S E R I E S 2

Optimizing Protocols in ObstetricsMANAGEMENT of OBSTETRIC HEMORRHAGE

D I S T R I C T I I

OCTOBER 2012

Management of Obstetric Hemorrhage

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Dear ACOG District II Member:On behalf of the American Congress of Obstetricians and Gynecologists (ACOG), District II we are pleased to provide you with the second chapter of the Optimizing Protocols in Obstetrics series. While the first chapter addressed the use of oxytocin for induction, this chapter’s content focuses on the Man-agement of Obstetric Hemorrhage. Twenty three existing hemorrhage protocols were reviewed from obstetric hospitals throughout New York State and many contained excellent educational and instructional components. However, most of these hospitals lacked the systematic approach required to ensure an effective guideline or protocol. Given the exceptional work done in this area by the California Maternal Quality Care Collaborative (CMQCC) and ACOG, the District II PSQI Committee encourages institutions to utilize these two extensive resources in the development of a hemorrhage protocol. Enclosed you will find:

• Core elements for the management of obstetric hemorrhage • Recommendations to optimize the management of obstetric hemorrhage • ACOG Practice Bulletin #76 – Postpartum Hemorrhage • CMQCC hemorrhage care checklist, flow chart, table chart and training tools for measurement of blood loss

Each institution is encouraged to review its existing hemorrhage protocols, and modify them if neces-sary 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 Dis-trict II Patient Safety Manager, at 518-436-3461 or kgilchrist@ny.acog.org.

Sincerely,

Richard L. Berkowitz, MD, FACOG Peter Bernstein, MD, FACOGCo-Chair, PSQI Committee Co-Chair, PSQI Committee ACOG District II ACOG District II

RB/PB/kg

Optimizing Protocols in ObstetricsS E R I E S 2

NURSING INTERVENTIONS

Index: Series 2

4 Executive Summary 4 Core Elements for the Management of Obstetric Hemorrhage 5 Introduction & California Maternal Quality Care Collaborative (CMQCC) Toolkit Overview 6 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

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OCTOBER 2012

Optimizing Protocols in ObstetricsS E R I E S 2

Management of Obstetric Hemorrhage

Purpose

ExecutiveSummary

Core Elements

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OCTOBER 2012

Optimizing Protocols in ObstetricsS E R I E S 2

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.

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 obstetri-cal 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 instruc-tional 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 Collabora-tive (CMQCC) and the American Congress of Obstetricians and Gynecologists (ACOG), we encour-age individuals to utilize these two extensive resources in the development of a hemorrhage protocol.

The following is a list of the components of any protocol that is created for the management of obstetri-cal 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

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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 preci-sion 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 as-sociated 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.

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 comprehen-sive document exists within the tool kit related to obstetric hemorrhage drills and simulations. This docu-ment 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 implementa-tion 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.

Introduction

CMQCC Toolkit

Overview

Management of Obstetric Hemorrhage

Recommendations to Optimize the Management of Obstetric Hemorrhage

OCTOBER 2012

Optimizing Protocols in ObstetricsS E R I E S 2

Antepartum assessment is essential to identify women at risk for obstetrical hemorrhage. • Risk factor identification • A prewritten order set for admission to L&D includes “risk scoring” for obstetric hemorrhage • Definition checklist n CMQCC Toolkit examples 3 Definitions & Early Recognition (pages 3-6) 3 Incidence Risks & Diagnosis (pages 22-25)

Each institution should develop an effective written protocol for responding to maternal hemorrhage, including rapid emergency blood transfusion, which requires coordination among physicians, nurses, anesthesiologists and the blood bank. • Blood bank protocols should ensure that the institution has appropriate blood products for obstetric emergencies, and they should eliminate barriers to rapid blood access when needed. n CMQCC Toolkit examples 3 Sample Hemorrhage Policy (pages 110-112) 3 Methods for developing training and tools for quantitative measurement of blood loss (page 126)Other suggestions include: • On initiation of the obstetric hemorrhage protocol, a complete set of prewritten orders should instantly be authorized and executed. The attending physician only will sign this order set after the emergency is completed. • Debriefings should occur after every drill and after every actual OB hemorrhage emergency. This allows for continuous quality improvement. • Flow charts, checklists, and other documentary materials needed for managing the OB hemorrhage emergency should be available to assist in the management. n See attached CMQCC examples n CMQCC Toolkit examples 3 Surgical Treatment (pages 72-73) i. Literature Review (pages 70-71) ii. Carts, Kits and Trays (pages 26-31) 3 Medical Treatment (pages 74-75) 3 Checklist/Algorithms (pages 86-92

Be vigilant regarding blood loss during pregnancy, labor, and delivery, and in the earlypostpartum period. • Nursing staff and physicians in the Labor, Delivery, Recovery and Postpartum areas must be trained in accurately assessing the degree of maternal hemorrhage. • When problems are identified, the nurse assigned must notify the physician immediately. n See attached CMQCC checklist example n CMQCC Toolkit examples 3 Definitions & Early Recognition (pages 3-6) 3 Simulation & Drills (pages 32-47)

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Use fluid resuscitation and transfusion based on the estimation of current blood loss and theexpectation of continued bleeding, regardless of apparent maternal hemodynamic stability. • Accurately estimate blood loss n CMQCC Toolkit examples 3 Simulation & Drills (pages 32-47) 3 Transfusion Policy (pages 60-69)

Work with hospital staff to conduct drills or simulation to ensure the most efficient management of obstetric hemorrhage. • Hospitals should run drills at different times of the day to ensure that appropriate hemorrhage team members are available at all times. • All members of the health care team should participate, including nurses, physicians and ancillary staff, as appropriate n CMQCC Toolkit example 3 Simulation & Drills (pages 32-47)

• The maternal hemorrhage team should include, in addition to a team leader: • A surgeon with experience and expertise in controlling massive hemorrhage as well as operating room staff in case surgery is needed. • A critical care physician or anesthesiologist who is familiar with severe hemorrhage to help with assessment of organ perfusion and cardiovascular function. • A hematologist or clinical pathologist available on site to advise on appropriate blood products, and to coordinate and mobilize appropriate personnel to provide these products immediately.

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 hospital’s mandatory annual educational programs and ensure all new staff is oriented to it’s content. • Findings from obstetrical quality improvement initiatives should be incorporated on an on-going basis into improvements of the hemorrhage protocol.

Management of Obstetric Hemorrhage

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VOL. 108, NO. 4, OCTOBER 2006 OBSTETRICS & GYNECOLOGY 1039

ACOGPRACTICEBULLETIN

CLINICAL MANAGEMENT GUIDELINES FOROBSTETRICIAN–GYNECOLOGISTS

NUMBER 76, OCTOBER 2006

(Replaces Committee Opinion Number 266, January 2002)

This Practice Bulletin wasdeveloped by the ACOG Com-mittee on Practice Bulletins—Obstetrics with the assistanceof William N. P. Herbert, MD,and Carolyn M. Zelop, MD.The information is designed toaid practitioners in makingdecisions about appropriateobstetric and gynecologic care.These guidelines should not beconstrued as dictating an exclu-sive course of treatment or pro-cedure. Variations in practicemay be warranted based on theneeds of the individual patient,resources, and limitationsunique to the institution or typeof practice.

Postpartum HemorrhageSevere bleeding is the single most significant cause of maternal death world-wide. 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 year—one every 4 minutes(1). In addition to death, serious morbidity may follow postpartum hemorrhage.Sequelae include adult respiratory distress syndrome, coagulopathy, shock, lossof fertility, and pituitary necrosis (Sheehan syndrome).

