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S E R I E S 2

Optimizing Protocols in ObstetricsMANAGEMENT of OBSTETRIC HEMORRHAGE

D I S T R I C T I I


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OCTOBER 2012

Management of Obstetric Hemorrhage

2

Dear ACOG District II Member:

On behal o the American Congress o Obstetricians and Gynecologists (ACOG), District II we arepleased to provide you with the second chapter o the Optimizing Protocols in Obstetrics series. Whilethe first chapter addressed the use o oxytocin or induction, this chapters content ocuses on the Man-agement o Obstetric Hemorrhage.

wenty three existing hemorrhage protocols were reviewed rom obstetric hospitals throughout NewYork State and many contained excellent educational and instructional components. However, mosto these hospitals lacked the systematic approach required to ensure an effective guideline or protocol.Given the exceptional work done in this area by the Caliornia Maternal Quality Care Collaborative(CMQCC) and ACOG, the District II PSQI Committee encourages institutions to utilize these twoextensive resources in the development o a hemorrhage protocol. Enclosed you will find:

Core elements or the management o obstetric hemorrhage Recommendations to optimize the management o obstetric hemorrhage ACOG Practice Bulletin #76 Postpartum Hemorrhage CMQCC hemorrhage care checklist, flow chart, table chart and training tools or

measurement o blood loss

Each institution is encouraged to review its existing hemorrhage protocols, and modiy them i neces-sary to maximize sae patient care, or consider the creation o a policy to optimize the management oobstetrical hemorrhage. Standardization o health care processes and reduced variation in practice has

been shown to improve outcomes and quality o care.

We extend our sincere appreciation to the committee o medical experts who offered their expertisethroughout the creation o this chapter. Teir knowledge and dedication to this initiative is invaluable.

Te District II PSQI Committee continues to develop additional chapters to be added to this resource.I you have any questions regarding the enclosed materials, please contact Kelly Gilchrist, ACOG Dis-

trict II Patient Saety Manager, at 518-436-3461 or [email protected].

Sincerely,

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

RB/PB/kg

Optimizing Protocols in ObstetricsS E R I E S 2


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NURSING INTERVENTIONS

Index: Series 2

4 Executive Summary

4 Core Elements or the Management o Obstetric Hemorrhage

5 Introduction & Caliornia Maternal Quality Care Collaborative

(CMQCC) oolkit Overview

6 Recommendations to Optimize the Management o Obstetric Hemorrhage

ACOG PUBLICATIONS

8 ACOG Practice Bulletin # 76 Postpartum Hemorrhage

CMQCC RESOURCES

17 Obstetric Hemorrhage Care Guidelines Checklist

22 Summary Flowchart

23 Summary able Chart

24 raining & ools or Measurement o Blood Loss

PAGE

3

OCTOBER 2012



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Purpose

ExecutiveSummary

Core Elements

4

OCTOBER 2012


Tis document reflects emerging clinical, scientific and patient saety advances as o the date issuedand is subject to change. Te inormation should not be construed as dictating an exclusive course otreatment or procedure to be ollowed. While the components o a particular protocol and/or checklistmay be adapted to local resources, standardization o protocols and checklists within an institution isstrongly encouraged.

wenty three hospitals throughout New York State responded to a request rom ACOG District II tosubmit their protocols regarding the diagnosis and management o obstetric hemorrhage. Althoughmany were well written policies and protocols, the committee did not identiy a single protocol thatcould meet the needs o all hospitals in New York State.

Te work group used a number o resources, in addition to reviewing the submitted protocols, to selectthe ideal requirements or a comprehensive approach to obstetrical hemorrhage. Tese included:

1. ACOG Practice Bulletin No. 76, Postpartum Hemorrhage 2. Caliornia Maternal Quality Care Collaborative (CMQCC), Improving Health Care Response to Obstetric Hemorrhage oolkit

Each hospital must take into account the resources available within its own institution and communityto design a protocol that will assist them in the optimal management o obstetrical hemorrhage. Eachinstitution is encouraged to review its existing policy and protocols, and modiy them i necessary toprovide sae patient care, or consider the creation o a policy to optimize the management o obstetri-cal hemorrhage. Te committee believes that all obstetric services must have a written hemorrhageprotocol in order to ensure the highest quality o patient care.

