2. دكتر مهديه مجيبيان متخصص زنان و زايمان

7. Section II: The following are laminated and displayed in a common area that is readily accessible to physicians, nurse midwives, nurses, and other staff who might need the information: ____WAPC “ Algorithm for Postpartum Hemorrhage ” ____WAPC list of “ Uterotonic Agents for Postpartum Hemorrhage ” ____Diagram of the B-Lynch compression suture technique

10. Oxytocin for Postpartum Hemorrhage Protocol revised October 2008 Preamble One of the associated risks associated with childbirth is a postpartum hemorrhage. In the out-of-hospital setting, early intervention to manage a significant and ongoing hemorrhage can prevent further blood loss. Oxytocin helps contract uterine smooth muscle and minimizes further uterine blood loss. Requirements 1. Fully licensed Technician-Paramedic. 2. Certification in postpartum hemorrhage protocol by the Medical Director. 3. Certification in administration of intramuscular (IM) medication by the Medical Director. Indications 1. Patients at greater than 20 weeks gestation who have delivered a newborn in the outof- hospital environment. and 2. Patients experiencing postpartum hemorrhage of greater than 500 ml blood.

11. Contraindications 1. Patient has not completed delivery of fetus(es). 2. Patient is less than 20 weeks gestation. Oxytocin for Postpartum Hemorrhage Protocol Drug Doses and Frequencies oxytocin IM: 10 IU after the newborn has delivered IV: in the event of ongoing with significant blood loss, an additional 40 IU can be added to each 1000 ml normal saline and infused based on the severity of hemorrhage and patient response Procedure 1. Perform patient assessment and record vital signs. 2. Assess that patient meets criteria for this protocol. 3. Ensure there are no contraindications to use of this protocol. 4. Initiate basic life support treatment measures, including supplemental oxygen. - these take precedence over management using this protocol

12. . Initiate an intravenous line with normal saline - add oxytocin to the intravenous bag - infuse at a rate based on severity of hemorrhage and patient condition 6. Manage the hemorrhage as per appropriate guideline or protocol. 7. While basic life support treatment measures and intravenous line are being initiated, and hemorrhage is being controlled, obtain a focused obstetrical history. Include the following details: · antenatal care · expected delivery date · history of current pregnancy (including results of any ultrasounds) · history of prior pregnancies (including history of previous difficulties) 8. If baby (last baby), but not placenta, has delivered: · provide appropriate care for mother and newborn · give mother oxytocin IM · assist with delivery of placenta · manage complications, if possible, as per appropriate guideline or protocol · initiate transport to hospital Oxytocin for Postpartum Hemorrhage Protocol 3

13. 9. If the baby (last baby) and placenta have delivered: · provide appropriate care for mother and newborn · give mother oxytocin IM if not already done as part of step 8 · manage complications, if possible, as per appropriate guideline or protocol · initiate transport to hospital 10.If possible, encourage mother to empty her bladder. 11.Massage the uterine fundus to promote uterine contraction and lessen the severity of the hemorrhage. 12.Repeat assessment, including vital signs, level of consciousness, oxygen saturation, and effect of oxytocin.

14. Documentation Requirements The following information must be documented on the patient care report form: 1. Patient ’ s presenting signs and symptoms, including vital signs. 2. Indications for protocol use. 3. Details of patient ’ s obstetrical history and current delivery. 4. Dose, route, and time for each oxytocin dose used, and resulting clinical effects. 5. Repeat assessment and vital signs, as indicated. 6. Changes from baseline, if any, that occur during treatment or transport. 7. Signature and license number of EMS personnel performing any transfer of function skills.

15. Certification Requirements 1. Attend in-depth classes and lectures on obstetrics and obstetrical emergencies. 2. Demonstrate an understanding of the pharmacology, mechanism of action, and potential side effects of oxytocin. 3. Do an acceptable clinical rotation on a labour and delivery ward. Oxytocin for Postpartum Hemorrhage Protocol 4 4. Pass a written examination. 5. Pass practical scenarios incorporating variations of the oxytocin – postpartum hemorrhage protocol. 6. Certification is by the Medical Director. Recertification Requirements 1. Review class and recertification is done every 12 months. 2. A record will be kept to document all cases where this protocol is used.

16. Decertification 1. Decertification is at the discretion of the Medical Director or the Provincial Medical Director, Emergency Medical Services, Manitoba Health & Healthy Living. Quality Assurance Requirements 1. Appropriate quality assurance policies must be in place. The Medical Director or designate must review all instances where this protocol is used. As a minimum, the following must be assessed: i) appropriateness of implementation ii) adherence to protocol iii) any deviation from the protocol iv) corrective measures taken, if indicated 2. Yearly statistics for protocol use compiled and forwarded to Emergency Medical Services, Manitoba Health & Healthy Living.

