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AIM SAFETY BUNDLESOBSTETRICAL HEMORRHAGE
Tersh McCracken, MD, FACOG
MOMS ECHO
October 27, 2020
Photo courtesy of David Lagrew, MD and used with permission
Obstetric Hemorrhage Safety Bundle
Readiness Recognition Response Reporting /
Systems Learning
North Carolina: Mortality Mostly PreventableCause of Death (n=108) % of All Deaths % PreventableCardiomyopathy 21% 22%
Hemorrhage 14 93PIH 10 60CVA 9 0Chronic condition 9 89AFE 7 0Infection 7 43Pulmonary embolism 6 17
Berg CJ, Harper MA, Atkinson SM, et al. Preventability of pregnancy-related deaths: results of a state-wide review. Obstet. Gynecol. Dec 2005;106(6):1228-1234.
CA-PAMR Pregnancy-Related Deaths, Chance to Alter Outcome by Grouped Cause of Death; 2002-2004 (N=143)
Key 2008 CMQCC Hemorrhage Task Force Survey Findings
40% of hospitals did not have a hemorrhage protocol
Inconsistent definitions of hemorrhage were used among responding hospitals
70% of hospitals were not performing drillsMDs were not regularly participating in drills in hospitals that were doing them
Most had access to all 4 uterotonics Many hospital reported they did not have access to
alternative treatment methods, e.g., Balloons Note: 173 hospitals responded to the first baseline survey. The response rate is 66.3% based on 173/261 hospitals (2008) with annual delivery volume > 50 births.
READINESS – EVERY UNIT
• Hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches
• Immediate access to hemorrhage medications (kit or equivalent)
• Establish a response team – who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services)
• Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)
• Unit education on protocols, unit-based drills (with post-drill debriefs)
DRILL AND REHEARSE
RECOGNITION & PREVENTION-
EVERY PATIENT
Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)
Measurement of cumulative blood loss (formal, as quantitative as possible)
Active management of the 3rd stage of labor (department-wide protocol)
Admission Risk Assessment & TestingLow
(Clot only)Medium
(Type and Screen)High
(Type & Crossmatch)No previous uterine incision
Prior cesarean birth(s) or uterine surgery
Placenta previa, low lying placenta
Singleton pregnancy Multiple gestation Suspected placenta accreta, percreta, increta
≤4 previous vaginal births
>4 previous vaginal births
Hematocrit <30 ANDother risk factors
No known bleeding disorder
Chorioamnionitis Platelets <100,000
No history of PPH History of previous PPH
Active bleeding (greater than show) on admit
Large uterine fibroids Known coagulopathy *Pre-transfusion testing strategy should be standardized to facility conditions depending
on blood bank resources, speed of testing, and availability of blood products.*
QBL VS EBL
RESPONSE - EVERY HEMORRHAGE
Unit-standard, stage-based, obstetric
hemorrhage emergency management plan with
checklists
Support program for patients, families, and staff for all significant
hemorrhages
MEDICAL MANAGEMENT
BAKRI BALLOON
• Intrauterine Compression Balloon
R EPORTING/SYSTEMS LEARN ING
EVERY UN IT
• Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities
• Multidisciplinary review of serious hemorrhages for systems issues
• Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
1. Identification of cases
2. Information collection, review by multidisciplinary
committee
3. Cause of Death, Contributing Factors and Quality Improvement (QI) Opportunities identified
4. Strategies to improve care and
reduce morbidity and mortality
5. Implementation and Evaluation of QI strategies and
tools
Toolkits• Hemorrhage • Preeclampsia• CVD
CA-PAMR Quality Improvement Review Cycle
OB Hemorrhage: We Can Do Better
Most maternal mortalities and near misses due to hemorrhage are preventable
1/3 of patients will have no risk factors prior to labor Must be prepared for every patient QBL every delivery so can respond early
Requires reliance not on individuals but on team approach
Creating a “Team For All Seasons”
OB Hemorrhage is the prototypic OB emergency Many of the system changes are directly applicable to
other obstetric emergencies Creating the team and systems to implement hemorrhage
project makes other OB QI projects easier and more successful