maternal hemorrhage risk assessment presentation
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8/9/2019 Maternal Hemorrhage Risk Assessment Presentation
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MATERNALMATERNALHEMORRHAGEHEMORRHAGE
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Prevention of MaternalPrevention of Maternal
DeathDeath High Rate of Maternal Death due to hemorrhageHigh Rate of Maternal Death due to hemorrhage
Most women who died of hemorrhage (97%) wereMost women who died of hemorrhage (97%) werehospitalized at the time of their deathhospitalized at the time of their death
To reduce the risk of death the ACOG/DOHTo reduce the risk of death the ACOG/DOH
recommends:recommends: Effective guidelines for maternal hemorrhageEffective guidelines for maternal hemorrhage
Prompt recognition and response to hemorrhagePrompt recognition and response to hemorrhage
DO NOT DELAY TRANSFUSION WHILEDO NOT DELAY TRANSFUSION WHILEAWAITING LAB RESULTS OR HEMODYNAMICAWAITING LAB RESULTS OR HEMODYNAMIC
INSTABILITYINSTABILITY
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Prevention of Maternal DeathPrevention of Maternal Death
RecommendationsRecommendations
Effective guidelines to respond,Effective guidelines to respond,including emergency transfusion, withincluding emergency transfusion, with
coordination among obstetricians,coordination among obstetricians,nurses, anesthesia and Blood Banknurses, anesthesia and Blood Bank
Be vigilant to blood loss, if clinicalBe vigilant to blood loss, if clinicaljudgment indicates transfusion,judgment indicates transfusion, do notdo not
delay awaiting lab resultsdelay awaiting lab results, slow blood, slow bloodloss can be life threateningloss can be life threatening
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Prevention of Maternal DeathPrevention of Maternal Death
RecommendationsRecommendations
Use fluid resuscitation and transfusion basedUse fluid resuscitation and transfusion based
on estimated blood loss and expectation ofon estimated blood loss and expectation of
continued bleedingcontinued bleeding
Work with Labor and Delivery on MaternalWork with Labor and Delivery on Maternal
Hemorrhage DrillsHemorrhage Drills
Conduct Continuing Medical Education for theConduct Continuing Medical Education for the
entire medical teamentire medical team
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Informed ConsentInformed Consent
Identify patients who express concernsIdentify patients who express concernsabout receiving blood products for anyabout receiving blood products for anyreason (i.e Jehovah Witness)reason (i.e Jehovah Witness)
Ensure that the patient has adequateEnsure that the patient has adequateopportunity to speak to an obstetrician andopportunity to speak to an obstetrician andan anesthesiologist regarding her concernsan anesthesiologist regarding her concernsand the risks/benefitsand the risks/benefits
Ensure that the Consent/Refusal to BloodEnsure that the Consent/Refusal to BloodProducts form is signedProducts form is signed
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Risk AssessmentRisk Assessment
for Hemorrhagefor Hemorrhage
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Low RiskLow Risk
First or early second trimester D&CFirst or early second trimester D&Cwithout history of bleeding (scheduled)without history of bleeding (scheduled)
CerclageCerclage
Vaginal BirthVaginal Birth No previous uterine incisionNo previous uterine incision
No history of bleeding problemsNo history of bleeding problems
No history of PP hemorrhageNo history of PP hemorrhage
Four or less previous vaginal birthsFour or less previous vaginal births
Singleton pregnancySingleton pregnancy
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Low RiskLow Risk
Send Hold specimen to the Blood BankSend Hold specimen to the Blood Bank
If patients status changes, notify bloodIf patients status changes, notify blood
