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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 kgilchrist@ny.acog.org.
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
Optimizing Protocols in ObstetricsS E R I E S 2
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Management of Obstetric Hemorrhage
Purpose
ExecutiveSummary
Core Elements
4
OCTOBER 2012
Optimizing Protocols in ObstetricsS E R I E S 2
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.pdf8/10/2019 Final Hemorrhage Web
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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
Management of Obstetric Hemorrhage
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.pdf8/10/2019 Final Hemorrhage Web
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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.
Management of Obstetric Hemorrhage
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.pdf8/10/2019 Final Hemorrhage Web
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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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VOL. 108, NO. 4, OCTOBER 2006 ACOG Practice Bulletin Postpartum Hemorrhage 1043
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.
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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)
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VOL. 108, NO. 4, OCTOBER 2006 ACOG Practice Bulletin Postpartum Hemorrhage 1047
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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OCTOBER 2012
21
Optimizing Protocols in ObstetricsS E R I E S 2
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: info@acogny.orgWebsite: www.acogny.org
ACOG District II Patient Safety & Quality Improvement Committee
D I S T RI C T I I