Obstetric Hemorrhage Program

1. Obstetric Hemorrhage Program

2. Review Committee

3. Obstetric hemorrhage-case #1 • 28 weeks EGA with complete previa presents with profuse vaginal bleeding • BP 109/70 mmHg; HR 110 Hct 22% (30% 2 days prior) • Immediate C-section performed under general anesthesia • EBL 750 ml • Fluid replacement of 2500 ml • Urine output 200 ml • Post extubation HR 120s

4. CASE #1-QUESTION The most appropriate next step in management of this patient is: • Aggressive volume replacement with blood products • Urology consult to assess for concealed GU injury • CT scan of abdomen to look for concealed bleeding • Renal consult to work up her renal disease

5. OBSTETRIC HEMORRHAGE-CASE #1 • Delay in diagnosis • Underestimation of blood loss • Prior to hospital admission • Hemorrhage & profound hypovolemia • Delay in treatment • Inadequate initial resuscitation → irreversible hemorrhagic shock, coagulopathy and Acute Tubular Necrosis (ATN) Time from admission to death was 21 hrs

6. World Maternal Mortality Ratio (MMR per 100,000 births in women aged 15-49)

9. Illinois Immediate Cause of Death Hemorrhage by year Initial Program Implementation

10. The Illinois Experience MMRC 2001 - 2013 *Does not include traumatic injury

11. Potentially Avoidable Factors in Care • No or inadequate identification of risk factors • Delayed or wrong diagnosis • Unrecognized abnormal vitals signs (s/s hypovolemia) • Underestimation of blood loss • Delayed and/or inadequate treatment • Under resuscitation • Inadequate/inappropriate referral, consultation, transfer of care • Inadequate documentation • Chain of communication issues

12. Program Goal Recognition and Prevention of Morbidity & Mortality from Obstetric Hemorrhage Program Objectives • To improve: • Risk assessment and preparation • Early recognition of obstetric hemorrhage • Quantification of blood loss • Recognition of hypovolemia • Treatment of hemorrhage andhypovolemia • To create and implement: • Rapid Response Teams for coordinated management • Policies and Guidelines • Rapid transfusion protocol • Active management of the third stage of labor The Intervention…Education!

13. Illinois Includes Antepartum Blood Loss in Totals Definition of Perinatal Hemorrhage “Persistent (ongoing) active bleeding >1000 mL within the 24 hours following birth that continues despite the use of initial measures including first-line uterotonic agents and uterine massage.” Treat the cause and calculate blood loss as you go!

14. A 42 year old G7 P5-0-1-4 at 37 weeks, with a prior IUFD, 3 prior C-sections and known placenta previa, presents for repeat C-section due to worsening hypertension • Pressure range on admission: 186/92-198/98, HR 80 • Initial labs: Hgb 14.6, Hct 43.8, Plts 190 • Findings at delivery: • Adhesions- omentum to anterior abdominal wall & bladder to lower uterine segment • Complete placenta previa • Viable male infant delivered @1743 • Intraoperative EBL 700 ml • Intraoperative BP 140/88 OB Hemorrhage - CASE #2

15. CASE #2 - Question • This patient’s history of 3 prior cesarean deliveries, and a known placenta previa puts her at increased risk for: • Antepartum hemorrhage • Placenta accreta • Ruptured uterus • All of the above

16. CASE #2 - Question • In addition to her placenta previa, which would be considered a risk factor for perinatal hemorrhage? Choose the best answer. • Chronic hypertension (CHTN) • Grand multiparity • Maternal age • IUFD history

17. CASE #2 - Question • What additional laboratory test(s) should you consider prior to her repeat C-section? Choose the best answer. • Type and screen • 24 hour urine collection for protein & Creatinine clearance • Uric acid • Type and cross-match

18. RISK ASSESSMENT AND PREPARATION

19. Risk factors associated with hemorrhage *

20. RISK FACTORPLAN 1. History of hemorrhage ________________________ 2. Placenta previa/accreta ________________________ 3. Grand multiparity ________________________ 4. Jehovah’s Witness ________________________ 5. Other (e.g. MgSO4, prolonged labor, chorio etc.) ________________________