On reviewing the submitted protocols, it is noted that many contain excellent educational and instruc-tional components. What most o them lack however, is the systematic approach required to ensurean effective guideline or protocol. Te inclusion o algorithms, charts, and checklists is helpul and theollowing examples could be useul as hospitals strive to urther improve their hemorrhage protocols.Given the previous excellent work done in this area by the Caliornia Maternal Quality Care Collabora-tive (CMQCC) and the American Congress o Obstetricians and Gynecologists (ACOG), we encour-age individuals to utilize these two extensive resources in the development o a hemorrhage protocol.

Te ollowing is a list o the components o any protocol that is created or the management o obstetri-cal hemorrhage. Hospitals should individualize their protocols based on an assessment o their ownresources.

Definition Risk Factors/Etiology Initial Interventions Medical reatment Surgical reatment Defined Care eam and Escalation Role Clarity Checklist Algorithm ransusion Policy Drills
http://mail.ny.acog.org/website/Optimizing_Hemorrhage/pb076.pdfhttp://www.cmqcc.org/ob_hemorrhagehttp://www.cmqcc.org/ob_hemorrhagehttp://www.cmqcc.org/ob_hemorrhagehttp://www.cmqcc.org/ob_hemorrhagehttp://www.cmqcc.org/ob_hemorrhagehttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/pb076.pdf


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5

Obstetric hemorrhage continues to cause maternal morbidity and mortality in New York and across theUnited States. Most o these cases occur in spite o women delivering in hospitals staffed by physicians,nurses, and support personnel who are knowledgeable, highly motivated, and well trained. Ofen thesecases occur in hospitals that have very well written obstetric hemorrhage protocols in place. Te nature oobstetric hemorrhage management is that it is a time and team dependent perormance that requires preci-sion choreography. Having a good protocol that has never been practiced as a drill or dry run is similar

to a ootball team that studies its plays but never works through the timing on the practice field, or a dancetroupe that never rehearses beore opening night.

Te Hemorrhage Protocol Work Group has been assigned the task o helping to prevent serious harm as-sociated with obstetric hemorrhage. o that end, this committee has evaluated and chosen resources thatcan be used to design very good hemorrhage protocols. However, to be effective, your protocol must havetwo 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 or easibility within the institution and taught andrehearsed through dry runs or drills to improve its quality and the precision team work necessary

to effectively manage obstetric hemorrhage.

Te toolkit begins with a section on, How o Use Tis oolkit(pages 1-2) ollowed by a compendium oevidence-based, best practices related to obstetric hemorrhage. Obstetric hemorrhage care guidelines arepresented in three orms starting with the most comprehensive Checklistollowed by a able chartandfinally the most streamlined version the Flowchart. Te comprehensive Checklist delineates all topicsthe workgroup thought should be included in a protocol except or simulation/drills topic. A comprehen-sive document exists within the tool kit related to obstetric hemorrhage drills and simulations. Tis docu-ment includes multiple detailed, ready to use scenarios which ocus on both the technical management oobstetric hemorrhage, and team unction, communication, and role clarity. Te document finishes with aHospital Level Implementation Guide (pages 95-109) which addresses practical planning or implementa-tion o new evidence-based protocols and guidelines or quality improvement.

We believe a successul protocol should contain the ollowing core elements. Links to examples rom theCMQCC oolkit are included.

Introduction

CMQCC

ToolkitOverview

http://mail.ny.acog.org/website/Optimizing_Hemorrhage/How_To_Use_This_Toolkit.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/checklist.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/table_chart.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/flow_chart.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/hospital_level_implementation.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/hospital_level_implementation.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/flow_chart.pdfhttp://mail.ny.acog.org/website/optimizing_hemorrhage/table_chart.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/checklist.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/How_To_Use_This_Toolkit.pdf


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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 oolkit examples 3 Simulation & Drills(pages 32-47) 3 ransusion 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 o the day to ensure that appropriate

hemorrhage team members are available at all times. All members o the health care team should participate, including nurses, physicians and

ancillary staff, as appropriate n CMQCC oolkit example 3 Simulation & Drills(pages 32-47)

Te 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 amiliar with severe hemorrhage to help

with assessment o organ perusion and cardiovascular unction. A hematologist or clinical pathologist available on site to advise on appropriate blood

products, and to coordinate and mobilize appropriate personnel to provide these productsimmediately.

