1. OB Emergencies for Dummies
(Not so)
OB Emergencies for Dummies
Presenters: Maj Karin Van Doren, Maj Niki Kamboris & Capt Gretchen Waldvogel

2. Goals/Objectives Collegial sharing of lessons learned
Checklists; what works
OB checklists: what’s out there
AF attempt at standardized protocols
Drugs and dosages commonly used in some emergency situations
TeamSTEPP principles in communications & drills

3. CHECKLISTS General background info
30 Oct 1935: Test flight of Boeing’s Model 299
Maj Hill, expert pilot…Fiery crash; deaths due to “pilot error”— “too much airplane for one man to fly”.
2001: Peter Pronovost: central line placement
"Safe Patients, Smart Hospitals” (2010).
Dr Atul Gawande (2007) Classic Article “The Checklist” (2009) The Checklist Manifesto: How to Get Things Right (book)

4. Effective Checklists & Strategies from Aviation to Medicine
Checklists are focused, unambiguous, succinct
No unintended consequences from checklist use
Evidence based, discrete tasks identified
Team work training, improve communication--Time outs/pt hand-offs
Non punitive incident reporting
Standardization
Simulator training

5. Checklists What they can’t solve
Errors due to lack of skills, training or experience
Checklists can standardize behavior but not “attention”
Practice issues when there is no established “gold standard”
Support/cultural change when Leadership is not engaged

6. The original Pronovovst “checklist” for central line placement
Based on CDC recommendations:
Wash hands
Use full-barrier precautions (drape pt from head to toe)
Clean skin with chlorhexidine
Avoid use of femoral site, if possible
Remove any unnecessary catheters

7. Success aided by:
Involvement from the top down: senior executives of health care system requested participation in study
“Daily goal sheets” implemented to improve clinician-to-clinician communication
Comprehensive unit –based safety program: assisted by patient safety/infection control depts
At least one MD and one RN team led each new step

8. Success…
Terminology standardized—NNIS (Nat’l Nosocomial Infections Surveillance System/CDC) definition of catheter-related blood stream infection used
Exact definition of central catheter, which could include a central catheter which was peripherally inserted
Defined “catheter day” so time of indwelling catheters would match

10. Post Partum Hemorrhage
Rate of maternal death by PPH increased 26 – 28% since 1994: uterine atony not explained by increased rates of c/s, VBAC, maternal age, multiple birth, HTN, diabetes Callaghan (2010) Bateman (2010)
Maternal deaths tripled between (CMQCC)
Nationwide, blood transfusions increased 92% during deliveries between ‘97-’05 Kuklina (2009)
Aviano: Sentinel event

11. Changes of pregnancy
Maternal blood volume  50%; plasma volume more than RBC vol: slight  hgb/hct
-fulfills perfusion demands of low-resistance uteroplacental unit, reserve for blood loss
Coagulation system: Increase in clotting factors/decrease fibrolytic activity
Uterine ctx: crisscrossing muscle bundles, occlude, contract, retract following expulsion of placenta: living ligature/physiologic sutures

12. Can we have an effective checklist?
Response to PPH is reactive not proactive
There is no established “Gold Standard” for PREVENTION of PPH
There is no one consensus for management of PPH, but many avenues
Triggers: Response based on clinical appearance (it may be too late…)
IN US clinically accepted >500 ml (vag) 1000 ml (c/s) Does not take into account initial volume status, arbitrary, may be clinically irrelevant to hemodynamic compromise (CMQCC)

13. Current recommendations
“Known” risk factors: 39% of cases had one or more: Numerically, more women die with no known risk factors
WHO, ACOG, SGOC recommendations (1A):
Injectable Oxytocin by skilled provider. 10 mu IM or 20 mu+ IV in IVF after delivery of anterior shoulder

14. Recommendations
Objective quantification of blood loss: Graduated collection containers, weigh blood soaked chux/pads (CMQCC, WHO)
Vital sign triggers (NHS, CMQCC)
If it isn’t working, don’t waste time…move on (CMQCC)
After 2 units PRBC start FFP then 1RBC:1FFP:1 PLT (CMQCC, Iraq theatre: Borgman, M. )

