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Postpartum Hemorrhage Case Study Providence Clinical Academy: Obstetrics Curriculum What risk factors for PPH do you see in this case? Choose all that apply. a) Low platelets b) Prolonged second stage of labor c) Use of prolonged oxytocin during the induction d) Epidural anesthesia e) History of preeclampsia f) Operative vaginal delivery 2 Knowledge Check JoAnn, a 25-year-old G1P0, The labor epidural is placed at is 5 cm induced of dilation.with The prolonged physician uses oxytocin at aterm for mild low forceps for prolonged (5 hr) preeclampsia. Her admission second stage and delivers a 9 lb hematocrit is 39% and her baby. After an uneventful delivery platelet count isheavy 190,000/µL. of the placenta, vaginal Systolic bleeding blood ensues.pressure Inspectionranged of the from 154 reveals to 142 no mmHg and placenta missing diastolic blood pressureoffrom cotyledons and inspection the 98 to 88 mmHg prior to lower genital tract reveals no admission during labor. lacerations orand source of bleeding. Palpation of the uterus reveals severe atony. Providence Clinical Academy: Obstetrics 2016.07 What medication should be ordered by physician at this point? Knowledge Check a) Oxytocin IV push b) Methergine 2 mg IM c) Hemabate (carboprost) 0.25 mg IV d) 3 Bimanual massage is initiated by the physician and IV oxytocin is infusing at a rapid rate. There is no immediate improvement in uterine tone. Current vital signs are: BP 130/75 mmHg P 96 bpm. Cytotec (misoprostol) 800 Providence Clinical Academy: Obstetrics 2016.07 Which of the following interventions would not be appropriate for JoAnn at this time? Choose all that apply. a) Vital signs and uterine assessment to q 5 minutes b) Weighing pads to accurately assess blood loss c) Bimanual fundal massage d) STAT laboratory testing such as CBC, PT, PTT, fibrinogen Knowledge Check Cytotec is administered and uterus remains atonic. The EBL is 800 mL during the delivery and another 700 mL. Hemabate is ordered and administered. Current vital signs: BP 119/69 mmHg P 108 bpm e) Order OB Hemorrhage Pack f) Continue to monitor patient status in the room 4 Providence Clinical Academy: Obstetrics 2016.07 Intervention & Management: Algorithm STAGE 1 Cumulative Blood Loss >500ml vag birth or >1000ml C/S OR Increased bleeding during recovery or postpartum 5 STAGE 2 Cumulative blood loss 1500 ml Continued bleeding Pulse >120 Decreased BP STAGE 3 Cumulative blood loss >1500 ml OR Suspicion of DIC Pulse >140 Decreased BP Providence Clinical Academy: Obstetrics 2016.07 Stage 1 Cumulative Blood Loss >500ml vag birth>1000ml C/S OR Increased bleeding during recovery or postpartum 6 Nursing Care: LIP: Establish IV access if not present, at least 18 gauge Methergine 0.2mg IM if not hypertensive Increase Oxytocin and titrate to uterine tone If hypertensive give *Hemabate 250mcg IM or *Misoprostol 800mcg rectally Continue vigorous fundal massage Assess and empty bladder Notify LIP/Charge Nurse Deferential Diagnosis - rule out retained products of conception, laceration, hematoma Administer uterotonics as ordered Vital Signs q 5-10 minutes including O2 sat & level of consciousness Weigh, calculate and record cumulative blood loss Administer oxygen to maintain O2 sats at >95% Type and Screen (if not already done) Keep patient warm Document Surgeon: (if cesarean birth and still open) Inspect for uncontrolled bleeding at all levels, especially, broad ligament, posterior uterus, and retained placenta Providence Clinical Academy: Obstetrics 2016.07 Stage 2 1500 mL cumulative blood loss and continued bleeding Pulse >120, Decreased BP Nursing Care: LIP: Start a 2nd IV and administer IV fluids (LR is preferred) Place Foley with urimeter Continue assessing frequent vital signs and blood loss I&O Maintain communication with charge nurse Assists anesthesia provider Apply Bair Hugger and SCDs Administer medications as ordered Assist Anesthesia as needed Document Anesthesia: 7 Continue uterotonic medications Move to the OR- D/C, tamponade balloon, uterine packing Order OB Hemorrhage Panel Type & Cross for 2 units PRBCs or OB Hemorrhage Pack (if patient bleeding is not responding to treatment and interventions Interventions follow underlying cause for bleeding Laborist