Deadly Deliveries? Working as a Team to Make a Difference ... · PDF filePreventing and/or Treating Obstetrical Hemorrhage ... health care providers in your perinatal ... •Pain –

Deadly Deliveries? – Working as a Team to Make a Difference in

Preventing and/or Treating Obstetrical Hemorrhage

Charlene Miranda-Wood, MS, RNC-OB

February 2012

NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf

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Objectives

• Apply the fundamentals of using Failure Mode Effects Analysis (FMEA) to drive change in your perinatal department to prevent/treat obstetrical hemorrhage

• Identify obstetrical hemorrhage risk factors and mechanisms to communicate risk to all health care providers in your perinatal department


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What is Your Best Guess? • Blood volume

– EBL vs QBL


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Meet Mrs. Lochia

• 30 y.o. G 3 P 2 0 0 2

• 31 2/7 weeks twin gestation (IVG dating)

– diamniotic and dichorionic

• c/o uterine contractions every 5 minutes and loss of mucous plug

• Pain – mild

• Location – suprapubic


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• Previous medical history

– Previous admit at 24 5/7 gestational weeks for shortened cervix at 1.3 cm

– One month prior cervical length was > 4 cm

– Medications during hospital course

• Received Betamethsone x 2

• Nifedipine 10 mg q 6

• Vaginal progesterone with 8% Crinone, nightly


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Discharged home after 4 weeks in hospital

– Continued on

• Nifedipine 10 mg q 6

• Vaginal progesterone nightly

– Past deliveries – NSVD and Vacuum assisted delivery

• no complications


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Current admission for PTL

• Started on Magnesium Sulfate for both neuroprotection and PTL

• Despite interventions proceeded to dilate

• Twin A and Twin B delivered without difficulties


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Emergently transported to OR

• Repeat D&C

• Bakri balloon placement, vaginal packing

• Massive transfusion protocol – 4 U PRBCs

– 4 U FFP

– 1 U Plt

– 1 U Cryoprecipitate

• H/H 9.7/28.2 Plt 127 Fibrinogen 231

• Blood loss – 3000 ml


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POD # 2 - Bakri balloon removed in two steps

POD # 4 – Discharged home in stable condition


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• How did we get to where we are today?

• Nurse Champion

• Creating a Team – Physician Champion

– Analyst

– Pharmacy

– Blood Bank

– Lab

– Admissions

• CMQCC – First Cohort


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• Defining the Problem Process mapping


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Failure Modes Effect Analysis


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OB Hemorrhage Algorithm


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• Developing the Plan

– Development and Implementation of Standardized OB Hemorrhage Risk Assessment


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– Development and Implementation of a process to quantify and document cumulative blood loss


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– Development and implementation of OB hemorrhage equipment and supplies

• OB hemorrhage cart

• Sterile equipment


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• Development and implementation of “doe packs” in OBER


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• Development and implementation of OB hemorrhage medication packs

– Pitocin

– Misoprostol

– Methergine

– Hemabate


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• Development and implementation of blood requisition and transfusion protocols for obstetrical patients

– Rapid infusion protocol


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• Implementation and Education

• Skills Fair

– Collection of pre-learning packet

– Quantification of blood loss

– Blood bank

– Lab – rapid infusion labs

– OBET

– OB hemorrhage cart

– Policies and procedures

– Post learning crossword puzzle

• “Go Live”


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We know we have made a difference for the women and families that have entrusted us with their lives and the lives of their babies.

http://www.youtube.com/watch?v=wgi24wPaWbs&feature=plcp&context=C3b5c70eUDOEgsToPDskIjM_NOLZ7-aDKTwZk112s6


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Documents

Deadly Deliveries? Working as a Team to Make a Difference ... · PDF filePreventing and/or Treating Obstetrical Hemorrhage ... health care providers in your perinatal ... •Pain –