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Obstetric Hemorrhage:
Event Planning and Training
Developed by
HealthEast and
Memorial Blood Centers
Funding provided by: Foundation for America’s Blood Centers
Principal Author: Jed B. Gorlin MD, MBA
Training Goals
• Discuss clinical importance of issue
• Explain the 4 R’s: Readiness, Recognition,
Response, Reporting
• Describe tools for response to hemorrhage
• Discuss hemorrhage care guidelines
• Discussion facilitated by video segments
• Awareness of additional resources and materials
Content Areas-Emergent Tx
• Emergency/Massive Transfusion
– Communication: SBAR
• Situation, Background, Assessment, Recommendation
– Assessing adequacy of preparedness
– Eliminating roadblocks
– Medical Emergency transfusion concepts:
• Emergent release of uncrossmatched blood
– O negative vs. type specific
• Massive transfusion issues
Malpractice lawsuit nets $4.6 million
A woman bled to death after giving birth at a hospital in Wright
• The family of a woman who
MNto death after delivering
her first child was awarded $4.6 million.
• C. C. began hemorrhaging and died hours after her son
was born on Jan. 18, 2008. Her doctors were unable to
perform surgery because the hospital failed to provide
blood for transfusion in time, even though it was "sitting
right in their refrigerator," an attorney for C.'s family
• (The patient was A- and identical type blood was
requested. Because the only Rh negative blood the small
hospital stocked was O-, the physician
tried to have her
Doctor’s Company Review
Closed Claim Review of Maternal Deaths from
• DENIAL: “Catch up” phenomenon: Initial manifestations of
hemorrhage were VS changes (hypotension and/or
tachycardia) NOT frank vaginal bleeding.
• DELAY: in delivery of products from the blood bank to the
labor and delivery operating room.
• DELAY: of administration to patient once products arrived at
• DELAY: Mobilization of equipment.
• DELAY: Waiting for cross-matched blood instead of utilizing O
negative or type specific blood.
• “Underutilization”-- DELAY in administering additional
amounts and types of blood products (i.e. FFP, platelets, and
Doctor’s Company Review
Among Team Members…
For example:
• Obstetrician and anesthesiologist regarding efficacy of
intervention(s) and need to escalate care or change
• Operating room and blood bank concerning urgency of
• Among support personnel concerning delivery of
products and location of specialized equipment (i.e.,
rapid infusion devices or specialized kits).
SOURCE: Doctors Company Reviews Maternal Arrests Cases
(Reprinted with permission from The Doctors Company); APSF
NEWSLETTER Summer 2007; page 28; Ann Lofsky, MD.
SOURCE: Taking stock of
decade report,
• Postpartum hemorrhage (PPH) is responsible for
35% of maternal mortality worldwide (WHO, 2007),
reaching as high as 60% in developing countries
• PPH can also be a cause of long-term severe
morbidity, and approximately 12% of women who
survive PPH will have severe anemia
(Abou-Zahr, 2003; WHO, 2006)
• Additionally, women who have severe PPH and
survive (“near misses”) are significantly more likely
to die in the year following the PPH
(Impact International, 2007)
Causes and Risk Factors
• More than one of these can cause postpartum
hemorrhage in any given woman:
– Uterine atony (failure of the uterus to contract properly after
– Trauma (cervical, vaginal, or perineal lacerations)
– Retained or adherent placental tissue
– Clotting disorders
– Inverted or ruptured uterus
• Two-thirds of women who have PPH have no risk
factors recognizable before delivery (Jhpiego, 2001)
UK SHOT Program
(Serious Hazards of Transfusion)
• UK National program for transfusion-related adverse events
• More death and morbidity was attributed to lack of or
miscommunication during transfusion emergencies than
adverse effects of transfused blood components
– During the period October 2006 to September 2010, the National
Patient Safety Agency (NPSA) received reports of 11 deaths and 83
incidents in which a patient was harmed as a result of delays in the
provision of blood in an acute situation.
• Awareness of this problem prompted a review and Rapid
Response Report (RRR)
• This Rapid Response Report (RRR) focuses attention of
hospitals on the systems and human factors that impact
provision of blood in emergencies.
Reducing the risk of harm
Local organizations should ensure that:
• The hospital transfusion committee reviews local
protocols and practices for requesting and obtaining
blood in an emergency (including out of hours), ensuring
that they include all actions required by clinical teams,
laboratories and support services, e.g. portering and
transport staff/drivers and any specific actions for sites
without an on-site transfusion lab.