bank to perform type and screen and/orbank to perform type and screen and/or
type and cross matchtype and cross match Examples include need for c/section, PPExamples include need for c/section, PP
hemorrhage, chorioamnionitis, prolongedhemorrhage, chorioamnionitis, prolonged
labor and exposure to oxytocinlabor and exposure to oxytocin
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Moderate RiskModerate Risk
VBACVBAC
Cesarean sectionsCesarean sections
Multiple gestations or macrosomiaMultiple gestations or macrosomia
History of prior post partum hemorrhageHistory of prior post partum hemorrhage
Uterine fibroidsUterine fibroids
Mid to late second trimester D&Es orMid to late second trimester D&Es or
induced vaginal birthsinduced vaginal births Other increased risks as designated byOther increased risks as designated by
physicianphysician
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Moderate RiskModerate Risk
Type and screen to Blood BankType and screen to Blood Bank
CBC with plateletsCBC with platelets
Additional labs as per OBAdditional labs as per OB Consider cell saver for JehovahConsider cell saver for Jehovah
Witness or any other patient whoWitness or any other patient who
refuses blood productsrefuses blood products
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High RiskHigh Risk
Placenta previaPlacenta previa
Suspected placenta accretaSuspected placenta accreta
Hematocrit less than 26Hematocrit less than 26 Vaginal bleeding on admissionVaginal bleeding on admission
Coagulation defectsCoagulation defects
Other high risks as designated by theOther high risks as designated by thephysicianphysician
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High RiskHigh Risk
Type and screen and cross match for 4 unitsType and screen and cross match for 4 units
CBC, PT, PTT, FibrinogenCBC, PT, PTT, Fibrinogen
Second large bore IVSecond large bore IV
Anesthesia to prepare Hot LineAnesthesia to prepare Hot Line Cell saver team on stand-byCell saver team on stand-by
1-800-235-57281-800-235-5728
(****especially for Jehovahs Witness****)(****especially for Jehovahs Witness****)
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MATERNAL BLOOD VOLUMEMATERNAL BLOOD VOLUME
Non pregnant femaleNon pregnant female
3600 ml3600 ml
Pregnant female (near term)Pregnant female (near term) 54005400
mlml
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DEGREES OF BLOOD LOSSDEGREES OF BLOOD LOSS
VolumeEstimate
Percent Type
500 ml or > 10-15% compensated
1000-1500 ml 15-25% mild
1500-2000 ml 25-35% moderate
2000-3000 ml 35-50% severe
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Caveats for the PregnantCaveats for the Pregnant
PatientPatient If the Obstetric Staff is consideringIf the Obstetric Staff is considering
transfusing a pregnant patient anesthesiatransfusing a pregnant patient anesthesiashould be notifiedshould be notified
Blood loss is almost alwaysBlood loss is almost always underestimatedunderestimated(especially after vaginal birth)(especially after vaginal birth) Pregnant patients can lose up to 40% ofPregnant patients can lose up to 40% of
their blood volume (compared to 25% intheir blood volume (compared to 25% in
non-pregnant patients) before showingnon-pregnant patients) before showingsigns of hemodynamic instabilitysigns of hemodynamic instability
Dont wait for hypotension to startDont wait for hypotension to startreplacing volumereplacing volume
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Causes of PP HemorrhageCauses of PP Hemorrhage
Uterine AtonyUterine Atony
Lacerations to the cervix and genitalLacerations to the cervix and genital
tracttract
Retained placenta and otherRetained placenta and other
placental abnormalitiesplacental abnormalities
Coagulation disordersCoagulation disorders
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Risk Factors for UterineRisk Factors for Uterine
AtonyAtony Multiple gestationMultiple gestation MacrosomiaMacrosomia PolyhydramniosPolyhydramnios