Provide continuing medical education on hemorrhage for your entire medical team. Ensure all hospital staff, including physicians, nurses, laboratory personnel and others are aware o the protocol related to dealing with maternal hemorrhage. Incorporate this protocol into your hospitals mandatory annual educational programs and ensure all new staff is

oriented to its content. Findings rom obstetrical quality improvement initiatives should be incorporated on an on-going basis into improvements o the hemorrhage protocol.


7
http://mail.ny.acog.org/website/Optimizing_Hemorrhage/Simulation_Drills.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/Transfusion_Policy.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/Simulation_Drills.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/Simulation_Drills.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/Transfusion_Policy.pdfhttp://mail.ny.acog.org/website/Optimizing_Hemorrhage/Simulation_Drills.pdf


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

ACOG

PRACTICE

BULLETINCLINICALMANAGEMENTGUIDELINES FOR

OBSTETRICIANGYNECOLOGISTS

NUMBER76, OCTOBER2006

(Replaces Committee Opinion Number 266, January 2002)

This Practice Bulletin was

developed by the ACOG Com-

mittee on Practice Bulletins

Obstetrics with the assistance

of William N. P. Herbert, MD,

and Carolyn M. Zelop, MD.

The information is designed to

aid practitioners in making

decisions about appropriate

obstetric and gynecologic care.

These guidelines should not beconstrued as dictating an exclu-

sive course of treatment or pro-

cedure. Variations in practice

may be warranted based on the

needs of the individual patient,

resources, and limitations

unique to the institution or type

of 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 yearone every 4 minutes

(1). In addition to death, serious morbidity may follow postpartum hemorrhage.

Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss

of 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 practitioners

must have the facilities, personnel, and equipment in place to manage this

emergency properly. Clinical drills to enhance the management of maternalhemorrhage have been recommended by the Joint Commission on Accreditation

of Healthcare Organizations (2). The purpose of this bulletin is to review the

etiology, 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. An

estimated 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 the

diagnosis, but the average volume of blood lost at delivery can approach these

amounts (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 postpartum

hemorrhage, but determinations of hemoglobin or hematocrit concentrations

may not reflect the current hematologic status (7). Hypotension, dizziness, pal-


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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 if

appropriate, packing the vagina are measures usually

successful in achieving hemostasis. Interventional radi-

ology is another option for management of a hematoma.

Genital tract hematomas may not be recognized until

hours after the delivery, and they sometimes occur in the

absence of vaginal or perineal lacerations. The main

symptoms 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 when

ultrasonography reveals a normal endometrial stripe.

Although ultrasonographic images of retained placental

tissue are inconsistent, detection of an echogenic mass in

the uterus is more conclusive. Ultrasound evaluation for

retained tissue should be performed before uterine

instrumentation is undertaken (9). Spontaneous expul-

sion of the placenta, apparent structural integrity on

inspection, and the lack of a history of previous uterine

surgery (suggesting an increased risk of abnormal pla-

centation) make a diagnosis of retained products of the

placenta 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, blunt

instrument, such as a banjo curette or ring forceps, guid-

ed by ultrasonography, makes removal of the retained

tissue easier and reduces the risk of perforation.

Less commonly, postpartum hemorrhage may be

caused by coagulopathy. Clotting abnormalities should

be suspected on the basis of patient or family history

Risk Factors for Postpartum Hemorrhage

Prolonged labor

Augmented labor

Rapid labor

History of postpartum hemorrhage

Episiotomy, especially mediolateralPreeclampsia

Overdistended uterus (macrosomia, twins,hydramnios)

Operative delivery

Asian or Hispanic ethnicity

Chorioamnionitis

Data from Stones RW, Paterson CM, Saunders NJ. Risk factors formajor obstetric haemorrhage. Eur J Obstet Gynecol Reprod Biol1993;48:158 and Combs CA, Murphy EL, Laros RK. Factors associ-ated with hemorrhage in cesarean deliveries. Obstet Gynecol1991;77:7782.

or clinical circumstances. Hemolysis, elevated liver

enzymes, and low platelet count (HELLP) syndrome,

abruptio placentae, prolonged intrauterine fetal demise,

sepsis, and amniotic fluid embolism are associated with

clotting abnormalities. Significant hemorrhage from any

cause can lead to consumption of clotting factors.

