian ligation
• Repair uterine rupture
• B-Lynch suture, multiple square B‐Lynch suture B‐Lynch suture
sutures
• Hysterectomy

Images used with permission from:

FEMALE PELVIC SURGERY VIDEO ATLAS SERIES
Mickey Karam, Series Editor

Management of Acute Obstetric Emergencies

Baha Sibai, MD
[Copyright 2011 by Saunders] Hayman uterine  Surgical ligation locations of 
compression suture uterine blood supply

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B lynch
• Equipment:
• Large Mayo needle with #1 or #2 chromic catgut
• Large suture to prevent breaking
• Rapid absorption to prevent a herniation of bowel through a suture loop after the
uterus has involuted

• Technique:

Measuring Blood Loss:

Estimating vs. Quantifying
• Underestimating blood loss leads to delayed recognition of
hemorrhage and initiation of life-saving measures
• Overestimating can lead to unnecessary and costly treatments
• Quantification of blood loss more accurate and reduces
likelihood of delays in recognition and treatment

AWHONN (2015). Quantification of blood loss: AWHONN Practice Brief Number 1.

Journal of Obstetric, Gynecologic & Neonatal Nursing.44, pp 158-160.

Quantification of Blood Loss Methods

• Quantification of blood loss is a formal measurement using

weighing and blood collection devices to determine the actual
amount of blood loss
• Methods to quantify blood loss, such as weighing, are
significantly more accurate than EBL (AI Kadri et al., 2011).
• The use of a calibrated drape had an error rate of less than
15% (Toledo et al., 2007).

AWHONN (2015). Quantification of blood loss: AWHONN Practice Brief Number 1.

Journal of Obstetric, Gynecologic & Neonatal Nursing.44, pp 158-160.
dbingham@perinatalQI.org  •  ©Institute for Perinatal Quality Improvement

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HOW WELL DO WE ESTIMATE

BLOOD LOSS?
Why should we try Quantitative Blood Loss??

Estimate the amount of blood on this peripad:

A. 50 mL
B. 100 mL
C. 150 mL
D. 200 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this bed pad:

A. 150 mL
B. 200 mL
C. 250 mL
D. 400 mL

Zuckerwise LC et al. 2014

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Estimate the amount of blood on this Chux pad:

A. 50 mL
B. 100 mL
C. 200 mL
D. 250 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this Chux pad:

A. 150 mL
B. 200 mL
C. 300 mL
D. 500 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood in this kidney basin:

A. 250 mL
B. 300 mL
C. 450 mL
D. 500 mL

Zuckerwise LC et al. 2014

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Estimate the amount of blood on this peripad:

A. 250 mL
B. 300 mL
C. 450 mL
D. 500 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this lap pad:

A. 30 mL
B. 50 mL
C. 100 mL
D. 150 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this mannequin and bed:

A. 500 mL
B. 750 mL
C. 1000 mL
D. 1500 mL

Zuckerwise LC et al. 2014

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Estimate the amount of blood on this peripad:

A. 50 mL
B. 100 mL
C. 150 mL
D. 200 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this bed pad:

A. 150 mL
B. 200 mL
C. 250 mL
D. 400 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this Chux pad:

A. 50 mL
B. 100 mL
C. 200 mL
D. 250 mL

Zuckerwise LC et al. 2014

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 10/5/2016

Estimate the amount of blood on this Chux pad:

A. 150 mL
B. 200 mL
C. 300 mL
D. 500 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood in this kidney basin:

A. 250 mL
B. 300 mL
C. 450 mL
D. 500 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this peripad:

A. 250 mL
B. 300 mL
C. 450 mL
D. 500 mL

Zuckerwise LC et al. 2014

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 10/5/2016

Estimate the amount of blood on this lap pad:

A. 30 mL
B. 50 mL
C. 100 mL
D. 150 mL

Zuckerwise LC et al. 2014

Estimate the amount of blood on this mannequin and bed:

A. 500 mL
B. 750 mL
C. 1000 mL
D. 1500 mL

Zuckerwise LC et al. 2014

AWHONN Video

https://www.youtube.com/embed/F_ac-aCbEn0

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References
The American College of Obstetricians and Gynecologists. “Postpartum Hemorrhage.” Practice Bulletin, Number 76. October 2006.

The American College of Obstetricians and Gynecologists. “Placenta Accreta.” Committee Opinion, Number 529. July 2012.
http://tinyurl.com/pf3rweu

The American College of Obstetricians and Gynecologists. “Postpartum Hemorrhage from Vaginal Delivery.” Patient Safety Checklist, Number 10.
May 2013. http://tinyurl.com/kltnspw

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Postpartum Hemorrhage Project: A Multi-Hospital Quality
Improvement Program, 2013. http://www.pphproject.org

AWHONN (2015). Quantification of blood loss: AWHONN Practice Brief Number 1. Journal of Obstetric, Gynecologic & Neonatal Nursing.44, pp
158-160.

Campbell KH, Savitz D, Werner EF, et al. “Maternal morbidity and risk of death at delivery hospitalization.” Obstetrics and Gynecology, 2013(122):
pp. 627-33.

Chen M, Chang Q, Duan T, et al. “Uterine massage to reduce blood loss after vaginal delivery.” Obstetrics and Gynecology, 2013(122): pp. 290-5.

Guly HR, Bouamra, O, Spiers M, et al. “Vital signs and estimated blood loss in patients with major trauma: Testing the validity of the ATLS
classification of hypovolaemic shock.” Resuscitation, 2011(82): pp. 556-9.

Lyndon A, Lagrew D, Shields L, Melsop K, Bingham B, Main E (Eds). “Improving Health Care Response to Obstetric Hemorrhage.” (California
Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of
Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, July 2010.
https://cmqcc.org/ob_hemorrhage

Mutschler M, Nienaber U, Brockamp T, et al. “A critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical
reality?” Resuscitation, 2013(84): pp. 309-13.

Parks JK, Elliott, AC, Gentilello LM, Shafi S. “Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma
Life Support principles in a large national sample.” The American Journal of Surgery, 2006(192): pp. 727-31.

Zuckerwise LC, Pettker CM, Illuzzi J, Raab CR, Lipkind HS. “Use of a novel visual aid to improve estimation of obstetric blood loss.” Obstetrics &
Gynecology, 2014; 123(5): 982-986.

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