21. Vitals: • On Admission: BP 186/92; HR 80 • Intra-op: BP 140/88; HR 90 EBL: 700cc • At what point do you first suspect potential hypovolemia? • 1815 BP 117/69; HR 108 • 1855 BP 98/61; HR 110 • 1903 BP 99/56; HR 118 • 1920 BP 90/50; HR 120 CASE #2 – cont’d

22. RECOGNITION, Visualization AND QUANTIFICATION OF BLOOD LOSS (QBL)

23. The blood loss at a vaginal delivery is given as 350mL. To quantify this amount correctly, the blood volume in the collection drape would fill a: • Standard soda can • Half gallon of milk • Pint of milk • Quart of milk EBL Recognition

24. Familiar Objects 1cup = 250ml = 5 cm clot (orange) = 1 unit PRBCs 2 cups = ~ 500 ml = 10 cm clot (softball)= 2 unit PRBCs Floor Spills • 23 inches (50 cm): 500 ml • 34 inches (75 cm): 1000 ml • 45 inches (100 cm):1500 ml 12 oz. soda can = 355 ml Estimating Blood Loss Ideal Method = Weighing 1gm of blood = 1 ml

25. 3 hrs postpartum in the recovery room • 3 orange size clots passed • 500 ml fluid bolus given • Post infusionBP 108/70; HR 115 • The first fluid bolus ordered at this time was 500 ml. This amount is: • Adequate • Adequate if vitals checked q 5 minutes & bleeding slows • Adequate if blood replacement is ordered • Inadequate CASE #2 – Cont’d

26. OB Hemorrhage: Recognition Less than 2.5 cm (1 inch/hour) Less than 10 cm (4 inches/hour) Scant 23-30 ml Less than 15 cm (6 inches/hour) Moderate Visual EBL Inaccurate Heavy 80-100 ml 1 pad saturated within 2 hours Light Scant Light Moderate Heavy WeighingMost accurate Lowdermilk & Perry (2012) Bose. BJOG 2006

27. EBL Recognition A standard 18in x 18in lap that is 75% saturated with blood represents a blood loss of: • 25 ml • 50 ml • 75 ml • 100 ml 

28. EBL Recognition

29. Quantification Examples (1 mL or 1 cc = 1 gram)

30. Quantification of Blood Loss (QBL) Quantification of blood loss has been shown to decrease the incidence of errors in blood loss estimation. • Blood loss estimation can lead to: • Overestimation • leads to unnecessary treatments • Underestimation • leads to delays in treatment • Methods such as a calibrated drapes had an error rate of less than 15% • Toledo, McCarthy & Wong (2007);Patel, Goudar, Geller, Kodkany, Edlavitch, Wagh, Patted, Naik, Moss, Derman (2006); Al Kadrik, H., Al Anazi,B., Tamim, H. (2010)

32. Blood Loss Quantification and Replacement

33. Recognition and Management of Hemorrhage ANTEPARTUM INTRAPARTUM POSTPARTUM Concealed Overt objective measurement of blood loss signs and symptoms of hypovolemia Blood Loss Recognized

34. Question Choose theearliestsign of compensatory change that occurs with hypovolemia? • Tachycardia • Hypotension • Hyperventilation • Pallor

35. Signs and Symptoms of Hemorrhage Look for trends in vital signs and patient status • Pulse • Respirations • Pallor • Change in Mental Status • Urinary Output • Capillary Refill • Blood Pressure

36. Question In cases of severe hemorrhage, the minimum rate of urine output per hour needed to prevent renal tubular necrosis is A. 10 ml/hr B. 30 ml/hr C. 100 ml/hr D. 300 ml/hr

37. Delayed Recognition of Hypovolemia Maternal Physiology Pregnancy - Hypervolemic State • Nearly 50% increase in blood volume • Up to 30% lossof volume • (1500 to 2000ml) to alter vitals • (vasoconstriction/SVR) Need earlier replacement of higher volumes for adequate resuscitation! Gordon, 2013. Obstetrics: Normal and Problem Pregnancies, 6th ed. Page 52.