16. NHS Triggers RR (red) < 10 > 30 RR (Amber) 21-29
O2 sat less than 95% (red)
T greater than 38 C (red)
Pulse (red) > 120 <40
P (Amber) > 100 <50
Pain 2-3 (red) but not 2-3/10: 2 means moderate, 3 severe pain
SBP >170 <80 (red)
>160 < 90 (amber)
DBP >110 (red)
> 100 ( amber)
DBP No lower limit
No uterine tone
No uterine tone

18. CMQCC Triggers EBL > 500 ml or hemodynamic instability (vag)
HR ≥ 110
BP ≤ 85/45 or noted > 15% drop
02 sat < 95%

24. Current AF triggers
Calculate MAP every 15 min for first 6 hours ; Want MAP > 65 mmHG MAP = (2x DBP) + SBP 120/80 = MAP of 93 3 Or SBP-DBP = x , then x ÷ 3, then add that number to DBP RR first trigger

28. Emergency OB Medications
Capt Gretchen Waldvogel

29. Uterotonic Agents Oxytocin (Pitocin) Methylergonovine (Methergine)
Carboprost (Hemabate)
Misoprostol (Cytotec)

30. Oxytocin **First line treatment for PP Hemorrhage Action:
Stimulates the upper uterine segment of the myometrium to contract rhythmically, constricts spiral arteries and decreases blood flow to uterus.
Dose: 10mu injected Intramuscularly or 20-60mu in 1000ml

31. Methergine
Action: Causes smooth muscle contraction in upper/lower uterine segments
Dose: 0.2mg IM, may be repeated PRN every two to four hours or Intrauterine by MD
Contraindicated in pts with Pre-Eclampsia or Hypertension because it causes raised blood pressure
Adverse Effects: nausea and vomiting

32. Hemabate
Action: Enhances uterine contractility and causes vasoconstriction
Dose: 0.25mg intramuscularly or Intrauterine by provider, can be repeated every 15 min for a total dose of 2mg
Contraindicated in pts with Asthma, Cardiac disease
Side Effects: Nausea, vomiting, DIARRHEA, hypertension, and flushing
Consider Immodium therapy as countermeasure

33. Cytotec
Action: Increases uterine tone and decreases postpartum bleeding
Dose: 200mcg-1000mcg sublingually, orally, vaginally, or rectally
**Recommended 1000mcg rectally
Side Effects: Shivering, pyrexia, and diarrhea
** Not approved by FDA for this indication

35. Hypertensive Disorder
Magnesium Sulfate
Hypertensive Disorder

36. Magnesium Sulfate Action: Acts peripherally to produce vasodilation
Dose: Adjusted for situation, Loading VS. Maintenance dose
---Can be given IM if no IV access
Side Effects: Flushing, sweating, nausea, fatigue, hypotension, CNS depression, depressed reflexes and respiratory effort

37. Safety Issues ** Use pre-mixed preparations from the pharmacy
---Compatible with LR or NS
All doses given should be on IV pump and Buretrol/Volutrol should be used
For all boluses, set VTBI at 100ml
Total IV intake should be 125ml/hr unless otherwise ordered by MD

39. Hypertension Box Aids Labetalol Hydralazine Hydrochloride
Diazepam (Valium)
Calcium Gluconate 10%

40. Labetalol Use multidose vial 100mg/20ml (5mg/ml)
Compatible with LR, NS, D5LR, D5W, D5 1/4NS
Give IVP over 2 min
Take B/P every 5 min
Initial dose usually 20mg with increasing doses of 40-80mg every 10min until max dose of 300mg
Doses using 100mg/20ml vial:
-20mg ordered: give 4ml
-40 mg ordered: give 8ml
-80mg ordered: give 16ml

41. Hydralazine
Use 20mg/ml single use vial Dose is 5mg (0.25ml) Compatible with LR, NS Give IVP over 1min, SLOW IVP Take B/P every 5min Initial dose done, then wait 20min before giving next dose, onset of action is 10-20min Repeat doses 5mg (0.25ml) to 10mg (0.50ml) every 20min up to total dose of 20mg If giving 10mg dose(0.50ml) give slowly over at least 2 min DO NOT GIVE HYDRALAZINE IN THE SAME IV LINE AS MAGNESIUM SULFATE (Either turn off the Magnesium Sulfate and flush the line or start a second IV)