Although many risk factors have been associated with postpartum hemor-rhage, it often occurs without warning. All obstetric units and practitionersmust have the facilities, personnel, and equipment in place to manage thisemergency properly. Clinical drills to enhance the management of maternalhemorrhage have been recommended by the Joint Commission on Accreditationof Healthcare Organizations (2). The purpose of this bulletin is to review theetiology, evaluation, and management of postpartum hemorrhage.

BackgroundThe physiologic changes over the course of pregnancy, including a plasma vol-ume increase of approximately 40% and a red cell mass increase of approxi-mately 25%, occur in anticipation of the blood loss that will occur at delivery(3). There is no single, satisfactory definition of postpartum hemorrhage. Anestimated blood loss in excess of 500 mL following a vaginal birth or a loss ofgreater than 1,000 mL following cesarean birth often has been used for thediagnosis, but the average volume of blood lost at delivery can approach theseamounts (4, 5). Estimates of blood loss at delivery are notoriously inaccurate,with significant underreporting being the rule. Limited instruction on estimat-ing 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 postpartumhemorrhage, but determinations of hemoglobin or hematocrit concentrationsmay not reflect the current hematologic status (7). Hypotension, dizziness, pal-

1040 ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

lor, and oliguria do not occur until blood loss is substan-tial—10% or more of total blood volume (8).

Postpartum hemorrhage generally is classified asprimary or secondary, with primary hemorrhage occur-ring within the first 24 hours of delivery and secondaryhemorrhage occurring between 24 hours and 6–12 weekspostpartum. Primary postpartum hemorrhage, whichoccurs in 4–6% of pregnancies, is caused by uterineatony in 80% or more of cases (7). Other etiologies areshown 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 evalu-ation and management are necessary. A number of gen-eral medical supportive measures may be instituted,including provision of ample intravenous access; crystal-loid infusion; blood bank notification that blood productsmay be necessary; prompt communication with anesthe-siology, nursing, and obstetrician–gynecologists; andblood collection for baseline laboratory determinations.

When treating postpartum hemorrhage, it is neces-sary to balance the use of conservative management tech-niques with the need to control the bleeding and achievehemostasis. A multidisciplinary approach often isrequired. In the decision-making process, less-invasivemethods should be tried initially if possible, but if unsuc-cessful, preservation of life may require hysterectomy.Management of postpartum hemorrhage may vary great-ly among patients, depending on etiology of the bleeding,available treatment options, and a patient’s desire for

future fertility. At times, immediate surgery is requiredbecause time spent using other treatment methods wouldbe dangerous for the patient. There are few randomizedcontrolled studies relevant to the management of post-partum hemorrhage, so management decisions usuallyare made based on clinical judgment.

Evaluation and ManagementConsiderationsIn an effort to prevent uterine atony and associated bleed-ing, it is routine to administer oxytocin soon after deliv-ery. This may be given at the time of delivery of theanterior shoulder of the fetus, or more commonly in theUnited States, following delivery of the placenta.

It may be helpful to post protocols for hemorrhagemanagement in delivery rooms or operating suites. A sam-ple poster from the New York City Department of Healthand Mental Hygiene is available at http://home2.nyc.gov/html/doh/downloads/pdf/ms/ms-hemorr-poster.pdf.

Clinical Considerations andRecommendations

What should be considered in the initial eval-uation of a patient with excessive bleeding inthe immediate puerperium?

Because the single most common cause of hemorrhage isuterine atony, the bladder should be emptied and abimanual pelvic examination should be performed. Thefinding of the characteristic soft, poorly contracted(“boggy”) uterus suggests atony as a causative factor.Compression or massage of the uterine corpus can dimin-ish bleeding, expel blood and clots, and allow time forother measures to be implemented.

If bleeding persists, other etiologies besides atonymust be considered. Even if atony is present, there maybe other contributing factors. Lacerations should be ruledout by careful visual assessment of the lower genitaltract. Proper patient positioning, adequate operativeassistance, good lighting, appropriate instrumentation(eg, Simpson or Heaney retractors), and adequate anes-thesia are necessary for the identification and properrepair of lacerations. Satisfactory repair may requiretransfer to a well-equipped operating room.

Genital tract hematomas also can lead to significantblood loss. Progressive enlargement of the mass indicatesa need for incision and drainage. Often a single bleedingsource is not identified when a hematoma is incised.Draining the blood within the hematoma (sometimes

Etiology of Postpartum Hemorrhage

PrimaryUterine atonyRetained placenta—especially placenta accretaDefects in coagulationUterine inversion

SecondarySubinvolution of placental siteRetained products of conceptionInfection Inherited coagulation defects

Adapted from Cunningham FG, Leveno KJ, Bloom SL, Hauth JC,Gilstrap L 3rd, Wenstrom KD. Obstetric hemorrhage. In: Williamsobstetrics. 22nd ed. New York (NY): McGraw-Hill; 2005. p. 809–54and Alexander J, Thomas P, Sanghera J. Treatments for secondarypostpartum haemorrhage. The Cochrane Database of SystematicReviews 2002, Issue 1. Art. No.: CD002867. DOI: 10.1002/14651858.CD002867.

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VOL. 108, NO. 4, OCTOBER 2006 ACOG Practice Bulletin Postpartum Hemorrhage 1041

placing a drain in situ), suturing the incision, and ifappropriate, packing the vagina are measures usuallysuccessful in achieving hemostasis. Interventional radi-ology is another option for management of a hematoma.Genital tract hematomas may not be recognized untilhours after the delivery, and they sometimes occur in theabsence of vaginal or perineal lacerations. The mainsymptoms are pelvic or rectal pressure and pain.

The possibility that additional products of concep-tion remain within the uterine cavity should be consid-ered. Ultrasonography can help diagnose a retainedplacenta. Retained placental tissue is unlikely whenultrasonography reveals a normal endometrial stripe.Although ultrasonographic images of retained placentaltissue are inconsistent, detection of an echogenic mass inthe uterus is more conclusive. Ultrasound evaluation forretained tissue should be performed before uterineinstrumentation is undertaken (9). Spontaneous expul-sion of the placenta, apparent structural integrity oninspection, and the lack of a history of previous uterinesurgery (suggesting an increased risk of abnormal pla-centation) make a diagnosis of retained products of theplacenta less likely, but a curettage may identify a suc-centuriate lobe of the placenta or additional placental tis-sue. When a retained placenta is identified, a large, bluntinstrument, such as a banjo curette or ring forceps, guid-ed by ultrasonography, makes removal of the retainedtissue easier and reduces the risk of perforation.

Less commonly, postpartum hemorrhage may becaused by coagulopathy. Clotting abnormalities shouldbe suspected on the basis of patient or family history

Risk Factors for Postpartum Hemorrhage

Prolonged laborAugmented laborRapid laborHistory of postpartum hemorrhageEpisiotomy, especially mediolateralPreeclampsiaOverdistended uterus (macrosomia, twins, hydramnios)Operative deliveryAsian or Hispanic ethnicityChorioamnionitis

Data from Stones RW, Paterson CM, Saunders NJ. Risk factors formajor obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol1993;48:15–8 and Combs CA, Murphy EL, Laros RK. Factors associ-ated with hemorrhage in cesarean deliveries. Obstet Gynecol1991;77:77–82.

or clinical circumstances. Hemolysis, elevated liverenzymes, and low platelet count (HELLP) syndrome,abruptio placentae, prolonged intrauterine fetal demise,sepsis, and amniotic fluid embolism are associated withclotting abnormalities. Significant hemorrhage from anycause can lead to consumption of clotting factors.Observation of the clotting status of blood recently lostcan provide important information. When a coagulopa-thy is suspected, appropriate testing should be ordered,with blood products infused as indicated. In some situa-tions, the coagulopathy may be caused or perpetuated bythe hemorrhage. In such cases, simultaneous surgery andblood product replacement may be necessary.