• Local protocols enable the release of blood and blood
components without the initial approval of a hematologist
although they should be advised of the situation at the
earliest opportunity.
• Active management of the third stage of labor
(AMSTL): intramuscular administration of 10 IU of
oxytocin, controlled cord traction (CCT) and fundal
massage after delivery of the placenta
• In the absence of a skilled birth attendant who can
provide all of the components of AMTSL, oxytocin
(10 IU) or misoprostol (400-600 mcg orally) should
be given by a health worker trained in its use to
prevent PPH.
Prevention (con’t)
Other preventive measures may increase survival or avoid PPH
• During labor:
– Monitor and guide management of labor and quickly detect unsatisfactory
progress, encourage bladder emptying, limit induction or augmentation use
for medical and obstetric reasons, do not encourage pushing before the
cervix is fully dilated, perform selective episiotomy for medical/obstetric
reasons only, control delivery of the baby’s head and shoulders to help
prevent tears.
During third stage of labor:
– Provide active management of the third stage of labor (AMTSL) do not
massage the uterus prior to delivery of the placenta, do not use fundal
pressure to assist the delivery of the placenta, do not perform controlled cord
traction (CCT) without administering a uterotonic drug, or without providing
countertraction to support the uterus.
After delivery of the placenta:
– Routine inspections to identify genital lacerations, assess the placenta and
membranes for completeness, evaluate and, if necessary, massage the
uterus at regular intervals after placental delivery (at least every 15 minutes
for the first two hours after birth), monitor for vaginal bleeding and uterine
hardness every 15 minutes for at least the first two hours
Reducing the risk of harm
Local organizations should ensure that:
• All clinical, laboratory and support staff know how to
access the massive blood loss protocol and are familiar
with it
– Supported by training and regular drills
• The blood transfusion laboratory staff are informed of
patients with a massive hemorrhage at the earliest
• Clinical teams dealing with patients with massive
hemorrhage nominate a specific member of the team to
coordinate communication with the laboratory and
support services staff for the duration of the incident
Example of
Specific MTP
Massive Transfusion Protocol
March 2010, Massive OB
Hemorrhage Presentation
by: Wendy MacLeod and Kallie
An Update on Rural Obstetric
Anesthesia held on June 15,
2011 in Kelowna, BC
Reducing the risk of harm (con’t)
Local organizations should ensure that:
• There is a clear and well understood trigger phrase to activate
the massive blood loss protocol, including location
– E.g. “I want to trigger the massive blood loss protocol in the delivery
• All subsequent communications should include a trigger phrase
– E.g. “This call relates to the massive blood loss protocol in the delivery
• All incidents where there are delays or problems in the provision of
blood in an emergency are reported and investigated locally, and
reported to the NPSA and the Serious Hazards of Transfusion
(SHOT) scheme (
• Each event triggering the massive blood loss protocol is recorded
and reviewed by the hospital transfusion committee to ensure local
protocols are applied appropriately and effectively
Diagnostic aid for assessment
of excessive OB hemorrhage
Obstetric Hemorrhage:
New Strategies,
New Protocol
This project was supported by Title V
funds received from the California
Department of Public Health; Maternal,
Child and Adolescent Health Division
California Pregnancy-related Mortality Review
Composite Case Example: 24yo G2 P1 at 38 wks
gestations induced for “tired of being pregnant”:
After 8hr active phase and 2 hr 2nd stage, had a NSVD of an 8lb 6oz infant.
After placental delivery, she had an episode of atony that firmed with massage. A second
episode responded to IM methergine and the physician went home (now 1am).
The nurses called the physician 30 min later to report more bleeding and further
methergine was ordered.
60min after the call, the physician performed a D&C with minimal return of tissue. More
methergine was given.
45 min later a second D&C was performed, again with minimal returns. EBL now >2,000
Delays in blood transfusion because of inability to find proper tubing.
Anesthesia is delayed, but a second IV started for more crystaloid. VS now markedly
abnormal, P=144, BP 80/30.
One further methergine given and patient taken for a 3 rd D&C. Now has gotten 2u PRBCs
After D&C is complete, she had a cardiac arrest from hypovolemia /hypoxia and was taken
to the ICU when she succumbed 3 hours later.