Observation of the clotting status of blood recently lost

can 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 by

the hemorrhage. In such cases, simultaneous surgery and

blood product replacement may be necessary.

Baseline studies should be ordered when excessive

blood loss is suspected and should be repeated periodi-

cally as clinical circumstances warrant. Clinicians

should remember that the results of some studies may be

misleading because equilibration may not have occurred.

In addition, response to hemorrhage may be required

before 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 bank

should be notified that transfusion may be necessary.

The clot observation test provides a simple measure

of fibrinogen (10). A volume of 5 mL of the patients

blood is placed into a clean, red-topped tube and

observed frequently. Normally, blood will clot within

810 minutes and will remain intact. If the fibrinogen

concentration is low, generally less than 150 mg/dL, the

blood in the tube will not clot, or if it does, it will under-

go partial or complete dissolution in 3060 minutes.

What is the appropriate medical management

approach for excessive postpartum bleeding?

Ongoing blood loss in the setting of decreased uterine

tone requires the administration of additional uterotonics

as the first-line treatment for hemorrhage (Table 1).

Some practitioners prefer direct injection of methyler-

gonovine maleate and 15-methyl prostaglandin (PG) F2

into the uterine corpus. Human recombinant factor VIIa

is a new treatment modality shown to be effective in

controlling severe, life-threatening hemorrhage by acting

on the extrinsic clotting pathway. Intravenous dosagesvary by case and generally range from 50 to 100 mcg/kg

every 2 hours until hemostasis is achieved. Cessation of

bleeding ranges from 10 minutes to 40 minutes after

administration (1114). Concern has been raised be-

cause of apparent risk of subsequent thromboembolic

events following factor VIIa use (15). Compared with

other agents, factor VIIa is extremely expensive.

Additional clinical experience in all specialties will help


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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 new

surgical technique for postpartum hemorrhage caused by

uterine atony, placenta previa, or placenta accreta. The

procedure eliminates space in the uterine cavity by sutur-

ing both anterior and posterior uterine walls. One study

reported on this technique in 23 women after conserva-

tive treatment failed. All patients were examined after 2

months, and ultrasound findings confirmed normal

endometrial linings and uterine cavities (23).

What are the clinical considerations for

suspected placenta accreta?

Abnormal attachment of the placenta to the inner uterine

wall (placenta accreta) can cause massive hemorrhage. Infact, accreta and uterine atony are the two most common

reasons for postpartum hysterectomy (24, 25). Risk factors

for placenta accreta include placenta previa with or with-

out previous uterine surgery, prior myomectomy, prior

cesarean delivery, Ashermans syndrome, submucous

leiomyomata, and maternal age older than 35 years (26).

Prior cesarean delivery and the presence of placenta

previa in a current pregnancy are particularly important risk

factors for placenta accreta. In a multicenter study of more

than 30,000 patients who had cesarean delivery without

labor, 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% for

those undergoing their first through their fifth or greater

cesarean deliveries, respectively (27).

Women with placenta previa or placenta accreta

have a higher incidence of postpartum hemorrhage and

are more likely to undergo emergency hysterectomy

(28). In the multicenter study cited previously, hysterec-

tomy was required in 0.7% for the first cesarean delivery

and increased with each cesarean delivery up to 9% for

patients with their sixth or greater cesarean delivery.

In the presence of previa or a history of cesarean

delivery, the obstetric care provider must have a high

clinical 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 in

imaging techniques, no diagnostic technique affords the

clinician complete assurance of the presence or absence

of placenta accreta.

If the diagnosis or a strong suspicion is formed

before delivery, a number of measures should be taken:

The patient should be counseled about the likelihood

of 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 delivery

should be considered to allow access to adequate

surgical personnel and equipment.

A preoperative anesthesia assessment should beob-

tained.