42. Diazepam
Use 10mg/2ml Tubex (5mg/ml) **Turn off Magnesium Sulfate Infusion and Disconnect From IV** Compatibility: give directly into IV at closest port to patient. Not recommended to mix with any solution. Has variable stability in NS, LR, and D5W Give 5mg/ml over at least 1 min May repeat doses in 10 min up to a dose of 20mg (Minimum of 10 min wait time)

43. Calcium Gluconate 10%
Use 10ml single use vial containing 100mg/ml (1 GM total dose) **Discontinue Magnesium Sulfate Infusion and Disconnect From IV** Compatible with LR, NS, D5LR, D10W, D5NS, D5W Give Slowly, Use Entire Vial Give at rate of 2ml/min OR Give the entire dose over 3 to 5 min Patient should be hooked up to an EKG if able- Especially if you need to repeat doses Stop After 3 Doses OR 3 GM

44. Team STEPPS
Principles in Communication/Drills/ Lessons Learned

45. Why use Team Stepps?
Goal: Produce highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes.
Teams of individuals who communicate effectively and back each other up dramatically reduce the consequences of human error

47. PUTTING Team STEPPS IN ACTION
MOES (Mobile Obstetric Emergency Simulator)
- simulated various scenarios (breech, stat c/s, shoulder dystocia, PPH, NRP, etc)
- various “issues” or areas for improvement brought to light
- continued drills, repetition strengthened use of Team Stepps principles

48. MOES TRAINING FEEDBACKS
COMMUNICATION ISSUES:
overhead paging system, call phones, training day?, who is in charge?, communication with clinic to L&D staff
SBAR vital to role clarity, proper hand-off and situational awareness
Closed-loop communication promotes understanding of order, report, etc.
Shared mental model promotes universal understanding of the scenario and what’s needed

49. MOES TRAINING FEEDBACKS, cont’d
LOGISTICAL ISSUES:
lack of standardization with supplies, medication access, knowledge of use of equipment, code blue vs. rapid response
Creation of emergency med boxes, med cards and algorithms binder
Standardized location of supplies in all LDR’s
Re-trained on use of equipment not consistently utilized
Revision of code blue MDGI with addition of RRT (Rapid Response Team)

50. MOES TRAINING FEEDBACKS, cont’d
MOTIVATION: staff motivation level high
increased occurrence/depth of training scenarios raises awareness of areas of self-improvement, empowers staff
Positive feedback on what we did well (debriefs)
Builds teamwork, rely on strengths of each member
Leadership supportive- makes changes when identified to promote patient safety

51. Lessons Learned
MOES, huddles, drills, debriefs promote Team STEPPS principles
Proof of importance of SBAR/communication to decrease patient errors
Confidence builder for response to emergency situations

52. References
ACOG, Practice Bulletin Number 76, Postpartum Hemorrhage, Bateman, B. et al (2010), The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries, Anesthesia and Analgesia, 110(5) Borgman, M, et al (2007) The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital, Journal of Trauma, 63: California Maternal Quality Care Collaborative, Obstetric Hemorrhage: New Strategies, New Protocol (2010)/ Improving Health Care Response to Obstetric hemorrhage (2010) Callaghan, W, Kuklina E & Berg C. (2010), Trends in postpartum hemorrhage: United States , American Journal of Obstetrics and Gynecology, 202(4), 353. Kuklina, E. et al (2009) Obstetric Morbidity in the US , Obstetrics and Gynecology (113),

53. References
Matthews, M., Gulmezoglu, A. & Hill, S (2007) Saving womens lives: evidence-based recommendations for the prevention of postpartum haemorrhage, Bulletin of the World Health Organization, 85(4) Provonost, P et al (2006), An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU, The New England Journal of Medicine, 335 (26), RCOG (2009), Prevention and Management of Postpartum Haemorrhage, Green Top Guideline 52 Smith, J., & Brennan, B. (2009), Management of the Third Stage of Labor, Medscape, eMedicine Specialties, Obstetric and Gynecology, Labor and Delivery SOGC Clinical Practice Guideline: Active Management of the Third Stage of Labour: Prevention and Treatment of Postpartum Hemorrhage, No 235, Oct 2009.