California Pregnancy-related Mortality Review
QI Opportunities and Learning Points from the
above composite case: How to reduce Mortality
and Morbidity from OB Hemorrhage?
Need a medical indication for induction
No documentation of actual blood loss, e.g., what does “more bleeding”
Only a few treatments tried, e.g., Methergine and D&C, and repeated
even when they were ineffective
Underestimation of blood loss
Delay in administration of blood
Lack of working equipment
Delay in response from other team members
Delays in adequate resuscitation
Lack of an organized approach
Summary: Key Survey Findings
• 40% of hospitals DO NOT have a hemorrhage protocol
• Inconsistent definitions
• 70% of hospitals DO NOT perform drills (MDs are not
regularly participating in drills)
• Most have access to all 4 uterotonics (More specific data
will be released after complete analysis)
• Many hospitals report they do not have access to
alternative treatment methods, e.g., Balloons
(More specific data will be released after complete
Quality Improvement Opportunities
for OB Hemorrhage
Reduce risks of hemorrhage
Perform admission risk assessments
Reduce Denial, Delay…
Quantify blood loss
Follow a step-by-step plan
Increase use of non-pharmacologic treatments
Improve treatments with blood products
– “Too little, too late”—Resuscitation v. Treatment
– “Old wine in new bottles”—“Whole blood” v. PRBCs
• Enhance Teamwork and Communications!
Four Major Recommendations for
California Birth Facilities:
• Improve readiness to hemorrhage by
implementing standardized protocols (general and
• Improve recognition of OB hemorrhage by
performing on-going objective quantification of
actual blood loss during and after all births.
• Improve response to hemorrhage by performing
regular on-site multi-professional hemorrhage
• Improve reporting of OB hemorrhage by
standardizing definitions and consistency in coding
and reporting.
What’s New?
Quantification of blood loss (QBL) for all births
Active management of the 3rd stage for all
Vital sign triggers
“Move along” on uterotonic medications
Bakri intrauterine balloon / B-Lynch suture
A rational approach to blood components
The value of a formal protocol
With kind permission of Bev VanderWal, CNS
Methods to Estimate Blood Loss
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.
Formally measure blood loss by weighing blood
soaked pads, chux
Formally measure blood loss by collecting blood in
graduated measurement containers
Methods to Estimate Blood Loss
Quantifying blood loss by weighing
• Establish dry
weights of
common items
• Standardize
use of pads
• Build weighing
of pads into
routine practice
• Develop
worksheet for
With kind permission of Bev VanderWal, CNS
Methods to Estimate Blood Loss
Quantifying blood loss by measuring
• Use graduated
collection containers
(C/S and vaginal
• Account for other
fluids (amniotic fluid,
urine, irrigation)
With kind permission of Bev VanderWal, CNS
Methods to Estimate Blood Loss
Develop Training Tools:
Visual aids
displayed in Labor
& Delivery and/or
Postpartum areas
are guides for
more accurate
visual estimation
(visual aids can be
discreetly for
With kind permission of Bev VanderWal, CNS
• Teach clot size using posters showing known blood quantities
on common materials or compared to common volumes (e.g.,
a Coke can=350ml)
• Weigh wet materials (with known dry weight); this can be
done by gathering a group of pads and weighing them all
• Measure what can be suctioned at CS (less irrigation+AF)
• Use calibrated under-buttock drapes (at vaginal birth, note the
volume of amniotic fluid, urine and stool after birth but before
the placenta)
• What we don’t know: How to estimate the blood loss that
we don’t see…
(i.e., intra- abdominal)
• Many centers will customize their approach to
quantification using a combination of approaches for
different settings
Vaginal deliveries
Cesarean sections
Minimal loss
Greater than usual loss
Massive loss
• The process is intentional—a formal effort!
– No more vague “Guesstimates”
– Continues and is cumulative
Who should determine QBL?
• Anesthesia is at the head of the table and often does not
see it all
• OB’s aren’t looking at the suction bottles or at the
collective sponges
• No one is doing it in a standardized manner—we
obstetricians need help! Collaboratively!
• We should be able to answer:
How much blood is in the suction bottle (after amniotic fluid)?
How much blood is on sponges?
How much blood is on the floor/on the table?