Baseline studies should be ordered when excessiveblood loss is suspected and should be repeated periodi-cally as clinical circumstances warrant. Cliniciansshould remember that the results of some studies may bemisleading because equilibration may not have occurred.In addition, response to hemorrhage may be requiredbefore laboratory results are known. Baseline studiesinclude a complete blood count with platelets, a pro-thrombin time, an activated partial thromboplastin time,fibrinogen, and a type and cross order. The blood bankshould be notified that transfusion may be necessary.

The clot observation test provides a simple measureof fibrinogen (10). A volume of 5 mL of the patient’sblood is placed into a clean, red-topped tube andobserved frequently. Normally, blood will clot within8–10 minutes and will remain intact. If the fibrinogenconcentration is low, generally less than 150 mg/dL, theblood in the tube will not clot, or if it does, it will under-go partial or complete dissolution in 30–60 minutes.

What is the appropriate medical managementapproach for excessive postpartum bleeding?

Ongoing blood loss in the setting of decreased uterinetone requires the administration of additional uterotonicsas the first-line treatment for hemorrhage (Table 1).Some practitioners prefer direct injection of methyler-gonovine maleate and 15-methyl prostaglandin (PG) F2αinto the uterine corpus. Human recombinant factor VIIais a new treatment modality shown to be effective in controlling severe, life-threatening hemorrhage by actingon the extrinsic clotting pathway. Intravenous dosagesvary by case and generally range from 50 to 100 mcg/kgevery 2 hours until hemostasis is achieved. Cessation ofbleeding ranges from 10 minutes to 40 minutes afteradministration (11–14). Concern has been raised be-cause of apparent risk of subsequent thromboembolicevents following factor VIIa use (15). Compared withother agents, factor VIIa is extremely expensive.Additional clinical experience in all specialties will help

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1042 ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

available to control bleeding (Table 3). Hypogastricartery ligation is performed much less frequently than inyears past. Its purpose is to diminish the pulse pressure ofblood flowing to the uterus via the internal iliac(hypogastric) vessels. Practitioners are less familiar withthis technique, and the procedure has been found to beconsiderably less successful than previously thought(17). Bilateral uterine artery ligation (O’Leary sutures)accomplishes the same goal, and this procedure is quick-er and easier to perform (18, 19). To further diminishblood flow to the uterus, similar sutures can be placedacross the vessels within the uteroovarian ligaments.

The B-Lynch technique is a newer procedure forstopping excessive bleeding caused by uterine atony (20).The suture provides even pressure to compress the uterinecorpus and decrease bleeding. One study reported more

determine factor VIIa’s role in the treatment of patientswith postpartum hemorrhage.

When is packing or tamponade of the uterinecavity advisable?

When uterotonics fail to cause sustained uterine contrac-tions and satisfactory control of hemorrhage after vaginaldelivery, tamponade of the uterus can be effective indecreasing hemorrhage secondary to uterine atony (Table2). Such approaches can be particularly useful as a tem-porizing measure, but if a prompt response is not seen,preparations should be made for exploratory laparotomy.

Packing with gauze requires careful layering of thematerial back and forth from one cornu to the other usinga sponge stick, packing back and forth, and ending withextension of the gauze through the cervical os. The sameeffect often can be derived more easily using a Foleycatheter, Sengstaken-Blakemore tube, or, more recently,the SOS Bakri tamponade balloon (16), specifically tai-lored for tamponade within the uterine cavity in cases ofpostpartum hemorrhage secondary to uterine atony.

When are surgical techniques used to controluterine bleeding?

When uterotonic agents with or without tamponademeasures fail to control bleeding in a patient who hasgiven birth vaginally, exploratory laparotomy is indicat-ed. A midline vertical abdominal incision usually is pre-ferred to optimize exposure. Several techniques are

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Table 1. Medical Management of Postpartum Hemorrhage

Drug* Dose/Route Frequency Comment

Oxytocin (Pitocin) IV: 10–40 units in 1 liter Continuous Avoid undiluted rapid IV infusion,normal saline or lactated which causes hypotension.Ringer’s solution IM: 10 units

Methylergonovine IM: 0.2 mg Every 2–4 h Avoid if patient is hypertensive.(Methergine)

15-methyl PGF2α IM: 0.25 mg Every 15–90 min, Avoid in asthmatic patients;(Carboprost) 8 doses maximum relative contraindication if(Hemabate) hepatic, renal, and cardiac

disease. Diarrhea, fever, tachycardia can occur.

Dinoprostone Suppository: vaginal Every 2 h Avoid if patient is hypotensive.(Prostin E2) or rectal Fever is common. Stored frozen,

20 mg it must be thawed to room temperature.

Misoprostol 800–1,000 mcg rectally(Cytotec, PGE1)

Abbreviations: IV, intravenously; IM, intramuscularly; PG, prostaglandin.*All agents can cause nausea and vomiting.Modified from Dildy GA, Clark SL. Postpartum hemorrhage. Contemp Ob/Gyn 1993;38(8):21–9.

Table 2. Tamponade Techniques for Postpartum Hemorrhage

Technique Comment

Uterine tamponade

—Packing —4-inch gauze; can soak with 5,000 units of thrombin in 5 mL of sterile saline

—Foley catheter —Insert one or more bulbs; instill 60–80 mL of saline

—Sengstaken–Blakemore tube

—SOS Bakri tamponade balloon —Insert balloon; instill 300–500 mL of saline

VOL. 108, NO. 4, OCTOBER 2006 ACOG Practice Bulletin Postpartum Hemorrhage 1043

than 1,000 B-Lynch procedures with only seven failures(21). However, because the technique is new, many clini-cians have limited experience with this procedure (22).

Hemostatic multiple square suturing is another newsurgical technique for postpartum hemorrhage caused byuterine atony, placenta previa, or placenta accreta. Theprocedure eliminates space in the uterine cavity by sutur-ing both anterior and posterior uterine walls. One studyreported on this technique in 23 women after conserva-tive treatment failed. All patients were examined after 2months, and ultrasound findings confirmed normalendometrial linings and uterine cavities (23).

What are the clinical considerations for suspected placenta accreta?

Abnormal attachment of the placenta to the inner uterinewall (placenta accreta) can cause massive hemorrhage. Infact, accreta and uterine atony are the two most commonreasons for postpartum hysterectomy (24, 25). Risk factorsfor placenta accreta include placenta previa with or with-out previous uterine surgery, prior myomectomy, priorcesarean delivery, Asherman’s syndrome, submucousleiomyomata, and maternal age older than 35 years (26).

Prior cesarean delivery and the presence of placentaprevia in a current pregnancy are particularly important riskfactors for placenta accreta. In a multicenter study of morethan 30,000 patients who had cesarean delivery withoutlabor, the risk of placenta accreta was approximately 0.2%,0.3%, 0.6%, 2.1%, 2.3%, and 7.7% for women experienc-ing their first through sixth cesarean deliveries, respective-ly. In patients with placenta previa in the current pregnancy,the risk of accreta was 3%, 11%, 40%, 61%, and 67% forthose undergoing their first through their fifth or greatercesarean deliveries, respectively (27).

Women with placenta previa or placenta accretahave a higher incidence of postpartum hemorrhage andare more likely to undergo emergency hysterectomy

(28). In the multicenter study cited previously, hysterec-tomy was required in 0.7% for the first cesarean deliveryand increased with each cesarean delivery up to 9% forpatients with their sixth or greater cesarean delivery.