17. Massive Transfusion Protocol for Obstetrical Hemorrhage I. PRINCIPLE The Massive Transfusion Protocol (MTP) for Obstetrical Hemorrhage is intended for antepartum; intrapartum or postpartum patients deemed candidates based on requirement for massive blood volume replacement. Currently at The University Hospital, University of Cincinnati, an MTP is in place. This protocol has been modified to meet the special needs of the obstetrical hemorrhage patient.

18. II. CLASSIFICATION OF OBSTETRICAL HEMORRHAGE A. LOW RISK: Minimal bleeding with reassuring maternal/fetal status. Vaginal bleeding, which will be expectantly managed. B. MODERATE RISK: Vaginal bleeding which requires active management. Transfusion of blood products as well as fetal/maternal intervention may be necessary. C. HIGH RISK: Vaginal bleeding which requires active management. Transfusion of blood products as well as fetal/maternal intervention will be necessary. A subset of these patients will require the implementation of the Massive Transfusion Protocol. Antepartum presentation to ER or OB Triage with abruption, previa or accrete and DIC from any source. Intrapartum hemorrhage immediately following 3 rd stage of labor. Postpartum hemorrhage occurring during recovery period or on postpartum unit

19. III. IMPLEMENTATION OF MTP (HAVE A LOW THRESHOLD FOR INITIATION) A. Criteria for implementation of MTP (any of below) 一. EBL > 2000 cc with ongoing blood loss of >150 cc/min. Obstetricians under estimate blood loss. (Refer to Box 1: Guidelines for Estimation of Blood Loss) 二. Hypotension decrease of BP by 20% in the setting of acute hemorrhage 三. Tachycardia HR >110 in the setting of acute hemorrhage 四. Mental status changes in the setting of acute hemorrhage 五. Chest pain/EKG changes in the setting of acute hemorrhage October 22, 2009

28. Postpartum Hemorrhage Algorithm The following algorithm is based the California Maternal Quality Care Collaborative OB Hemorrhage Protocol. Stage 0 Blood Loss less than 500ml with Vaginal delivery; less than 1000 ml with cesarean section. Stable vital signs All women receive active management of 3rd stage Oxytocin IV infusion or 10 Units IM Vigorous fundal massage for 15 seconds minimum

29. Stage 1 Blood Loss > 500ml Vaginal delivery; > 1000 ml cesarean section 15% Vital Sign change -or-HR equal to or greater than 110, BP equal to or less than 85/45 O2 Sat less than 95%, pallor, delayed capillary refill, or decreased urine output. can indicate Decreased urine output, decreased BP and tachycardia may be late signs of compromise Call for help. Provide adequate ventilation Assist airway protection Establish large-bore intravenous access Supplemental O2 5-7 L/min by tight face mask Prepare 2 units of packed red cells. Evaluate for atony, lacerations, hematoma, inverted uterus, retained tissue, accreta, coagulopathy. Medication for uterine atony  Oxytocin 10-40 units in 1 liter NS or LR IV rapid infusion  Methylergonovine (Methergine) 0.2 milligrams intramuscular q 2-4 hrs up to 5 doses

30. Stage 2 1000-1500 ml estimated blood loss with continued bleeding. Move to operating room Transfuse 2 Units PRBCs per clinical signs Consider thawing 2 Units FFP Order CBC, PT/INR/PTT, Fibrinogen Warm blood products and infusions to prevent hypothermia, coagulopathy and arrhythmias Prostaglandin F2 Alpha (Hemabate) 250 micrograms intramuscular, intramyometrial, repeat q 15-90 minutes, maximum 8 doses Prostaglandin E2 suppositories (Dinoprostone, Prostin E2) 20 milligrams per rectum q 2 hrs Misoprostol (Cytotec) 1000 micrograms per rectum Surgical intervention Vaginal Birth: Atony Bimanual Fundal Massage Retained POC: Dilation and Curettage Lower segment/Implantation site/Atony: Intrauterine Balloon Laceration/Hematoma: Packing, Repair as Required Cesarean Birth: Continued Atony: B-Lynch Suture/Intrauterine Balloon Continued Hemorrhage: Uterine Artery Ligation Hypogastric Ligation (experienced surgeon only)

31. Stage 3 Estimated blood loss gretaer than 1500 ml with continued blood loss. Activate massive transfusion protocol (MTP),  MTP "Pack", to be sent from the Blood Bank is: o 4 units PRBC o 2 OR 4 units FFP o 1 apheresis pack of platelets  Obtain CBC, PT/INR/PTT, and fibrinogen every 4 hours after the standard MTP "Pack" is given. Laboratory studies should be monitored for at least 24 hours after discontinuing the protocol.  Note: 10 units cryoprecipitate should be given for fibrinogen <100mg/dl If bleeding continues after 2 MTP packs have been administered, or women is refusing transfusions (e.g. Jehovah Witnesses), consider recombinant activated factor VII (rFVIIa, NovoSeven®) 60 mcg/kg. May repeat in 30 minutes Surgical intervention  B-Lynch Suture/Intrauterine Balloon  Uterine Artery Ligation  Hypogastric Ligation (experienced surgeon only)  Hysterectomy