The extent (area, depth) of the abnormal attachment

will determine the responsecurettage, 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 arterial

embolization 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 in

such circumstances. Embolization can be used for bleeding

that continues after hysterectomy or can be used as an

alternative 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 the

extent of blood loss is significant and ongoing, particu-

larly if vital signs are unstable. Postpartum transfusion

Table 3. Surgical Management of Postpartum Hemorrhage

Technique Comment

Uterine curettage

Uterine artery l igation Bilateral; also can l igate uteroovarianvessels

B-Lynch suture

Hypogastric artery ligation Less successful than earlier thought;difficult technique; generallyreserved for practitionersexperienced in the procedure

Repair of rupture

Hysterectomy


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progressive upward traction on the inverted corpus using

Babcock or Allis forceps (35). The Haultain procedure

involves incising the cervical ring posteriorly, allowing

for 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% of

pregnancies; often the specific etiology is unknown.

Postpartum hemorrhage may be the first indication for

von Willebrands disease for many patients and should

be considered. The prevalence of von Willebrands dis-

ease is reported to be 1020% among adult women with

menorrhagia (37). Hence, testing for bleeding disorders

should be considered among pregnant patients with a

history of menorrhagia because the risk of delayed or

secondary postpartum hemorrhage is high among

women 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 postpartum

hemorrhage. Ultrasound evaluation can help identify

intrauterine tissue or subinvolution of the placental site.

Treatment may include uterotonic agents, antibiotics,

and curettage. Often the volume of tissue removed by

curettage is minimal, yet bleeding subsides promptly.

Care must be taken in performing the procedure to avoid

perforation 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 initiating

any operative procedures.

What is the best approach to managing

excessive blood loss in the postpartum period

once the patients 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) will

maximize 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 the

U.S. Food and Drug Administration for postoperative ane-

mia, and it can be costly (40). Postpartum hemorrhage in

a subsequent pregnancy occurs in approximately 10% of

patients (8).

Summary ofRecommendations andConclusions

The following recommendations and conclusions

are based primarily on consensus and expert opin-

ion (Level C):

Uterotonic agents should be the first-line treatment

for postpartum hemorrhage due to uterine atony.

Management may vary greatly among patients,

depending on etiology and available treatment

options, and often a multidisciplinary approach is

required.

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 provider

must have a high clinical suspicion and take appro-priate precautions.

Proposed PerformanceMeasureIf hysterectomy is performed for uterine atony, there

should be documentation of other therapy attempts.

References1. AbouZahr C. Global burden of maternal death and dis-

ability. Br Med Bull 2003;67:111. (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;84:127182. (Level III)

5. Clark SL, Yeh SY, Phelan JP, Bruce S, Paul RH.Emergency hysterectomy for obstetric hemorrhage.Obstet Gynecol 1984;64:37680. (Level III)

6. Dildy GA 3, Paine AR, George NC, Velasco C. Estimatingblood loss: can teaching significantly improve visual esti-mation? Obstet Gynecol 2004;104:6016. (Level III)

7. Combs CA, Murphy EL, Laros RK Jr. Factors associatedwith postpartum hemorrhage with vaginal birth. ObstetGynecol 1991;77:6976. (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;168:87983. (LevelII-3)

26. Clark SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior cesarean section. Obstet Gynecol1985;66:8992. (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;107:122632. (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;77:3914. (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;26:904. (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;186:7374. (Level II-2)

31. Kruskall MS, Leonard S, Klapholz H. Autologous blooddonation during pregnancy: analysis of safety and blooduse. Obstet Gynecol 1987;70:93841. (Level III)

32. Herbert WN, Owen HG, Collins ML. Autologous bloodstorage in obstetrics. Obstet Gynecol 1988;72:16670.(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;179:71520. (Level II-2)

34. Johnson AB. A new concept in the replacement of theinverted uterus and a report of nine cases. Am J Obstet

Gynecol 1949;57:55762. (Level III)35. Huntington JL, Irving FC, Kellogg FS. Abdominal reposi-

tion in acute inversion of the puerperal uterus. Am JObstet Gynecol 1928;15:3440. (Level III)

36. Haultain FW. The treatment of chronic uterine inversionby abdominal hysterotomy, with a successful case. BrMed J 1901;2:9746. (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;27:70732. (Level III)