In the presence of previa or a history of cesareandelivery, the obstetric care provider must have a highclinical suspicion for placenta accreta and take appropri-ate precautions. Ultrasonography may be helpful inestablishing the diagnosis in the antepartum period.Color Doppler technology may be an additional adjunc-tive tool for suspected accreta (29). Despite advances inimaging techniques, no diagnostic technique affords theclinician complete assurance of the presence or absenceof placenta accreta.

If the diagnosis or a strong suspicion is formedbefore delivery, a number of measures should be taken:

• The patient should be counseled about the likelihoodof hysterectomy and blood transfusion.

• Blood products and clotting factors should be avail-able.

• Cell saver technology should be considered if avail-able.

• The appropriate location and timing for deliveryshould be considered to allow access to adequatesurgical personnel and equipment.

• A preoperative anesthesia assessment should beob-tained.

The extent (area, depth) of the abnormal attachmentwill determine the response—curettage, wedge resection,medical management, or hysterectomy. Uterine conserv-ing options may work in small focal accretas, but abdom-inal hysterectomy usually is the most definitive treatment.

Under what circumstances is arterialembolization indicated?

A patient with stable vital signs and persistent bleeding,especially if the rate of loss is not excessive, may be a can-didate for arterial embolization. Radiographic identifica-tion of bleeding vessels allows embolization with Gelfoam,coils, or glue. Balloon occlusion is also a technique used insuch circumstances. Embolization can be used for bleedingthat continues after hysterectomy or can be used as analternative to hysterectomy to preserve fertility.

When is blood transfusion recommended? Is there a role for autologous transfusions or directed donor programs?

Transfusion of blood products is necessary when theextent of blood loss is significant and ongoing, particu-larly if vital signs are unstable. Postpartum transfusion

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Table 3. Surgical Management of Postpartum Hemorrhage

Technique Comment

Uterine curettage

Uterine artery ligation Bilateral; also can ligate uteroovarian vessels

B-Lynch suture

Hypogastric artery ligation Less successful than earlier thought; difficult technique; generally reserved for practitioners experienced in the procedure

Repair of rupture

Hysterectomy

1044 ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

rates vary between 0.4% and 1.6% (30). Clinical judg-ment is an important determinant, given that estimates ofblood loss often are inaccurate, determination of hemat-ocrit or hemoglobin concentrations may not accuratelyreflect the current hematologic status, and symptoms andsigns of hemorrhage may not occur until blood lossexceeds 15% (8). The purpose of transfusion of bloodproducts is to replace coagulation factors and red cells foroxygen-carrying capacity, not for volume replacement.To avoid dilutional coagulopathy, concurrent replace-ment with coagulation factors and platelets may be nec-essary. Table 4 lists blood components, indications fortransfusion, and hematologic effects.

Autologous transfusion (donation, storage, retrans-fusion) has been shown to be safe in pregnancy (31, 32).However, it requires anticipation of the need for transfu-sion, as well as a minimal hematocrit concentration oftenabove that of a pregnant woman. Autologous transfusiongenerally is reserved for situations with a high chance oftransfusion in a patient with rare antibodies, where thelikelihood of identifying compatible volunteer-providedblood is very low. Blood donated by directed donors hasnot been shown to be safer than blood from unknown,volunteer donors. Cell saver technology has been usedsuccessfully in patients undergoing cesarean delivery. Ina multicenter study of 139 patients using such devices, nountoward outcomes were noted when compared withcontrol patients (33).

What is the management approach for hemorrhage due to a ruptured uterus?

Rupture can occur at the site of a previous cesarean deliv-ery or other surgical procedure involving the uterine wallfrom intrauterine manipulation or trauma or from con-genital malformation (small uterine horn), or it can occurspontaneously. Abnormal labor, operative delivery, andplacenta accreta can lead to rupture. Surgical repair is

required, with the specific approach tailored to recon-struct the uterus, if possible. Care depends on the extentand site of rupture, the patient’s current clinical condi-tion, and her desire for future childbearing. Rupture of aprevious cesarean delivery scar often can be managed byrevision of the edges of the prior incision followed byprimary closure. In addition to the myometrial disrup-tion, consideration must be given to neighboring struc-tures, such as the broad ligament, parametrial vessels,ureters, and bladder. Regardless of the patient’s wishesfor the avoidance of hysterectomy, this procedure maybe necessary in a life-threatening situation.

What is the management approach for aninverted uterus?

Uterine inversion, in which the uterine corpus descendsto, and sometimes through, the uterine cervix, is associ-ated with marked hemorrhage. On bimanual examina-tion, the finding of a firm mass below or near the cervix,coupled with the absence of identification of the uterinecorpus on abdominal examination, suggests inversion. If the inversion occurs before placental separation,detachment or removal of the placenta should not beundertaken; this will lead to additional hemorrhage.Replacement of the uterine corpus involves placing thepalm of the hand against the fundus (now inverted andlowermost at or through the cervix), as if holding a ten-nis ball, with the fingertips exerting upward pressure circumferentially (34). To restore normal anatomy, re-laxation of the uterus may be necessary. Terbutaline,magnesium sulfate, halogenated general anesthetics, andnitroglycerin have been used for uterine relaxation.

Manual replacement with or without uterine relax-ants usually is successful. In the unusual circumstance inwhich it is not, laparotomy is required. Two procedureshave been reported to return the uterine corpus to theabdominal cavity. The Huntington procedure involves

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Table 4. Blood Component Therapy

Product Volume (mL) Contents Effect (per unit)

Packed red cells 240 Red blood cells, Increase hematocrit 3 percentage white blood cells, plasma points, hemoglobin by 1 g/dL

Platelets 50 Platelets, red blood cells, Increase platelet count 5,000–white blood cells, plasma 10,000/mm3 per unit

Fresh frozen plasma 250 Fibrinogen, antithrombin III, Increase fibrinogen by 10 mg/dLfactors V and VIII

Cryoprecipitate 40 Fibrinogen, factors VIII and Increase fibrinogen by 10 mg/dLXIII, von Willebrand factor

Modified from Martin SR, Strong TH Jr. Transfusion of blood components and derivatives in the obstetric intensive carepatient. 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.

progressive upward traction on the inverted corpus usingBabcock or Allis forceps (35). The Haultain procedureinvolves incising the cervical ring posteriorly, allowingfor digital repositioning of the inverted corpus, with sub-sequent repair of the incision (36).

What is the management approach for secondary postpartum hemorrhage?

Secondary hemorrhage occurs in approximately 1% ofpregnancies; often the specific etiology is unknown.Postpartum hemorrhage may be the first indication forvon Willebrand’s disease for many patients and shouldbe considered. The prevalence of von Willebrand’s dis-ease is reported to be 10–20% among adult women withmenorrhagia (37). Hence, testing for bleeding disordersshould be considered among pregnant patients with ahistory of menorrhagia because the risk of delayed orsecondary postpartum hemorrhage is high amongwomen with bleeding disorders (38, 39).

Uterine atony (perhaps secondary to retained prod-ucts of conception) with or without infection contrib-utes to secondary hemorrhage. The extent of bleeding usually is less than that seen with primary postpartumhemorrhage. Ultrasound evaluation can help identifyintrauterine tissue or subinvolution of the placental site.Treatment may include uterotonic agents, antibiotics,and curettage. Often the volume of tissue removed bycurettage is minimal, yet bleeding subsides promptly.Care must be taken in performing the procedure to avoidperforation of the uterus. Concurrent ultrasound assess-ment at the time of curettage can be helpful in prevent-ing this complication. Patients should be counseledabout the possibility of hysterectomy before initiatingany operative procedures.

What is the best approach to managingexcessive blood loss in the postpartum periodonce the patient’s condition is stable?

