1. MATERNAL HEMORRHAGE

2. Prevention of Maternal Death High Rate of Maternal Death due to hemorrhage High Rate of Maternal Death due to hemorrhage Most women who died of hemorrhage (97%) were hospitalized at the time of their death Most women who died of hemorrhage (97%) were hospitalized at the time of their death To reduce the risk of death the ACOG/DOH recommends: To reduce the risk of death the ACOG/DOH recommends: –Effective guidelines for maternal hemorrhage –Prompt recognition and response to hemorrhage DO NOT DELAY TRANSFUSION WHILE AWAITING LAB RESULTS OR HEMODYNAMIC INSTABILITY

3. Prevention of Maternal Death Recommendations Effective guidelines to respond, including emergency transfusion, with coordination among obstetricians, nurses, anesthesia and Blood Bank Effective guidelines to respond, including emergency transfusion, with coordination among obstetricians, nurses, anesthesia and Blood Bank Be vigilant to blood loss, if clinical judgment indicates transfusion, do not delay awaiting lab results, slow blood loss can be life threatening Be vigilant to blood loss, if clinical judgment indicates transfusion, do not delay awaiting lab results, slow blood loss can be life threatening

4. Prevention of Maternal Death Recommendations Use fluid resuscitation and transfusion based on estimated blood loss and expectation of continued bleeding Use fluid resuscitation and transfusion based on estimated blood loss and expectation of continued bleeding Work with Labor and Delivery on Maternal Hemorrhage Drills Work with Labor and Delivery on Maternal Hemorrhage Drills Conduct Continuing Medical Education for the entire medical team Conduct Continuing Medical Education for the entire medical team

5. Informed Consent Identify patients who express concerns about receiving blood products for any reason (i.e Jehovah Witness) Identify patients who express concerns about receiving blood products for any reason (i.e Jehovah Witness) Ensure that the patient has adequate opportunity to speak to an obstetrician and an anesthesiologist regarding her concerns and the risks/benefits Ensure that the patient has adequate opportunity to speak to an obstetrician and an anesthesiologist regarding her concerns and the risks/benefits Ensure that the “ Consent/Refusal to Blood Products” form is signed Ensure that the “ Consent/Refusal to Blood Products” form is signed

6. Refusal of Blood Products All L&D personnel must be notified when there is a patient on the floor who refuses blood products All L&D personnel must be notified when there is a patient on the floor who refuses blood products Identify a health care proxy who can make decisions for the patient if she is unable Identify a health care proxy who can make decisions for the patient if she is unable Consider cell saver back up Consider cell saver back up

7. Risk Assessment for Hemorrhage

8. Low Risk First or early second trimester D&C without history of bleeding (scheduled) First or early second trimester D&C without history of bleeding (scheduled) Cerclage Cerclage Vaginal Birth Vaginal Birth –No previous uterine incision –No history of bleeding problems –No history of PP hemorrhage –Four or less previous vaginal births –Singleton pregnancy

9. Low Risk Send “Hold” specimen to the Blood Bank Send “Hold” specimen to the Blood Bank If patient’s status changes, notify blood bank to perform type and screen and/or type and cross match If patient’s status changes, notify blood bank to perform type and screen and/or type and cross match Examples include need for c/section, PP hemorrhage, chorioamnionitis, prolonged labor and exposure to oxytocin Examples include need for c/section, PP hemorrhage, chorioamnionitis, prolonged labor and exposure to oxytocin

10. Moderate Risk VBAC VBAC Cesarean sections Cesarean sections Multiple gestations or macrosomia Multiple gestations or macrosomia History of prior post partum hemorrhage History of prior post partum hemorrhage Uterine fibroids Uterine fibroids Mid to late second trimester D&Es or induced vaginal births Mid to late second trimester D&Es or induced vaginal births Other increased risks as designated by physician Other increased risks as designated by physician

11. Moderate Risk Type and screen to Blood Bank Type and screen to Blood Bank CBC with platelets CBC with platelets Additional labs as per OB Additional labs as per OB Consider cell saver for Jehovah Witness or any other patient who refuses blood products Consider cell saver for Jehovah Witness or any other patient who refuses blood products

12. High Risk Placenta previa Placenta previa Suspected placenta accreta Suspected placenta accreta Hematocrit less than 26 Hematocrit less than 26 Vaginal bleeding on admission Vaginal bleeding on admission Coagulation defects Coagulation defects Other high risks as designated by the physician Other high risks as designated by the physician

13. High Risk Type and screen and cross match for 4 units Type and screen and cross match for 4 units CBC, PT, PTT, Fibrinogen CBC, PT, PTT, Fibrinogen Second large bore IV Second large bore IV Anesthesia to prepare Hot Line Anesthesia to prepare Hot Line Cell saver team on stand-by Cell saver team on stand-by 1-800-235-5728 1-800-235-5728 (****especially for Jehovah’s Witness****)