38. BP remains stable until 25 – 30% (1500 – 2000 ml) of volume is lost BP Late Finding Francois. (2013). Obstetrics Normal and Problem Pregnancies 6d.ed. p. 416

39. 12 hrs postpartum • 4 hrs postpartum • 1st unit PRBC’s started • BP 90/50, P128 • Patient combative • Blood oozing from IV site • Pelvic exam: two 5cm clots • An additional estimated blood loss of 1600 ml • Patient coded five minutes after pelvic exam • Urine output 20 ml/hr • 1 liter D5LR given over 2 hours • HGB ordered – Result of 5.9 mg/dL reported back CASE #2 - Outcome

40. No/inadequate identification of risk factors • 4th C/S → • Previa → • High Parity Delayed/Wrong Diagnosis • Unrecognized abnormal vitals (s/s hypovolemia) • Inadequate assessment of vitals and physical findings Underestimation of blood loss in OR and postpartum • Pre-op Hgb 14.6 • Post-op Hgb 5.9 Delayed/Inadequate Treatment • Inadequate volume replacement • 1st unit of PRBCs started 14 hours post-cesarean Risk of accreta CASE #2 Summary of Issues

41. Lack of documentation has been identified as a major problem! Documentation must include: • Date/time, name of provider for each person who provides care during the event • Ongoing vital signs • Signs of hypovolemia • Actual blood loss amount* • Interventions • Patient response • Above information reported to…? • Discussion with family member(s) IDPH recommends the quantification of actual Blood Loss for All deliveries CASE #2 Summary of Issues Continued

42. Treatment & Product Replacement

43. Recognition and Management of Hemorrhage ANTEPARTUM INTRAPARTUM POSTPARTUM Concealed Overt objective measurement of blood loss signs and symptoms of hypovolemia Blood Loss Recognized Stop the hemorrhage treat the cause Homeostasis correct hypovolemia

44. ACTIVATE RAPID RESPONSE TEAM Identify Source of Bleeding & Abate Simultaneous actions Intervention

45. Remember “ORDER” for Action ACOG Technical Bulletin 235, April 1997

46. Question After a normal spontaneous vaginal delivery (NSVD), bright red bleeding continues in the presence of a firmly contracted uterus. This is likely the result of: • Uterine rupture • Retained placenta • Vaginal laceration • Thrombocytopenia

47. Active Versus Expectant Management for Women in the Third Stage of Labor (Review) Begley, Gyte, Devane, McGuire, Weeks (2011) • Objective: To compare the effectiveness of active versus expectant management of thethird stage of labor • Definitions: • Recommendations: • Active management of third stage was associated with reduced • Blood loss • Postpartum anemia • Need for blood transfusion • Risk of prolonged third stage labor • Use of additional therapeutic uterotonic drugs • Give women information on the risk and benefits to support an informed choice • Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical to look at the individual components of third stage management

48. Administration of uterotonic drugs • Controlled cord traction • Uterine massage Active Management of the Third Stage of Labor (AMTSL)

49. Suggested Third Stage Oxytocin Management Protocol • Standardized, pre-mixed concentration of Oxytocin • Consider a 1mU/mL rate for safe calculation and infusion • Same protocol for vaginal and cesareandeliveries • Safe medication practices for a high-alert drug

50. Interventions for the Third Stage of Labor • Hemorrhage risk factors • Utilized uterotonics sequentially • Use of computerized infusion pumps • Document dosages (units) of oxytocin administered rather than a rate • Empty bladder to maintain uterine tone • Uterine massage • Maintain IV site for at-risk or actual hemorrhage patients • Assess for signs of hypervolemia and shock • Quantify blood loss • Strict intake and output Burke, 2010