Regardless of the cause of postpartum hemorrhage, sub-sequent 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) willmaximize red cell production and restoration. Erythro-poietin can hasten red cell production in postpartum ane-mic patients to some extent, but it is not approved by theU.S. Food and Drug Administration for postoperative ane-mia, and it can be costly (40). Postpartum hemorrhage ina subsequent pregnancy occurs in approximately 10% ofpatients (8).

Summary ofRecommendations andConclusionsThe following recommendations and conclusionsare based primarily on consensus and expert opin-ion (Level C):

Uterotonic agents should be the first-line treatmentfor postpartum hemorrhage due to uterine atony.

Management may vary greatly among patients,depending on etiology and available treatmentoptions, and often a multidisciplinary approach isrequired.

When uterotonics fail following vaginal delivery,exploratory laparotomy is the next step.

In the presence of conditions known to be associat-ed with placenta accreta, the obstetric care providermust have a high clinical suspicion and take appro-priate precautions.

Proposed PerformanceMeasureIf hysterectomy is performed for uterine atony, thereshould be documentation of other therapy attempts.

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ability. Br Med Bull 2003;67:1–11. (Level III)

2. Preventing infant death and injury during delivery.Sentinel Event ALERT No. 30. Joint Commission onAccreditation of Healthcare Organizations. Available at:http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_30.htm. Retrieved June 12, 2006. (LevelIII)

3. Chesley LC. Plasma and red cell volumes during pregnan-cy. Am J Obstet Gynecol 1972;112:440–50. (Level III)

4. Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM.Blood volume changes in pregnancy and the puerperium.Am J Obstet Gyencol 1962;84:1271–82. (Level III)

5. Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH.Emergency hysterectomy for obstetric hemorrhage.Obstet Gynecol 1984;64:376–80. (Level III)

6. Dildy GA 3, Paine AR, George NC, Velasco C. Estimatingblood loss: can teaching significantly improve visual esti-mation? Obstet Gynecol 2004;104:601–6. (Level III)

7. Combs CA, Murphy EL, Laros RK Jr. Factors associatedwith postpartum hemorrhage with vaginal birth. ObstetGynecol 1991;77:69–76. (Level II-2)

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1046 ACOG Practice Bulletin Postpartum Hemorrhage OBSTETRICS & GYNECOLOGY

25. Stanco LM, Schrimmer DB, Paul RH, Mishell DR Jr.Emergency peripartum hysterectomy and associated riskfactors. Am J Obstet Gynecol 1993;168:879–83. (LevelII-3)

26. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol1985;66:89–92. (Level III)

27. Silver RM, Landon MB, Rouse DT, Leveno KJ, Song CY,Thom EA, et al. Maternal morbidity associated with mul-tiple repeat cesarean delivery. Obstet Gynecol 2006;107:1226–32. (Level II-2)

28. Zaki ZM, Bahar AM, Ali ME, Albar HA, Gerais MA. Riskfactors and morbidity in patients with placenta previa ac-creta compared to placenta previa non-accreta. ActaObstet Gynecol Scand 1998;77:391–4. (Level II-3)

29. Kirkinen P, Helin-Martikainen HL, Vanninen R, PartanenK. Placenta accreta: imaging by gray-scale and contrast-enhanced color Doppler sonography and magnetic reso-nance imaging. J Clin Ultrasound 1998;26:90–4. (Level III)

30. Petersen LA, Lindner DS, Kleiber CM, Zimmerman MB,Hinton AT, Yankowitz J. Factors that predict low hemat-ocrit levels in the postpartum patient after vaginal deliv-ery. Am J Obstet Gynecol 2002;186:737–4. (Level II-2)

31. Kruskall MS, Leonard S, Klapholz H. Autologous blooddonation during pregnancy: analysis of safety and blooduse. Obstet Gynecol 1987;70:938–41. (Level III)

32. Herbert WN, Owen HG, Collins ML. Autologous bloodstorage in obstetrics. Obstet Gynecol 1988;72:166–70.(Level III)

33. Rebarber A, Lonser R, Jackson S, Copel JA, Sipes S. Thesafety of intraoperative autologous blood collection andautotransfusion during cesarean section. Am J ObstetGynecol 1998;179:715–20. (Level II-2)

34. Johnson AB. A new concept in the replacement of theinverted uterus and a report of nine cases. Am J ObstetGynecol 1949;57:557–62. (Level III)

35. Huntington JL, Irving FC, Kellogg FS. Abdominal reposi-tion in acute inversion of the puerperal uterus. Am JObstet Gynecol 1928;15:34–40. (Level III)

36. Haultain FW. The treatment of chronic uterine inversionby abdominal hysterotomy, with a successful case. BrMed J 1901;2:974–6. (Level III)

37. Demers C, Derzko C, David M, Douglas J. Gynaecolog-ical and obstetric management of women with inheritedbleeding disorders. Society of Obstetricians and Gyne-cologists of Canada. J Obstet Gynaecol Can 2005;27:707–32. (Level III)

38. Kadir RA, Aledort LM. Obstetrical and gynaecologicalbleeding: a common presenting symptom. Clin LabHaematol 2000 Oct;22 suppl 1:12–6; discussion 30–2.(Level III)

39. James AH. Von Willebrand disease. Obstet Gynecol Surv2006;61:136–45. (Level III)

40. Kotto-Kome AC, Calhoun DA, Montenegro R, Sosa R,Maldonado L, Christensen RD. Effect of administeringrecombinant erythropoietin to women with postpartumanemia: a meta-analysis. J Perinatol 2004;24:11–5.(Meta-analysis)

8. Bonnar J. Massive obstetric haemorrhage. Baillieres BestPract Res Clin Obstet Gynaecol 2000;14:1–18. (Level III)

9. Hertzberg BS, Bowie JD. Ultrasound of the postpartumuterus. Prediction of retained placental tissue. J Ultra-sound Med 1991;10:451–6. (Level III)

10. Poe MF. Clot observation test for clinical diagnosis of clot-ting defects. Anesthesiology 1959;20:825–9. (Level III)

11. Bouwmeester FW, Jonkhoff AR, Verheijen RH, van GeijnHP. Successful treatment of life-threatening postpartumhemorrhage with recombinant activated factor VII. ObstetGynecol 2003;101:1174–6. (Level III)

12. Tanchev S, Platikanov V, Karadimov D. Administration ofrecombinant factor VIIa for the management of massivebleeding due to uterine atonia in the post-placental period.Acta Obstet Gynecol Scand 2005;84:402–3. (Level III)

13. Boehlen F, Morales MA, Fontaana P, Ricou B, Irion O, deMoerloose P. Prolonged treatment of massive postpartumhaemorrhage with recombinant factor VIIa: case reportand review of the literature. BJOG 2004;111:284–7.(Level III)

14. Segal S, Shemesh IY, Blumental R, Yoffe B, Laufer N,Mankuta D, et al. The use of recombinant factor VIIa insevere postpartum hemorrhage. Acta Obstet GynecolScand 2004;83:771–2. (Level III)

15. O’Connell KA, Wood JJ, Wise RP, Lozier JN, Braun MM.Thromboembolic adverse events after use of recombinanthuman coagulation factor VIIa. JAMA 2006;295:293–8.(Level III)

16. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloonfor obstetrical bleeding. Int J Gynaecol Obstet 2001;74:139–42. (Level III)

17. Clark AL, Phelan JP, Yeh SY, Bruce SR, Paul RH.Hypogastric artery ligation for obstetric hemorrhage.Obstet Gynecol 1985:66:353–6. (Level III)

18. O’Leary JL, O’Leary JA. Uterine artery ligation in thecontrol of intractable postpartum hemorrhage. Am JObstet Gynecol 1966;94:920–4. (Level III)

