1. Maternal Affinity Group September 25, 2013

2. Objectives Name at least 3 of the core elements of Postpartum Hemorrhage Identify the need for a risk factor Postpartum Hemorrhage admission assessment Understand the necessity of accurately assessing blood loss for Postpartum Hemorrhage

3. Why is this important? Postpartum Hemorrhage occurs in about 18% of births Common cause of maternal morbidity massive transfusions secondary surgical procedures ICU admissions fertility loss

4. Early Intervention is the KEY Early intervention requires the following: Recognition of risk factors leading to heightened surveillance; Standardized approach to estimating blood loss; The use of clinical triggers or alerts such as: heart rate (>/= 110) blood pressure ( 15% drop) oxygen saturation (<95%)

5. Core Elements Develop a policy for PPH with the at least the following components: Definition of PPH for your institution Risk Factors Initial Interventions Medical Treatments Surgical Treatments Defined Care Team and Role Clarity Checklist Algorithm Transfusion Policy Drills

6. Obstetric Hemorrhage Key Element Checklist Highest Priority: Unit-standard OB Hemorrhage protocol Hemorrhage Cart Partnership with Blood Bank Post-event debrief/huddle Assessment of hemorrhage risk on admission Assessment of cumulative blood loss

7. Hemorrhage Risk Assessment

8. Hemorrhage Cart OB Hemorrhage Cart: Recommended Instruments (California Maternal Quality Care Collaborative - CMQCC) Set of vaginal retractors (long right angle); long weighted speculum Sponge forceps (minimum: 2) Sutures (for cervical laceration repair and B-Lynch Vaginal Packs Uterine balloon Banjo curettes, several sizes Long needle holder Uterine forceps

9. Hemorrhage Medication Tray As recommended by CMQCC Pitocin 20 units per liter NS 1 bag Hemabate 250 mcg/ml 1 ampule Cytotec 200mg tablets 5 tabs Methergine 0.2 mg/ml 1 ampule

10. Partnership with Blood Bank Have a partnership with your blood bank for especially for PPH Involve them in the protocols (even development of them) Make sure they have what you need and can get it quickly They also make for a great partner in data collection

11. Assessment of Blood Loss Often blood loss in underestimated Develop a standard in your hospital Important to have training involving the estimation of blood loss >500 ml for vaginal birth >1000 ml for cesarean birth may be the most common clinical definition in the U.S

12. Estimating Blood Loss Methods for quantifying blood loss: 1.Percent saturation of blood soaked items with visual cues: pictures, posters 2.Weighing blood soaked pads/chux 3.Collecting blood in graduated measurement container Important to standardize methods in hospital that everyone understands and is trained to use!

13. Slide 13

14. S lide 14

15. Slide 15 British Journal of Anaesthesia;Hemostatic Monitoring During Postpartum Hemorrhage and Implications for Management; C. Solomon, R. E. Collis, P. W. Collins;DisclosuresBr J Anaesth. 2012;109(6):851-863

16. Post-Event Important to debrief the event Establish a culture of ALWAYS performing a huddle/debrief using a tool: CMQCC Debrief Form Mini-RCA IHI Trigger Tool

17. Slide 17

18. References http://mail.ny.acog.org/website/Optimizing_Hemorrhage/Sim ulation_Drills.pdf http://mail.ny.acog.org/website/Optimizing_Hemorrhage/Sim ulation_Drills.pdf http://mail.ny.acog.org/website/optimizing_hemorrhage/defi nition_early_recognition.pdf http://mail.ny.acog.org/website/optimizing_hemorrhage/defi nition_early_recognition.pdf http://www.pqcnc.org/documents/fpqc/FPQCOHIHospitalImp lementationGuide.pdf http://www.pqcnc.org/documents/fpqc/FPQCOHIHospitalImp lementationGuide.pdf http://www.cmqcc.org/resources/ob_hemorrhage/protocols_ guidelines http://www.cmqcc.org/resources/ob_hemorrhage/protocols_ guidelines

19. Questions? Lynne Hall lhall@gha.org 770-249-4525