High ParityHigh Parity Prolonged labor especially if augmentedProlonged labor especially if augmentedwith oxytocinwith oxytocin
Precipitous laborPrecipitous labor
ChorioamnionitisChorioamnionitis Use of tocolytic agentsUse of tocolytic agents Abnormal placentationAbnormal placentation
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Trauma to the Genital TractTrauma to the Genital Tract
Large episiotomy, including
extensions
Lacerations of perineum, vagina orcervix
Ruptured uterus
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Placental AbnormalitiesPlacental Abnormalities
Retained placentaRetained placenta
Abnormal placentationAbnormal placentation
AccretaAccreta
PercretaPercreta
IncretaIncreta
PreviaPrevia
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Coagulation AbnormalitiesCoagulation Abnormalities
DIC (may result from excessive blood loss)
Thrombocytopenia
abruption
ITP
TTP
Pre-eclampsia including HELLP Syndrome
Anticardiolipin/Antiphospholipid Syndrome
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IDENTIFICATION ANDIDENTIFICATION AND
EVALUATIONEVALUATION
Assessment:Assessment:
Mental StatusMental Status
Vital Signs including BP, Pulse and OVital Signs including BP, Pulse and O22
saturationsaturation
Intake: Blood Products and FluidsIntake: Blood Products and Fluids
Output: Urine and Blood LossOutput: Urine and Blood Loss
Hemoglobin and HematocritHemoglobin and Hematocrit Assess uterine tone and vaginal bleedingAssess uterine tone and vaginal bleeding
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Identify Team LeadersIdentify Team Leaders
(MD/RN)(MD/RN)
Call Code Noelle
MFM on-call
AnesthesiaAttending
Blood BankDirector
Antepartum Back-
up (if MFM isprimary OB)
L&D NurseManager
ADN
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MANAGEMENTMANAGEMENT
Non-surgicalNon-surgical
IDENTIFY CAUSE OF BLEEDING
Examine :
Uterus to r/o atony
Uterus to r/o ruptureVagina to r/o laceration
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MANAGEMENTMANAGEMENT
Non-surgicalNon-surgical ManagementManagement
Atony:Atony: Firm Bimanual Compression
Order
Oxytocin infusion
15-methyl prostaglandin F2alpha IM
Second line:
(methergine (if BP normal), PGE1, PGE2)
MANAGEMENT: NonMANAGEMENT: Non
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MANAGEMENT: Non-MANAGEMENT: Non-
surgicalsurgical
Hypovolemic ShockHypovolemic Shock Management: Secure 2 large bore IVs, consider a central venous catheter
Insert indwelling foley catheter
Order:
LR at desired infusion rate Second line NS with Y-Type infusion set
Two units of PRBCs for stat infusion
Cross match 4 additional units of PRBCs
Thaw 4 units of FFP
Supplemental O2 at 8-10 L Non re-breather mask
MANAGEMENT: NonMANAGEMENT: Non
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MANAGEMENT: Non-MANAGEMENT: Non-
surgicalsurgical
NursingNursing Registered Nurses: Administer O2 at 8-10 L face mask
Cardiorespiratory, BP and SAO2 monitors
Secure 2 Large bore IVs
Pick up orders as written
Administer warmed IV Fluids
Administer Blood Products
Insert indwelling foley catheter
Trendelenberg position
Administer medications
MANAGEMENT: NonMANAGEMENT: Non
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MANAGEMENT: Non-MANAGEMENT: Non-
surgicalsurgical
NursingNursing Nursing Station Clerks:
Enter Lab and Blood Bank Orders
Page all members of MaternalHemorrhage team
Await addition instructions for: Cell Saver Team
Gyn-Oncology Surgeon
MANAGEMENT: NonMANAGEMENT: Non
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MANAGEMENT: Non-MANAGEMENT: Non-
surgicalsurgical
NursingNursing Clinical Assistants: Assists RN/MD as needed
Prep OR; including gyn long,
hysterectomy and/or gyn surgery trays
Pick up blood products from Blood Bank
Obtain Blood/Fluid Warmer
Obtain Cell Saver Equipment from OR
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MANAGEMENT: SurgicalMANAGEMENT: Surgical
OR PersonnelOR Personnel
OB AttendingOB Attending
MFM Back upMFM Back up
