3a - BRV 4PM Obstetric Hemorrhage Bernstein - LT2 · is warranted for certain obstetric events. STATEMENT ON THE USE OF BLOOD PRODUCTS Blood transfusion or crossmatching should not

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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.

CONFLICT OF INTEREST DISCLOSURE STATEMENT

We have no financial interest or other relationships with the industry relative to the topics being discussed.

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OBSTETRIC HEMORRHAGE: KEY ELEMENTS

• RECOGNITION & PREVENTION

(every patient)

• Risk assessment

• Universal active management of 3rd stage of labor

• READINESS (every unit)

• Blood bank (massive transfusion protocol)

• Cart & medication kit

• Hemorrhage team with education & drills for all stakeholders

• RESPONSE (every hemorrhage)

• Checklist

• Support for patients/families/staff for all significant hemorrhages

• REPORTING / SYSTEMS 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 INSTRUMENTSVaginal

[ ] Vaginal retractors; long weighted speculum

[ ] Long instruments

(needle holder, scissors,

Kelly clamps, sponge forceps)

[ ] Intrauterine balloon

[ ] Banjo curette

[ ] Bright task light

[ ] Procedural instructions (balloon)

Cesarean/Laparotomy

[ ] Hysterectomy tray

[ ] #1 chromic or plain catgut suture & reloadable straight needle for B-Lynch sutures

[ ] Intrauterine balloon

[ ] Procedural instructions(balloon, B-Lynch, arterialligations)

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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

INITIAL STEPS Ensure 16G or 18G IV access Increase IV fluid (crystalloid without

oxytocin) Insert indwelling urinary catheter Fundal massageMEDICATIONS Increase oxytocin, additional

uterotonicsBLOOD BANK Type & crossmatch 2 units RBCsACTION Determine etiology & treat Prepare OR, if clinically indicated

(optimize visualization/examination)

Oxytocin (Pitocin)10-40 units per 500-1000mL solution

Methylergonovine (Methergine)0.2 milligrams IM (may repeat)

15-methyl PGF2α (Hemabate, Carboprost)250 micrograms IM (may repeat in q15minutes, maximum 8 doses)

Misoprostol (Cytotec)800-1000 micrograms PR600 micrograms PO or 800 micrograms SL

Tone (i.e., atony) Trauma (i.e., laceration) Tissue (i.e., retained products)Thrombin (i.e., coagulation dysfunction)

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CHECKLIST: STAGE 2Continued 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 3Continued 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

Move to OR

Announce clinical status

(vital signs, cumulative blood loss, etiology)

Outline & communicate plan

MEDICATIONS

Continue Stage 1 medications

BLOOD BANK

Initiate massive transfusion protocol

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

ACTION

Achieve hemostasis, interventions based on etiology

Oxytocin (Pitocin)10-40 units per 500-1000mL solution

Methylergonovine (Methergine)0.2 milligrams IM (may repeat)

15-methyl PGF2α (Hemabate, Carboprost)250 micrograms IM (may repeat in q15minutes, maximum 8 doses)

Misoprostol (Cytotec)800-1000 micrograms PR600 micrograms PO or 800 micrograms SL

CHECKLIST: STAGE 4Cardiovascular 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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CHECKLIST: POST-HEMORRHAGE MANAGEMENT

Determine disposition of patient (whether ICU required)

Debrief with the whole obstetric care team

Debrief with patient and family

Document

EXAMPLE25

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 OUTCOMESNon-surgical & Surgical interventionsQuantifying 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 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]

B‐Lynch suture B‐Lynch suture

Hayman uterine compression suture

Surgical ligation locations of 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).

[email protected] • ©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


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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



A. 150 mL

B. 200 mL

C. 300 mL

D. 500 mL


Estimate the amount of blood in this kidney basin:

A. 250 mL

B. 300 mL

C. 450 mL

D. 500 mL


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A. 250 mL

B. 300 mL

C. 450 mL

D. 500 mL


Estimate the amount of blood on this lap pad:

A. 30 mL

B. 50 mL

C. 100 mL

D. 150 mL


Estimate the amount of blood on this mannequin and bed:

A. 500 mL

B. 750 mL

C. 1000 mL

D. 1500 mL


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A. 50 mL

B. 100 mL

C. 150 mL

D. 200 mL


Estimate the amount of blood on this bed pad:

A. 150 mL

B. 200 mL

C. 250 mL

D. 400 mL



A. 50 mL

B. 100 mL

C. 200 mL

D. 250 mL


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A. 150 mL

B. 200 mL

C. 300 mL

D. 500 mL


Estimate the amount of blood in this kidney basin:

A. 250 mL

B. 300 mL

C. 450 mL

D. 500 mL



A. 250 mL

B. 300 mL

C. 450 mL

D. 500 mL


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Estimate the amount of blood on this lap pad:

A. 30 mL

B. 50 mL

C. 100 mL

D. 150 mL


Estimate the amount of blood on this mannequin and bed:

A. 500 mL

B. 750 mL

C. 1000 mL

D. 1500 mL


AWHONN Video

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

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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


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.” (CaliforniaMaternal 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.

References

3a - BRV 4PM Obstetric Hemorrhage Bernstein - LT2 · is warranted for certain obstetric events. STATEMENT ON THE USE OF BLOOD PRODUCTS Blood transfusion or crossmatching should not

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