38. Kadir RA, Aledort LM. Obstetrical and gynaecologicalbleeding: a common presenting symptom. Clin LabHaematol 2000 Oct;22 suppl 1:126; discussion 302.(Level III)

39. James AH. Von Willebrand disease. Obstet Gynecol Surv2006;61:13645. (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;24:115.(Meta-analysis)

8. Bonnar J. Massive obstetric haemorrhage. Baillieres BestPract Res Clin Obstet Gynaecol 2000;14:118. (Level III)

9. Hertzberg BS, Bowie JD. Ultrasound of the postpartumuterus. Prediction of retained placental tissue. J Ultra-sound Med 1991;10:4516. (Level III)

10. Poe MF. Clot observation test for clinical diagnosis of clot-ting defects. Anesthesiology 1959;20:8259. (Level III)

11. Bouwmeester FW, Jonkhoff AR, Verheijen RH, van GeijnHP. Successful treatment of life-threatening postpartumhemorrhage with recombinant activated factor VII. ObstetGynecol 2003;101:11746. (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;84:4023. (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;111:2847.(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;83:7712. (Level III)

15. OConnell KA, Wood JJ,Wise RP, Lozier JN, Braun MM.Thromboembolic adverse events after use of recombinanthuman coagulation factor VIIa. JAMA 2006;295:2938.(Level III)

16. Bakri YN, Amri A, Abdul Jabbar F. Tamponade-balloonfor obstetrical bleeding. Int J Gynaecol Obstet 2001;74:13942. (Level III)

17. Clark AL, Phelan JP, Yeh SY, Bruce SR, Paul RH.Hypogastric artery ligation for obstetric hemorrhage.Obstet Gynecol 1985:66:3536. (Level III)

18. OLeary JL, OLeary JA. Uterine artery ligation in the

control of intractable postpartum hemorrhage. Am JObstet Gynecol 1966;94:9204. (Level III)

19. OLeary JL, OLeary JA. Uterine artery ligation for con-trol of postcesarean section hemorrhage. Obstet Gynecol1974;43:84953. (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;104:3725. (Level III)

21. Allam MS, B-Lynch C. The B-Lynch and other uterinecompression suture techniques. Int J Gynaecol Obstet2005;89:23641. (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;115:3942. (Level III)

23. Cho JH, Jun HS, Lee CN. Hemostatic suturing techniquefor uterine bleeding during cesarean delivery. ObstetGynecol 2000;96:12931. (Level III)

24. Zelop CM, Harlow BL, Frigoletto FD, Safon LE,Saltzman DH. Emergency peripartum hysterectomy. AmJ Obstet Gynecol 1993;168:14438. (Level II-3)


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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 also

were 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 obstetriciangynecologists 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 controlled

trials without randomization.II-2 Evidence obtained from well-designed cohort orcasecontrol 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 ARecommendations are based on good and consis-

tent scientific evidence.

Level BRecommendations are based on limited or incon-sistent scientific evidence.

Level CRecommendations are based primarily on con-sensus and expert opinion.

Copyright October 2006 by the American College of Obstetricians

and Gynecologists. All rights reserved. No part of this publication may

be reproduced, stored in a retrieval system, posted on the Internet, or

transmitted, in any form or by any means, electronic, mechanical, pho-

tocopying, recording, or otherwise, without prior written permission

from the publisher.

Requests for authorization to make photocopies should be directed to

Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA

01923, (978) 750-8400.

The American College of Obstetricians and Gynecologists

409 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;108:103947.


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Obstetric Hemorrhage Care Guidelines: Checklist Format versioPrenatal 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 & PlanningOngoing RiskAssessment

Verify Type & Antibody Screenfrom prenatal recordIf not available,!Order Type & Screen (lab will notify if 2

ndclot needed

for confirmation)

If prenatal or current antibody screen positive (if notlow 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

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

!Evaluate for development of additiorisk factors in labor:Prolonged 2

ndStage labor

Prolonged oxytocin useActive bleedingChorioamnionitis Magnesium sulfate treatment

!Increase Risk level (see below) andconvertto Type & Screen orType & Crossmatch

!Treat multiple risk factors as High R

Admission Hemorrhage Risk Factor EvaluationLow (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 500ml vaginal birth or >1000ml C/S -OR-Vital signs >15% change or HR 110, BP 85/45, O2 sat


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STAGE 1: OB HemorrhageCumulative Blood Loss >500ml vaginal birth or >1000ml C/S -OR-

Vital signs >15% change or HR 110, BP 85/45, O2 sat 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 atonyTrauma/Laceration Retained placenta Amniotic Fluid EmbolismUterine InversionCoagulopathyPlacenta AccretaUterine Rupture

Once stabilized: Modified Postpamanagement with increasedsurveillance

If: Continued bleeding or Continued Vital Sign instability, and


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21/25

OCTOBER 2012

21


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.