Monitor patient vital signs Provide pain relief Begin blood replacement as indicated Providence Clinical Academy: Obstetrics 2016.07 Stage 3 Cumulative blood loss >1500 OR Pulse >140, Decreased BP Nursing Care: Maintains communication with team members Administer medications as ordered Set up cell saver Assists anesthesia as needed Monitor cumulative blood loss and update team Document Draw labs LIP: Order OB Hemorrhage Pack Uterotonics Call for GYN/ONC and/or Adult Intensivist Consider uterine artery ligation, interventional radiology, or hysterectomy Anesthesia: 8 Suspicion of DIC Monitor frequent vital signs and communicate to team Arterial blood gases and repeat OB Hemorrhage Panel Place central line as needed Continue to administer meds and blood products Providence Clinical Academy: Obstetrics 2016.07 APPLY WHAT YOU LEARNED Postpartum Hemorrhage Case Study 9 Providence Clinical Academy: Obstetrics 2016.07 Case Study: Background Information 10 34 y.o. G2 P1001, 39 1/7 weeks Planned, repeat C/S A Neg/ Rubella Pos/ Hepatitis B Neg/ RPR nonreactive Uneventful prenatal course No pertinent medical history 16 g IV placed in left wrist Cefazolin 2 gms IV pre-op Providence Clinical Academy: Obstetrics 2016.07 Case Study: Background Information What would this patient’s risk factors be for PPH? Prior C/S (Trauma) What labs should be drawn pre-op? CBC Type & Screen Admission Hct 36.9 TySc sent 11 Providence Clinical Academy: Obstetrics 2016.07 Case Study 1533 C/S delivery 150 140 130 120 1536 Oxytocin 20 units in 1 L LR BP 116/68 110 100 BP 105/52 90 HR 90 80 70 HR 70 60 1500 12 1600 0 mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed 150 140 130 120 1600 – Admit to recovery room 110 EBL 1200 ml per anesthesia, < 1000 ml per surgeon BP 107/50 100 90 80 HR 76 70 60 1500 13 1600 1000+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 1615- Nursing note “large clot expressed oozing , fundus boggy 150 firmed with massage “ 1630 – Nursing Note “large clots expressed MD called to bedside” 140 130 120 1615-1620 Methergine 200 mcg IM Misoprostol 800 mcg PR HR 105 110 100 BP 100/48 90 80 1645 Return to the OR 70 60 1500 14 1600 1000+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 1700 D&C, EBL noted at 500 ml 1715 Hemabate 250 mcg IM 150 140 130 120 1715 Bakri balloon placed Active bleeding stopped 1730 T&C for 4 units CBC, Coags drawn HR 115 110 100 90 BP 98/50 80 70 60 1500 15 1600 1500+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 150 1745 Bleeding slowed to minimal HR 140 140 Oxytocin 30 units in 500 mL 130 120 110 BP 95/60 100 90 1840 Hct 32.5 Platelets 129 Fibrinogen 205 80 70 60 Cefazolin 2 gm IV 1500 16 1600 1500+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study HR 150 1945 200 mL noted in Bakri Balloon Fundus 3-5 cm above umbilicus Abdomen tender 150 140 1955 OB at bedside U/S done – shows large clot 130 120 2000 Hct 26.9 Platelets 131 Fibrinogen 151 110 100 90 BP 89/45 80 70 2015 Hct 21 per I-Stat 60 1500 17 1600 1700+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 2015 1 unit PRBCs 150 HR 140 2030 Pt transferred to interventional radiology “moderate amount of bleeding continues” 140 2045 Midazolam and Fentanyl for sedation 130 120 110 100 2055 Hemorrhage pack ordered 90 2100 1 unit PRBCs 2130 1 unit PRBCs 80 70 60 2140 Bilateral uterine artery embolization. Hemostatsis achieved. 500 ml blood loss into Bakri Balloon 1500 18 BP 80/39 1600 2200+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study 2200 Transferred to recovery 150 140 HR 125 2200 4-pack FFP 130 120 2225 4-pack FFP 110 100 BP 92/64 90 2245 4-pack FFP 80 2250 Cryoprecipitate 70 60 2300 Cryoprecipitate, and 1 unit PRBCs 1500 19 1600 2200+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Conclusion The patient remained stable in recovery after the uterine artery embolization with scant lochia rubra then transferred to ICU after recovery Labs were the following: 0000 Hct 30.6, WBC 24.9, Platelets 88, Fibrinogen 164 0400 Hct 29.1, WBC 19.1, Platelets 75, Fibrinogen 199 0730 Hct 28.6, WBC 15.9, Platelets 67, Fibrinogen 226 Bakri Balloon removed at noon post-op day #1 with 200 mL blood loss in bag Total EBL = ??? Pt transferred in stable condition to postpartum at 1500 Discharged to home on post-op day #5 20 Providence Clinical Academy: Obstetrics 2016.07 Which of these common mistakes occurred in this case? 