19. O’Leary JL, O’Leary JA. Uterine artery ligation for con-trol of postcesarean section hemorrhage. Obstet Gynecol1974;43:849–53. (Level III)

20. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. TheB-Lynch surgical technique for the control of massivepostpartum haemorrhage: an alternative to hysterectomy?Five cases reported. Br J Obstet Gynaecol 1997;104:372–5. (Level III)

21. Allam MS, B-Lynch C. The B-Lynch and other uterinecompression suture techniques. Int J Gynaecol Obstet2005;89:236–41. (Level III)

22. Holtsema H, Nijland R, Huisman A, Dony J, van den BergPP. The B-Lynch technique for postpartum haemorrhage:an option for every gynaecologist. Eur J Obstet GynecolReprod Biol 2004;115:39–42. (Level III)

23. Cho JH, Jun HS, Lee CN. Hemostatic suturing techniquefor uterine bleeding during cesarean delivery. ObstetGynecol 2000;96:129–31. (Level III)

24. Zelop CM, Harlow BL, Frigoletto FD, Safon LE,Saltzman DH. Emergency peripartum hysterectomy. Am J Obstet Gynecol 1993;168:1443–8. (Level II-3)

VOL. 108, NO. 4, OCTOBER 2006 ACOG Practice Bulletin Postpartum Hemorrhage 1047

The MEDLINE database, the Cochrane Library, and theAmerican College of Obstetricians and Gynecologists’ owninternal resources and documents were used to conduct aliterature search to locate relevant articles published be-tween January 1901 and June 2006. The search was re-stricted to articles published in the English language.Priority was given to articles reporting results of originalresearch, although review articles and commentaries alsowere consulted. Abstracts of research presented at sympo-sia and scientific conferences were not considered adequatefor inclusion in this document. Guidelines published by or-ganizations or institutions such as the National Institutes ofHealth and ACOG were reviewed, and additional studieswere located by reviewing bibliographies of identified arti-cles. When reliable research was not available, expert opin-ions from obstetrician–gynecologists were used.

Studies were reviewed and evaluated for quality accordingto the method outlined by the U.S. Preventive Services TaskForce:

I Evidence obtained from at least one properly de-signed randomized controlled trial.

II-1 Evidence obtained from well-designed controlledtrials without randomization.

II-2 Evidence obtained from well-designed cohort orcase–control analytic studies, preferably from morethan one center or research group.

II-3 Evidence obtained from multiple time series with orwithout the intervention. Dramatic results in uncon-trolled experiments also could be regarded as thistype of evidence.

III Opinions of respected authorities, based on clinicalexperience, descriptive studies, or reports of expertcommittees.

Based on the highest level of evidence found in the data,recommendations are provided and graded according to thefollowing categories:

Level A—Recommendations are based on good and consis-tent scientific evidence.

Level B—Recommendations are based on limited or incon-sistent scientific evidence.

Level C—Recommendations are based primarily on con-sensus and expert opinion.

Copyright © October 2006 by the American College of Obstetriciansand Gynecologists. All rights reserved. No part of this publication maybe reproduced, stored in a retrieval system, posted on the Internet, ortransmitted, in any form or by any means, electronic, mechanical, pho-tocopying, recording, or otherwise, without prior written permissionfrom the publisher.

Requests for authorization to make photocopies should be directed toCopyright Clearance Center, 222 Rosewood Drive, Danvers, MA01923, (978) 750-8400.

The American College of Obstetricians and Gynecologists409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

12345/09876

Postpartum hemorrhage. ACOG Practice Bulletin No. 76. AmericanCollege of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–47.

Obstetric Hemorrhage Care Guidelines: Checklist Format version 1.4

Prenatal Assessment & Planning Identify and prepare for patients with special considerations: Placenta Previa/Accreta, Bleeding Disorder, or those who Decline Blood Products Screen and aggressively treat severe anemia: if oral iron fails, initiate IV Iron Sucrose Protocol to reach desired Hgb/Hct, especially for at risk mothers.

Admission Assessment & Planning Ongoing Risk Assessment

Verify Type & Antibody Screen from prenatal record If not available, Order Type & Screen (lab will notify if 2nd clot needed

for confirmation) If prenatal or current antibody screen positive (if not

low level anti-D from Rho-GAM), Type & Crossmatch 2 units PRBCs

All other patients, Send Clot to blood bank

Evaluate for Risk Factors (see below) If medium risk: Order Type & Screen Review Hemorrhage Protocol

If high risk: Order Type & Crossmatch 2 units PRBCs Review Hemorrhage Protocol Notify OB Anesthesia

Identify women who may decline transfusion Notify OB provider for plan of care Early consult with OB anesthesia Review Consent Form

Evaluate for development of additional risk factors in labor: • Prolonged 2nd Stage labor • Prolonged oxytocin use • Active bleeding • Chorioamnionitis • Magnesium sulfate treatment

Increase Risk level (see below) and convert to Type & Screen or Type & Crossmatch

Treat multiple risk factors as High Risk

Admission Hemorrhage Risk Factor Evaluation Low (Clot only) Medium (Type and Screen) High (Type and Crossmatch)

No previous uterine incision Prior cesarean birth(s) or uterine surgery Placenta previa, low lying placenta Singleton pregnancy Multiple gestation Suspected Placenta accreta or percreta ≤4 previous vaginal births >4 previous vaginal births Hematocrit <30 AND other 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 Estimated fetal weight greater than 4 kg Morbid obesity (BMI >35)

STAGE 0: All Births: Prevention & Recognition of OB Hemorrhage

Active Management of Third Stage Oxytocin infusion: 10-20 units oxytocin/1000ml solution titrate infusion rate to uterine tone; or 10 units IM; do not give oxytocin as IV push Vigorous fundal massage for at least 15 seconds

Ongoing Quantitative Evaluation of Blood Loss Using formal methods, such as graduated containers, visual comparisons and weight of blood soaked materials (1gm = 1ml)

Ongoing Evaluation of Vital Signs If: Cumulative Blood Loss >500ml vaginal birth or >1000ml C/S -OR- Vital signs >15% change or HR ≥110, BP ≤85/45, O2 sat <95% -OR-

Increased bleeding during recovery or postpartum, proceed to STAGE 1

California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details Page 1 of 4 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 -OR-

Vital signs >15% change or HR ≥110, BP ≤85/45, O2 sat <95% -OR- Increased bleeding during recovery or postpartum

MOBILIZE ACT THINK Primary nurse, Physician or Midwife to: Activate OB Hemorrhage

Protocol and Checklist Primary nurse to: Notify obstetrician

(in-house and attending) Notify charge nurse Notify anesthesiologist

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

Consider potential etiology: • Uterine atony • Trauma/Laceration • Retained placenta • Amniotic Fluid Embolism • Uterine Inversion • Coagulopathy • Placenta Accreta • Uterine Rupture

Once stabilized: Modified Postpartum management with increased surveillance

If: Continued bleeding or Continued Vital Sign instability, and <1500 mL cumulative blood loss proceed to STAGE 2

UTEROTONIC AGENTS for POSTPARTUM HEMORRHAGE Drug Dose Route Frequency Side Effects Contraindications Storage

Pitocin® (Oxytocin) 10 units/ml

10-40 units per 1000 ml,

rate titrated to uterine tone

IV infusion 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

Methergine® (Methylergonivine)

0.2mg/ml 0.2 mg IM

(not given IV)

-Q 2-4 hours -If no response after first dose, it is unlikely that additional doses will be of benefit

Nausea, vomiting Severe hypertension, esp. with rapid administration or in patients with HTN or PIH

Hypertension, PIH, Heart disease Hypersensitivity to drug Caution if multiple doses of ephedrine have been used, may exaggerate hypertensive response w/possible cerebral hemorrhage

Refrigerate Protect from light

Hemabate® (15-methyl PG F2a)

250mcg/ml 250 mcg

IM or intra-myometrial

(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.

