1. Initiation of a Massive Transfusion Protocol in the Obstetric Hemorrhage Patient
Brittany Waggoner MSN,RN, AGCNS-BC
Hendricks Regional Health
Danville, IN.

2. Hendricks Regional Health Danville, IN.
Childbirth Center
Labor & Delivery
Postpartum
Level II NICU
Approximately 1,200 deliveries/year

3. Objectives
Identify obstetric hemorrhage and massive transfusion protocol implementation strategies
Explain the purpose of quantified blood loss
Understand how to Standardize a Postpartum Hemorrhage Process to include a Massive Transfusion Protocol
Identify ways to address barriers to implementation

4. Introduction
Obstetric hemorrhage remains one of the leading causes of severe morbidity and mortality in the United States.
The overall rate in the United States increased 26% between 1994 – 2006
Obstetric hemorrhage is one of the National Partnership for Maternal Safety Initiatives.
Bullet 1 – 54-93% of these deaths could have been prevented
Bullet –
This presentation can also pertain to other populations suffering from massive hemorrhage such as trauma (40% of deaths are due to hemorrhage in first 24 hours), post op, Ruptured aneurysms, and GI bleed

6. Implementation Get your Quality Department to start the discussion.
Create OB Harm Quality Improvement Team
Identify which measure is your # 1 priority
OB Hemorrhage
Developed an OB Hemorrhage QI Team
Set a timeline of 6 months
Developed taskforces
Readiness
Response
Recognition
Reporting

7. Readiness
Hemorrhage Cart
Hemorrhage Kit
Resources
Mock Drills

8. Recognition Prenatal Assessment and Planning
Hemorrhage Risk Assessment
Admission
Delivery
Postpartum
Standardize Measuring Blood Loss
QBL vs. EBL
First bullet (are they going to decline blood products?) develop a plan, do they have an bleeding disorder?
2nd Bullet- There are several different population specific risk assessments, such as a GI bleed one
Last bullet – women die from postpartum hemorrhage because they DO NOT receive early initiation of effective interventions

9. Quantified Blood Loss How do you do it? Every Birth, Every Time
Weigh blood soaked items
Measure using calibrated items
Every Birth, Every Time
Standardizes the process
Too late when you “think” you need to do it
Most accurate way to measure blood loss to a cumulative quantification
Blood soaked items examples– “such as peri pads, lap sponges”
Calibrated items examples – under buttocks drapes and containers

10. Estimating Blood Loss
Nine blood soaked items were underestimated by eleven nurses by a total of -7800mls when estimating blood loss.
One RN underestimated by approximately 1500ml

11. Estimating Blood Loss
81% of Nurses failed to accurately capture an obstetric hemorrhage when measuring by estimating blood loss.

12. Estimating Blood Loss

13. Response Advance through Postpartum Hemorrhage Protocol
Mobilize help and blood bank support
Activate Massive Transfusion Protocol
Assist in moving toward invasive surgical approaches to control bleeding.
Advance through medications and procedures. Everyone has a specific role when this is activated.

14. To ensure rapid and timely availability of blood components to facilitate resuscitation.
Overal goal of this care bundle is…

15. Postpartum Hemorrhage Protocol
Stage 0
Every woman in labor/giving birth
Focus on risk assessment and active management of third stage labor
Stage 1
Quantitative blood loss >500ml for vaginal delivery or > 1000ml for cesarean section.
Activate Postpartum Hemorrhage Protocol

16. Postpartum Hemorrhage Protocol
Standardized process
Primary Nurse
First Responder
Second Responder
Recorder
Tech
Manager
Anesthesia
Provider
House Supervisor

17. Postpartum Hemorrhage Protocol
Stage 2
Continued bleeding or vital sign instability, and total blood loss remains < 1500ml
Advance through medications and procedures
Mobilizing help
Stage 3
Total QBL > 1500 ml or > 2 u PRBC’s given, Vital sign unstable, possible DIC
Focus on Massive Transfusion Protocol and invasive surgical control of bleeding.

18. Massive Transfusion Protocol
Collaborative process between medical staff and blood bank to provide blood component therapy for massively bleeding patients.
Adults requiring four units of packed red blood cells within four hours or ten or more units in less than 24 hours would qualify.

19. Process The provider recognizes the need for and initiates
Call is made to the blood bank to initiate with the appropriate patient information
Runner is sent to pick up 2 units of “O-Negative” uncrossmatched PRBC’s.
They will stay stationed in the Blood Bank when not delivering blood.
Additional MTP packs are sent continuously
Blood Bank will continue to supply MTP packs until the someone notifies them to stop.

20. MTP Pack
Package
PRBC
PLASMA
PLATELETS
CRYO 1 4 - 2 3

21. Addressing the Barriers
Difficulty obtaining blood product in a timely manner when patients did not have a Type & Screen upon admission
Began Type & Screening every laboring patient’s blood upon admission.
Reduced our process steps by 60% and crossmatched blood is available immediately.

22. Addressing the Barriers
Lack of trust in the process
Mock Drills!

23. Results

24. Results
Reduced Blood Product Administration by 37%

25. Summary Most maternal mortalities and near misses due
to hemorrhage are preventable
Preparation is key
1/3 of patients will have no risk factors prior to labor
Must be prepared for every patient
QBL every delivery so can respond early
Requires support not on individuals but on team approach

26. Summary Early recognition Team work
Sequential standardized application of patient monitoring, evaluation, medications, and procedures
What resources are available
‥ What resources need to be developed
‥ Do all team members know what they are and how
 Aggressive early therapy including transfusion when bleeding continues
empowering any team member to activate protocol and call for help

27. References Awhonn PPH Project.
Behringer G, Albright N. Diverticular disease of the colon: a frequent cause of massive rectal bleeding. Am J Surg 1973;1 25:
California Maternal Quality Care Collaborative; OB Hemorrhage Toolkit V. 2.0
Committee on Trauma: Advanced Trauma Life Support Manual. Chicago: American College of Surgeons; 1997:
Holcomb JB, McMullin NR, Pearse L, et al. Cause of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–991.
Kauvar, D.S., Lefering, R., and Wade, C.E. (2006) Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 60, S3-11
Patel A, Walia R, Patel D.Blood loss: accuracy of visual estimation in A Textbook of PostPartum Hemorrhage (ed C. B-Lynch et al.)Sapiens Publishing Oct 1, 2006
Riggs BM, Ewing MR. Current attitudes on diverticulitis with particular reterence to colonic bleeding. Arch Surg 1966;92:
World Health Organization. Recommendations for the prevention and treatment of postpartum haemorrhage. Geneva 2012.