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 21 Treating postpartum hemorrhage as a diagnosis and not identifying the cause Underestimation of blood loss Inattention to vital sign trends Delay in intervening surgically if needed Delay in laboratory assessment Delay in instituting blood replacement therapy Delay in moving from “normal delivery” to “life threatening emergency” Poor communication between nurse and OB providers on amount of blood loss, vital signs and other clinical indicators Lack of communication between OB provider and anesthesia who is managing blood loss and replacement therapy Insufficient preoperative preparation for massive hemorrhage (placenta previa, known or suspected accreta) Providence Clinical Academy: Obstetrics 2016.07 Case Study Reflection 22 Underestimation of blood loss- it was difficult to determine cumulative blood loss during this case. The RN should of weighed blood loss and a cumulative total should have been noted. Inattention to vital signs and delay in instituting blood replacement therapy - the patient was tachycardic an hypotensive, blood replaced was delayed until laboratory values reflected the need for blood replacement. Providence Clinical Academy: Obstetrics 2016.07 Case Study: Stage 0 1533 C/S delivery 150 140 130 120 1536 Oxytocin 20 units in 1 L LR BP 116/68 110 100 BP 105/52 90 HR 90 80 70 HR 70 60 1500 23 1600 0 mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 1 1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed 150 140 130 120 1600 – Admit to recovery room 110 EBL 1200 ml per anesthesia, < 1000 ml per surgeon BP 107/50 100 90 80 HR 76 70 60 1500 24 1600 1000+ mL Cumulative Blood Loss 1700 1800 Stage 1: Greater than 1000 mL blood loss with stable vital signs •Exact blood loss unknown as laps have not been weighed •Oxytocin should be increased 1900 2000 2100 2200 Providence Clinical Academy: Obstetrics 2016.07 Case Study: Stage 2 1615- Nursing note “large clot expressed oozing , fundus boggy 150 firmed with massage “ 1630 – Nursing Note “large clots expressed MD called to bedside” 140 130 120 1615-1620 Methergine 200 mcg IM Misoprostol 800 mcg PR HR 105 110 100 BP 100/48 90 80 1645 Return to the OR 70 Stage 2: Less than 1500 mL blood loss & continued bleeding & decreased BP/elevated HR • Need a 2nd IV • OB Hemorrhage labs and at least 2 units of PRBCs should be ordered • Increase Oxytocin rate • Give Hemabate and repeat all Uterotonics per guidelines 60 1500 25 1600 1000+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 3 1700 D&C, EBL noted at 500 ml 1715 Hemabate 250 mcg IM 150 140 130 120 1715 Bakri balloon placed Active bleeding stopped 1730 T&C for 4 units CBC, Coags drawn HR 115 110 100 90 Stage 3: Greater than 1500 mL blood loss • 2nd IV, labs, and PRBCs should have already been ordered • Hemabate may be repeated q 15-90 mins x 8 BP 98/50 80 70 60 1500 26 1600 1500+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 3 150 1745 Bleeding slowed to minimal HR 140 140 Oxytocin 30 units in 500 mL 130 120 Stage 3: Greater than 1500 mL blood loss • Methergine may be repeated q 24 hours x 5 (only given 1x at this point) • Hemabate may be repeated q 1590 mins x 8 (only given x1 at this point) • OB Hemorrhage blood products should be ordered 110 BP 95/60 100 90 1840 Hct 32.5 Platelets 129 Fibrinogen 205 80 70 60 Cefazolin 2 gm IV 1500 27 1600 1500+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 3 HR 150 1945 200 mL noted in Bakri Balloon Fundus 3-5 cm above umbilicus Abdomen tender 150 140 1955 OB at bedside U/S done – shows large clot 130 120 110 100 90 80 70 60 1500 28 2000 Hct 26.9 Platelets 131 Fibrinogen 151 Stage 3: Greater than 1500 mL blood loss • Methergine may be repeated q 2-4 hours x 5 (only given 1x at this point) • Hemabate may be repeated q 15-90 mins x 8 (only given x1 at this point) • OB Panel to be repeated q 30 mins (this was done 1 hour ago at this point) • No blood has yet been transfused at this time (Type & Cross for 4 units ordered at 1730) 1600 1700+ mL Cumulative Blood Loss 1700 1800 1900 BP 89/45 2015 Hct 21 per I-Stat 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 3 2015 1 unit PRBCs 150 HR 140 2030 Pt transferred to interventional radiology “moderate amount of bleeding continues” 140 2045 Midazolam and Fentanyl for sedation 130 120 110 100 90 80 Stage 3: • 1st unit of PRBCs given 3 hours after it was ordered • Still only 1 dose of Hemabate and Methergine given at this time • OB Hem blood products ordered 5 hours after start of Stage 3 2055 Hemorrhage pack ordered 2100 1 unit PRBCs 2130 1 unit PRBCs 70 60 2140 Bilateral uterine artery embolization. Hemostatsis achieved. 