Nausea, vomiting, Diarrhea Fever (transient), Headache Chills, shivering Hypertension Bronchospasm

Caution in women with hepatic disease, asthma, hypertension, active cardiac or pulmonary disease Hypersensitivity to drug

Refrigerate

Cytotec® (Misoprostol)

100 or 200mcg tablets 800-1000mcg Per rectum

(PR) One time Nausea, vomiting, diarrhea Shivering, Fever (transient) Headache

Rare Known allergy to prostaglandin Hypersensitivity to drug

Room temp

California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details Page 2 of 4 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 Primary nurse (or charge nurse): Call obstetrician to bedside Call Anesthesiologist Activate Response Team: PHONE #:________________ Notify Blood bank of

hemorrhage; order products as directed

Charge nurse: Notify Perinatologist or 2nd OB Initiate OB Hemorrhage

Record If selective embolization, call-

in Interventional Radiology Team and second anesthesiologist

Notify nursing supervisor Assign single person to

communicate with blood bank Call medical social worker or

assign other family support person

Team leader (OB physician): Additional uterotonic medication: Hemabate 250 mcg IM [if not

contraindicated] OR Misoprostol 800-1000 mcg PR o Can repeat Hemabate up to 3 times every 20 min;

(note-75% respond to first dose) Do not delay other interventions (see right column) while waiting for

response to medications Bimanual uterine massage Move to OR (if on postpartum unit, move to L&D or OR) Order 2 units PRBCs and bring to the bedside Order labs STAT (CBC/Plts, Chem 12, PT/aPTT, Fibrinogen, ABG) Transfuse PRBCs based on clinical signs and response, do not

wait for lab results Primary nurse:

Establish 2nd large bore IV, at least 18 gauge. Maintain adequate fluid volume with Lactated Ringers and adequate uterine tone with oxytocin infusion

Assess and announce Vital Signs and cumulative blood loss q 5-10 minutes

Set up blood administration set and blood warmer for transfusion Administer meds, blood products and draw labs, as ordered Keep patient warm

Second nurse (or charge nurse): Place Foley with urimeter (if not already done) Obtain portable light and OB procedure tray or Hemorrhage cart Obtain blood products from the Blood Bank Assist with move to OR (if indicated)

Blood Bank: Determine availability of thawed plasma, fresh frozen plasma, and

platelets; initiate delivery of platelets if not present on-site Consider thawing 2 FFP (takes 30 min), use if transfusing >2 units

PRBCs Prepare for possibility of massive hemorrhage

Sequentially advance through procedures and other interventions based on etiology: Vaginal birth If trauma (vaginal, cervical or uterine): • Visualize and repair

If retained placenta: • D&C

If uterine atony or lower uterine segment bleeding: • Intrauterine Balloon

If above measures unproductive: • Selective embolization (Interventional

Radiology if available & adequate experience)

C-section: • Uterine hemostatic suture, e.g.,B-Lynch

Suture, O’Leary, Multiple Squares • Intrauterine Balloon

If Uterine Inversion: • Anesthesia and uterine relaxation drugs

for manual reduction If Amniotic Fluid Embolism:

• Maximally aggressive respiratory, vasopressor and blood product support

If vital signs are worse than estimated or measured blood loss: possible uterine rupture or broad ligament tear with internal bleeding; move to laparotomy Once stabilized: Modified Postpartum management with increased surveillance

Re-Evaluate Bleeding and Vital Signs If cumulative blood loss >1500ml, >2 units PRBCs given, VS unstable or suspicion for DIC,

proceed to STAGE 3 California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details Page 3 of 4 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 ACT THINK 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

Establish team leadership and assign roles Team leader (OB physician + OB anesthesiologist, anesthesiologist

and/or perinatologist and/or intensivist): Order Massive Hemorrhage Pack

(RBCs + FFP + 1 pheresis pack PLTS—see note in right column Move to OR if not already there Repeat CBC/PLTS, Chem 12, PT/aPTT, Fibrinogen, ABG STAT q

30-60 min Anesthesiologist (as indicated):

Arterial blood gases Central hemodynamic monitoring CVP or PA line Arterial line Vasopressor support Intubation

Primary nurse: Announce VS and cumulative measured blood loss q 5-10 minutes Apply upper body warming blanket if feasible Use fluid warmer and/or rapid infuser for fluid & blood product

administration Apply sequential compression stockings to lower extremities Circulate in OR

Second nurse and/or anesthesiologist: Continue to administer meds, blood products and draw labs, as

ordered Third Nurse (or charge nurse): Recorder

• Selective Embolization (IR) • Interventions based on etiology not yet

completed • Prevent hypothermia, Acidemia

Conservative or Definitive Surgery:

• Uterine Artery Ligation • Hysterectomy

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 crossmatch—assuming no sample is in the lab and assuming no antibodies are present) Transfuse O Negative blood if you cannot wait

Best first-line product for blood loss 1 unit = 450ml volume If antibody positive, may take 1-24 hrs. for crossmatch 1 unit=450 ml volume and typically increases Hct by 3%

Fresh Frozen Plasma (FFP) (approx. 35-45 min. to thaw for release)

Highly desired if >2 units PRBCs given, or for prolonged PT, aPTT >1.5x control 1 unit = 180ml volume and typically increases Fibrinogen by 10mg/dL

Platelets (PLTS) Local variation in time to release (may need to come from regional blood bank)

Priority for women with Platelets <50,000 Single-donor Apheresis unit (= 6 units of platelet concentrates) provides 40-50k transient increase in platelets

Cryoprecipitate (CRYO) (approx. 35-45 min. to thaw for release)

Priority for women with Fibrinogen levels <80 10 unit pack typically raises Fibrinogen 80-100mg/dL Best for DIC with low fibrinogen and don’t need volume replacement Caution: 10 units come from 10 different donors, so infection risk is proportionate.

California Maternal Quality Care Collaborative (CMQCC): Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details Page 4 of 4 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

OCTOBER 2012

21

Optimizing Protocols in ObstetricsS E R I E S 2

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.

Blood Loss:

1000-1500 ml

Stage 2

Sequentially

Advance through

Medications &

Procedures

Pre-

Admission

Time of

admission

Identify patients with special consideration:

Placenta previa/accreta, Bleeding disorder, or

those who decline blood products

Follow appropriate workups, planning, preparing of

resources, counseling and notification

Screen All Admissions for hemorrhage risk:

Low Risk, Medium Risk and High Risk

Low Risk: Hold clot

Medium Risk: Type & Screen, Review Hemorrhage Protocol

High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage

Protocol

All women receive active management of 3rd

stage

Oxytocin IV infusion or 10 Units IM

Vigorous fundal massage for 15 seconds minimum

Standard Postpartum

Management

Fundal Massage

Vaginal Birth:

Bimanual Fundal Massage

Retained POC: Dilation and Curettage

Lower segment/Implantation site/Atony: Intrauterine Balloon

Laceration/Hematoma: Packing, Repair as Required

Consider IR (if available & adequate experience)

Cesarean Birth:

Continued Atony: B-Lynch Suture/Intrauterine Balloon

Continued Hemorrhage: Uterine Artery Ligation

To OR (if not there);

Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team

TRANSFUSE AGGRESSIVELY

RBC:FFP:Plts à 6:4:1 or 4:4:1

Increased

Postpartum

Surveillance

Definitive Surgery

Hysterectomy

Conservative Surgery

B-Lynch Suture/Intrauterine Balloon

Uterine Artery Ligation

Hypogastric Ligation (experienced surgeon only)

Consider IR (if available & adequate experience)

Fertility Strongly Desired

Consider ICU

Care; Increased

Postpartum

Surveillance

Verify Type & Screen on prenatal

record;

if positive antibody screen on prenatal

or current labs (except low level anti-D

from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELP

Give Meds: Hemabate 250 mcg IM -or-

Misoprostol 800-1000 mcg PR

Cumulative Blood Loss

>500 ml Vag; >1000 ml CS

>15% Vital Sign change -or-

HR ≥110, BP ≤85/45

O2 Sat <95%, Clinical Sx

Ongoing

Evaluation:

Quantification of

blood loss and

vital signs

Unresponsive Coagulopathy:

After 10 Units PBRCs and full

coagulation factor replacement,

may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:

>1500 ml

Stage 3

Activate

Massive

Hemorrhage

Protocol

Blood Loss:

>500 ml Vaginal

>1000 ml CS

Stage 1Activate

Hemorrhage

Protocol

NO

Stage 0

All Births

Transfuse 2 Units PRBCs per clinical

signs

Do not wait for lab values

Consider thawing 2 Units FFP

YES

YES NO

Ongoin

g C

um

ula

tive B

lood

Lo

ss E

va

luation

Cumulative Blood Loss

>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV rate (LR); Increase Oxytocin

Methergine 0.2 mg IM (if not hypertensive)

Continue Fundal massage; Empty Bladder; Keep Warm

Administer O2 to maintain Sat >95%

Rule out retained POC, laceration or hematoma

Order Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage Protocol

CALL FOR EXTRA HELP

Continued heavy

bleeding

Increased

Postpartum

Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

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

OBSTETRIC HEMORRHAGE CARE SUMMARY: FLOW CHART FORMAT

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

Obstetric Hemorrhage Care Summary: Table Chart Format version 1.4

Assessments Meds/Procedures Blood Bank Stage 0 Every woman in labor/giving birth

Stage 0 focuses on risk assessment and active management of the third stage.

• Assess every woman for risk factors for hemorrhage

• Ongoing quantitative evaluation of blood loss on every birth

Active Management 3rd Stage:

• Oxytocin IV infusion or 10u IM

• Fundal Massage-vigorous, 15 seconds min.

• If Medium Risk:T&Scr • If High Risk: T&C 2 U • If Positive Antibody

Screen (prenatal or current, exclude low level anti-D from RhoGam):T&C 2 U

Stage 1 Blood loss: >500 ml vaginal or >1000 ml Cesarean, or VS changes (by >15% or HR ≥110, BP ≤85/45, O2 sat <95%)

Stage 1 is short: activate hemorrhage protocol, initiate preparations and give Methergine IM.

• Activate OB Hemorrhage Protocol and Checklist

• Notify Charge nurse, Anesthesia Provider

• VS, O2 Sat q5’ • Calculate cumulative

blood loss q5-15’ • Weigh bloody materials • Careful inspection with

good exposure of vaginal walls, cervix, uterine cavity, placenta

• IV Access: at least 18gauge • Increase IV fluid (LR) and

Oxytocin rate, and repeat fundal massage

• Methergine 0.2mg IM (if not hypertensive) May repeat if good response to first dose, BUT otherwise move on to 2nd level uterotonic drug (see below)

• Empty bladder: straight cath or place foley with urimeter

• T&C 2 Units PRBCs (if not already done)

Stage 2 Continued bleeding with total blood loss under 1500ml

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.

OB back to bedside (if not already there) • Extra help: 2nd OB,

Rapid Response Team (per hospital), assign roles • VS & cumulative blood

loss q 5-10 min • Weigh bloody materials • Complete evaluation

of vaginal wall, cervix, placenta, uterine cavity • Send additional labs,

including DIC panel • If in Postpartum: Move

to L&D/OR • Evaluate for special

cases: -Uterine Inversion -Amn. Fluid Embolism

2nd Level Uterotonic Drugs: • Hemabate 250 mcg IM or • Misoprostol 800-1000 mcg

PR 2nd IV Access (at least 18gauge)

Bimanual massage Vaginal Birth: (typical order) • Move to OR • Repair any tears • D&C: r/o retained placenta • Place intrauterine balloon • Selective Embolization

(Interventional Radiology) Cesarean Birth: (still intra-op) (typical order) • Inspect broad lig, posterior

uterus and retained placenta

• B-Lynch Suture • Place intrauterine balloon

• Notify Blood Bank of OB Hemorrhage

• Bring 2 Units PRBCs to bedside, transfuse per clinical signs – do not wait for lab values • Use blood warmer for transfusion • Consider thawing 2 FFP (takes 35+min), use if transfusing >2u PRBCs • Determine availability of additional RBCs and other Coag products

Stage 3 Total blood loss over 1500ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

Stage 3 is focused on the Massive Transfusion protocol and invasive surgical approaches for control of bleeding.

• Mobilize team -Advanced GYN surgeon -2nd Anesthesia Provider -OR staff -Adult Intensivist • Repeat labs including

coags and ABG’s • Central line • Social Worker/ family

support

• Activate Massive Hemorrhage Protocol • Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy • Patient support -Fluid warmer -Upper body warming device -Sequential compression stockings

Transfuse Aggressively Massive Hemorrhage Pack • Near 1:1 PRBC:FFP • 1 PLT pheresis pack per 6units PRBCs

Unresponsive Coagulopathy: After 10 units PRBCs and full coagulation factor replacement: may consider rFactor VIIa

OB HEMORRHAGE TOOLKIT

126

APPENDIX E.3. METHODS FOR DEVELOPING TRAINING AND TOOLS FOR QUANTITATIVE MEASUREMENT OF BLOOD LOSS

Used with kind permission of Bev VanderWal, CNS

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

Quantifying blood loss by measuring (see image below right)

• Use graduated collection containers (C/S and vaginal deliveries) • Account for other fluids (amniotic fluid, urine, irrigation)

Richard Berkowitz, MD, FACOGCo-Chair

Peter Bernstein, MD, MPH, FACOGCo-Chair

Traci Burgess, MD, FACOGElisa Burns, MD, FACOGCynthia Chazotte, MD, FACOGKirsten L. Cleary, MD, FACOGEdward Denious, MD, FACOGDena Goffman, MD, FACOGAmos Grunebaum, MD, FACOGVictor Klein, MD, FACOGDenise Lester, MD, FACOGAbraham Lichtmacher, MD, FACOGSandra McCalla, MD, FACOGPaul Ogburn, MD, FACOGMichael Scalzone, MD, MHCM, FACOGJoseph Sclafani, MD, FACOGHeather Shannon, MS, CNM, NP, MPHAlexander Shilkrut, MD, DO, FACOGToni Stern, MD, MS, FACOG, CPEJohn Vullo, DO, FACOGBrian Wagner, MD, FACOGRichard Waldman, MD, FACOG

Executive CommitteeEva Chalas, MD, FACOG, FACSRonald Uva, MD, FACOGNicholas Kulbida, MD, FACOGCynthia Chazotte, MD, FACOGScott Hayworth, MD, FACOG

ACOG StaffDonna Montalto, MPPKelly Gilchrist

American Congress of Obstetricians & Gynecologists (ACOG), District II152 Washington Ave, Suite 300Albany, New York 12210

Phone: 518-436-3461 • Fax: 518-426-4728E-mail: info@acogny.orgWebsite: www.acogny.org

ACOG District II Patient Safety & Quality Improvement Committee

D I S T R I C T I I