OB Resident(s)OB Resident(s) AnesthesiaAnesthesia
AttendingAttending
AnesthesiaAnesthesia
Resident(s)Resident(s)
2 Circulating RNs2 Circulating RNs
1 Scrub Tech/RN1 Scrub Tech/RN
Gyn-Onc SurgeonGyn-Onc Surgeon
(prn)(prn) InterventionalInterventional
Radiology (prn)Radiology (prn)
Cell SaverCell Saver
Personnel (prn)Personnel (prn)
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MANAGEMENT: SurgicalMANAGEMENT: Surgical
OR EquipmentOR EquipmentTraysTrays
Gyn Long TrayGyn Long Tray
Hysterectomy TrayHysterectomy Tray
Gyn Surgery TrayGyn Surgery Tray
Cell Saver EquipmentCell Saver Equipment
Preparation of fibrin gluePreparation of fibrin glue
(1-30 ml syringe with 2 vials Topical Thrombin + 0.5 ml of 10% CaCl, 1-(1-30 ml syringe with 2 vials Topical Thrombin + 0.5 ml of 10% CaCl, 1-
30 ml syringe with 30 ml of cryoprecipitate, both attached to 18 g30 ml syringe with 30 ml of cryoprecipitate, both attached to 18 g
angiocaths)angiocaths)
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MANAGEMENT: SurgicalMANAGEMENT: Surgical
ANESTHESIAANESTHESIA
Team CoordinatorTeam Coordinator
Airway managementAirway management
Hemodynamic MonitoringHemodynamic Monitoring FluidsFluids
Blood ProductsBlood Products
OutputOutput
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MANAGEMENT: SurgicalMANAGEMENT: Surgical
OBSTETRICIAN/SURGEONOBSTETRICIAN/SURGEON Control Source of HemorrhageControl Source of Hemorrhage Perform indicated Procedure:Perform indicated Procedure:
REPAIR LACERATIONREPAIR LACERATION
BILATERAL UTERINE ARTERY LIGATIONBILATERAL UTERINE ARTERY LIGATION
BILATERAL HYPOGASTRIC ARTERY LIGATIONBILATERAL HYPOGASTRIC ARTERY LIGATION
HYSTERECTOMYHYSTERECTOMY
Utilize additional resources if surgeryUtilize additional resources if surgerycontinues and emergency transfusion iscontinues and emergency transfusion is
occurring (Gyn-Onc Surgeon)occurring (Gyn-Onc Surgeon) Consider Interventional RadiologyConsider Interventional Radiology
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MANAGEMENT: SurgicalMANAGEMENT: Surgical
NURSINGNURSING Assist anesthesia as neededAssist anesthesia as needed
Assist with surgery (scrub/circulate)Assist with surgery (scrub/circulate)
Assess for the need for further additionalAssess for the need for further additionalsurgical expertisesurgical expertise
Ongoing surgery with emergencyOngoing surgery with emergency
transfusion continuingtransfusion continuing
Obtain NICU as needed if infant undeliveredObtain NICU as needed if infant undelivered
Obtain/administer medications as neededObtain/administer medications as needed
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Post-op DispositionPost-op Disposition
Anesthesiologist and obstetrician willAnesthesiologist and obstetrician will
determine post op disposition of thedetermine post op disposition of the
patient and call appropriate consultspatient and call appropriate consults
( i.e. SICU attending)( i.e. SICU attending) All intubated patients must go to theAll intubated patients must go to the
SICUSICU
Other patients at anesthesiologistsOther patients at anesthesiologistsdiscretiondiscretion
Nursing to give report to SICUNursing to give report to SICU
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SummarySummary
Maternal hemorrhage remains the numberMaternal hemorrhage remains the number
one cause of maternal death in NYSone cause of maternal death in NYS
Identification of high risk patients canIdentification of high risk patients can
prevent severe complicationsprevent severe complications Early intervention for the low risk patientEarly intervention for the low risk patient
who starts to bleed is also crucialwho starts to bleed is also crucial
Proper communication between nursing,Proper communication between nursing,OB, anesthesia and neonatology willOB, anesthesia and neonatology will
provide best outcome for mother and babyprovide best outcome for mother and baby
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