500 ml blood loss into Bakri Balloon 1500 29 BP 80/39 1600 2200+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 Case Study: Stage 3 150 140 130 120 2200 Transferred to recovery Stage 3: • Still no other uterotonics administered • No labs since 2015 •OB Hem Panel to be done q 30 mins in PPH HR 125 2200 4-pack FFP 2225 4-pack FFP 110 100 BP 92/64 90 2245 4-pack FFP 80 2250 Cryoprecipitate 70 60 2300 Cryoprecipitate, and 1 unit PRBCs 1500 30 1600 2200+ mL Cumulative Blood Loss 1700 1800 1900 2000 2100 Providence Clinical Academy: Obstetrics 2200 2016.07 What are the possible physiologic reasons for Sarah’s current condition? (choose all that apply) a) Knowledge Check After C/S delivery Sarah is transferred to the OB/PACU. Nausea due to ice chips b) Tachycardia related to pain, repositioning, and movement during transfer from OB/PACU to postpartum c) Possible internal bleeding The 2nd PP check reveals: BP 99/50 Pulse 126 RR 20 Temp 98.2° F (oral) The abdominal dressing is C, D, & I FF @ 2 cm below Abdomen palpates slightly distended Patient complains of slight nausea. 31 Providence Clinical Academy: Obstetrics 2016.07 Nursing interventions should include all of the following EXCEPT? a) Request a bedside assessment by the charge nurse b) Request a bedside assessment by the physician c) Request an order to type and crossmatch the patient Knowledge Check At the next assessment: Sarah’s fundus is difficult to palpate. Abd dressing C, D, & I d) Administer additional antiemetics e) Bolus with IV fluids BP 88/50 mmHg Prepare to start second IV line for access After administration of an antiemetic, Sarah starts vomiting and her skin is clammy to touch. She says she feels weak and cold. f) 32 Lochia is scant. Pulse is 130 bpm. Providence Clinical Academy: Obstetrics 2016.07 What should be the next management plan? (choose all that apply) a) Notify anesthesia and immediately transfer to OR Knowledge Check b) Continue to monitor, blood pressure, and pulse oximetry monitors Sarah's physician is at the bedside. BP 85/30 mmHg c) Run IV of LR wide open to increase her fluid volume d) Administer 2 units of blood emergently without verification There is no new urine output e) Order OB Hemorrhage labs ABD dressing is C,D, & I. f) Apply oxygen via non-rebreather face mask The abdomen is distended and the uterus cannot be palpated. P 140 bpm Lochia is scant. Sarah now rates her pain at 7. 33 Providence Clinical Academy: Obstetrics 2016.07 What transfusion orders should be given at this time? (choose all that apply) a) Transfuse 4 units of PRBC now and anticipate an order for 2 additional units b) Transfuse 1 unit of PRBC pending lab results c) Thaw fresh frozen plasma and give as soon as available d) Give 1 unit of pooled platelets e) Give recombinant factor VIIa Knowledge Check When the surgery starts, the obstetrician finds Sarah’s abdomen full of blood. The LIP found the left uterine artery is lacerated. The bleeding is controlled with additional suturing. After suctioning, the canister contains 1500 mL of blood. Capillary oozing is visible. The lab results will be available in 5 minutes. BP 80/42 mmHg Pulse is 140 bpm. 34 Providence Clinical Academy: Obstetrics 2016.07 Further management of this patient should include? (choose all that apply) Knowledge Check Anticipate that more blood and blood products will be ordered and administered Sarah’s active bleeding has subsided and there is only slight capillary oozing after the laparotomy. b) Apply warming unit to the patient (warming blankets such as Bear Hugger®) Initial PACU lab values include: Hct 20% Fibrinogen 60 mg/dL Platelets 55,000/µL c) Strict input and output records Core temp 96.2°F BP 104/58 mmHg Pulse 112 bpm. d) Follow PACU protocol a) 35 Providence Clinical Academy: Obstetrics 2016.07
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