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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 3rdstage

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 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 StronglyDesired

Consider ICU

Care; IncreasedPostpartum

Surveillance

Verify Type & Screen on prenatal

record;

if positive antibody screen on prenat

or current labs (except low level anti-

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-HR110,BP 85/45

O2Sat 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

OngoingCumulativeBloodLossEvaluation

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 O2to 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 detaiThis 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 Divisio

OBSTETRIC HEMORRHAGE CARE SUMMARY: FLOW CHART FORMATv 1.4 5/7/20


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Obstetric Hemorrhage Care Summary: Table Chart Formatversion 1

Assessments Meds/Procedures Blood Bank

Stage 0 Every woman in labor/giving birth

Stage 0 focuses

on riskassessment andactivemanagement ofthe third stage.

Assess every womanforrisk factorsfor

hemorrhageOngoing quantitative

evaluation of bloodloss on every birth

Active Management3rdStage:

OxytocinIV infusion or10u IM

Fundal Massage-vigorous, 15 seconds min.

If Medium Risk:T&ScrIfHigh Risk:T&C 2 UIf Positive Antibody

Screen (prenatal orcurrent, exclude low leanti-D fromRhoGam):T&C 2 U

Stage 1Blood loss: >500 ml vaginal or >1000 ml Cesarean, orVS changes (by >15% or HR 110, BP 85/45, O2 sat 2u PRBC

Determine availability oadditional RBCs andother Coag products

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


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OB HEMORRHAGE TOOLKIT

APPENDIX E.3. METHODS FOR DEVELOPING TRAINING AND TOOLS FOR QUANTITATIVE M

LOSS

Used with kind permission of Bev VanderWal, CNS

Recommended methods for ongoing quantitative measurement of bloodloss:

1. Formally estimate blood loss by recording percent (%) saturation ofblood soaked items with the use of visual cues such as pictures/postersto determine blood volume equivalence of saturated/blood soaked

pads, chux, etc.2. Formally measure blood loss by weighing blood soaked pads/chux3. 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)


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Richard Berkowitz, MD, FACOGCo-Chair

Peter Bernstein, MD, MPH, FACOG

Co-ChairTraci Burgess, MD, FACOG

Elisa Burns, MD, FACOG

Cynthia Chazotte, MD, FACOG

Kirsten L. Cleary, MD, FACOG

Edward Denious, MD, FACOG

Dena Goffman, MD, FACOG

Amos Grunebaum, MD, FACOG

Victor Klein, MD, FACOG

Denise Lester, MD, FACOG

Abraham Lichtmacher, MD, FACOGSandra McCalla, MD, FACOG

Paul Ogburn, MD, FACOG

Michael Scalzone, MD, MHCM, FACOG

Joseph Sclafani, MD, FACOG

Heather Shannon, MS, CNM, NP, MPH

Alexander Shilkrut, MD, DO, FACOG

Toni Stern, MD, MS, FACOG, CPE

John Vullo, DO, FACOG

Brian Wagner, MD, FACOG

Richard Waldman, MD, FACOGExecutive Committee

Eva Chalas, MD, FACOG, FACS

Ronald Uva, MD, FACOG

Nicholas Kulbida, MD, FACOG

Cynthia Chazotte, MD, FACOG

Scott Hayworth, MD, FACOG

ACOG Staff

Donna Montalto, MPP

Kelly Gilchrist

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

Phone: 518-436-3461 Fax: 518-426-4728

E-mail: [email protected]: www.acogny.org

ACOG District II Patient Safety & Quality Improvement Committee

D I S T RI C T I I

final hemorrhage web

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