In a big case, hourly and cumulatively
Active management of the third
stage of labour
• Active management of the third stage of labour consists
of interventions designed to facilitate the delivery of the
placenta by increasing uterine contractions and to
prevent PPH by averting uterine atony. The usual
components include:
– Administration of uterotonic agents
– Controlled cord traction
– Uterine massage after delivery of the placenta, as appropriate.
SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum
Haemorrhage, International Confederation of Midwives (ICM), International Federation of
Gynaecologists and Obstetricians (FIGO)
Meta Analysis of Active vs. Expectant 3rd
Stage Management at vaginal birth:
Outcome of postpartum EBL ≥ 500 ml
62% fewer PPH in Active Management
group versus Expectant Management
SOURCE: Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management
in the third stage of labour. Cochrane Database Syst Rev 2000; 3: CD000007
Every attendant at birth needs to have the knowledge,
skills and critical judgment to carry out active
management of the third stage of labour and access to
needed supplies and equipment.
In this regard, national professional associations have an important and
collaborative role to play in:
Advocacy for skilled care at birth;
Public education about the need for adequate prevention and treatment
of post-partum haemorrhage;
Address legislative and other barriers that impede the prevention and
treatment of post-partum haemorrhage;
Incorporation of active management of the third stage of labour in
national standards and clinical guidelines, as appropriate;
Incorporation of active management of the third stage into pre-service
and in-service curricula for all skilled birth attendants;
Working with national pharmaceutical regulatory agencies,
policymakers and donors to assure that adequate supplies of
uterotonics and injection equipment are available.
SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International
Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO)
Within one minute of the delivery of the baby, palpate the abdomen to rule out the
presence of an additional baby(s) and give:
• Oxytocin 10 units IM. Oxytocin is preferred over other uterotonic drugs because it
is effective 2-3 minutes after injection, has minimal side effects and can be used
in all women.
• If oxytocin is not available, other uterotonics can be used such as: ergometrine
0.2 mg IM, syntometrine (1 ampoule) IM or
• Misoprostol 400-600 mcg orally. Oral administration of misoprostol should be
reserved for situations when safe administration and/or appropriate storage
conditions for injectable oxytocin and ergot alkaloids are not possible.
• Uterotonics require proper storage:
Ergometrine: 2-8°C and protect from light and from freezing.
Misoprostol: room temperature, in a closed container.
Oxytocin: 15-30°C, protect from freezing
Counseling on the side effects of these drugs should be given.
Warning! Do not give ergometrine or syntometrine (because it contains
ergometrine) to women with pre-eclampsia, eclampsia or high blood
SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage,
International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO)
Clamp the cord close to the perineum (once pulsation stops in a healthy newborn) and hold in one
Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying
counter-pressure during controlled cord traction.
Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes).
With the strong uterine contraction, encourage the mother to push and very gently pull downward
on the cord to deliver the placenta. Continue to apply counter-pressure to the uterus.
If the placenta does not descend during 30-40 seconds of controlled cord traction do not continue
to pull on the cord:
Gently hold the cord and wait until the uterus is well contracted again;
With the next contraction, repeat controlled cord traction with counter-pressure.
Never apply cord traction (pull) without applying counter traction (push) above the pubic
bone on a well-contracted uterus.
As the placenta delivers, hold the placenta in two hands and gently turn it until the membranes are
twisted. Slowly pull to complete the delivery.
If the membranes tear, gently examine the upper vagina and cervix wearing sterile/disinfected
gloves and use a sponge forceps to remove any pieces of membrane that are present.
Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface
is missing or there are torn membranes with vessels, suspect retained placenta fragments and
take appropriate action (ref Managing Complications in Pregnancy and Childbirth).
SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage,
International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians
• Immediately massage the fundus of the
uterus until the uterus is contracted.
– Palpate for a contracted uterus every 15
minutes and repeat uterine massage as
needed during the first 2 hours.
– Ensure that the uterus does not become
relaxed (soft) after you stop uterine massage.
SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage,
International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians
Vital Signs are Often Ignored
Concept of “Triggers”
• Triggers identify patients that need more
attention (from on-call physician, in-house
physician, or rapid response team (RRT))
• Prevent such patients from being ignored
• Independent of diagnosis, useful for all OB
• Used in many areas of hospital medicine
• Do not wait for lab results before acting
Trigger Tool
graphical display
of vital signs:
“Contact doctor if
one red or two
With kind permission of Fiona McIlveney, PhD