14. MATERNAL BLOOD VOLUME Non pregnant female3600 ml Non pregnant female3600 ml Pregnant female (near term)5400 ml Pregnant female (near term)5400 ml

15. DEGREES OF BLOOD LOSS Volume Estimate PercentType 500 ml or > 10-15%compensated 1000-1500 ml 15-25%mild 1500-2000 ml 25-35%moderate 2000-3000 ml 35-50%severe

16. Caveats for the Pregnant Patient If the Obstetric Staff is considering transfusing a pregnant patient anesthesia should be notified If the Obstetric Staff is considering transfusing a pregnant patient anesthesia should be notified Blood loss is almost always underestimated (especially after vaginal birth) Blood loss is almost always underestimated (especially after vaginal birth) Pregnant patients can lose up to 40% of their blood volume (compared to 25% in non- pregnant patients) before showing signs of hemodynamic instability Pregnant patients can lose up to 40% of their blood volume (compared to 25% in non- pregnant patients) before showing signs of hemodynamic instability Don’t wait for hypotension to start replacing volume Don’t wait for hypotension to start replacing volume

17. Causes of PP Hemorrhage Uterine Atony Uterine Atony Lacerations to the cervix and genital tract Lacerations to the cervix and genital tract Retained placenta and other placental abnormalities Retained placenta and other placental abnormalities Coagulation disorders Coagulation disorders

18. Risk Factors for Uterine Atony Multiple gestation Multiple gestation Macrosomia Macrosomia Polyhydramnios Polyhydramnios High Parity High Parity Prolonged labor especially if augmented with oxytocin Prolonged labor especially if augmented with oxytocin Precipitous labor Precipitous labor Chorioamnionitis Chorioamnionitis Use of tocolytic agents Use of tocolytic agents Abnormal placentation Abnormal placentation

19. Trauma to the Genital Tract Large episiotomy, including extensions Lacerations of perineum, vagina or cervix Ruptured uterus

20. Placental Abnormalities Retained placenta Retained placenta Abnormal placentation Abnormal placentation –Accreta –Percreta –Increta –Previa

21. Coagulation Abnormalities DIC (may result from excessive blood loss) Thrombocytopenia abruption ITP TTP Pre-eclampsia including HELLP Syndrome Anticardiolipin/Antiphospholipid Syndrome

22. IDENTIFICATION AND EVALUATION Assessment: Assessment: –Mental Status –Vital Signs including BP, Pulse and O 2 saturation –Intake: Blood Products and Fluids –Output: Urine and Blood Loss –Hemoglobin and Hematocrit –Assess uterine tone and vaginal bleeding

23. Identify Team Leaders (MD/RN) Identify Team Leaders (MD/RN) Call Code Noelle MFM on-call Anesthesia Attending Blood Bank Director Antepartum Back-up (if MFM is primary OB) L&D Nurse Manager ADN

24. MANAGEMENT Non-surgical IDENTIFY CAUSE OF BLEEDING Examine : Uterus to r/o atony Uterus to r/o rupture Vagina to r/o laceration

25. MANAGEMENT Non-surgical Management Management –Atony: –Atony: Firm Bimanual Compression Order – –Oxytocin infusion – –15-methyl prostaglandin F2alpha IM – –Second line:   (methergine (if BP normal), PGE1, PGE2)

26. MANAGEMENT: Non-surgical Hypovolemic Shock Management: – –Secure 2 large bore IVs, consider a central venous catheter – –Insert indwelling foley catheter Order: – –LR at desired infusion rate – –Second line NS with Y-Type infusion set – –Two units of PRBCs for stat infusion – –Cross match 4 additional units of PRBCs – –Thaw 4 units of FFP – –Supplemental O 2 at 8-10 L Non re-breather mask

27. MANAGEMENT: Non-surgical Nursing Registered Nurses: – –Administer O2 at 8-10 L face mask – –Cardiorespiratory, BP and SAO 2 monitors – –Secure 2 Large bore IVs – –Pick up orders as written – –Administer warmed IV Fluids – –Administer Blood Products – –Insert indwelling foley catheter – –Trendelenberg position – –Administer medications

28. MANAGEMENT: Non-surgical Nursing Nursing Station Clerks: – –Enter Lab and Blood Bank Orders – –Page all members of Maternal Hemorrhage team – –Await addition instructions for:   Cell Saver Team   Gyn-Oncology Surgeon

29. MANAGEMENT: Non-surgical Nursing Clinical Assistants: – –Assists RN/MD as needed – –Prep OR; including gyn long, hysterectomy and/or gyn surgery trays – –Pick up blood products from Blood Bank – –Obtain Blood/Fluid Warmer – –Obtain Cell Saver Equipment from OR

30. MANAGEMENT: Surgical OR Personnel OB Attending OB Attending MFM Back up MFM Back up OB Resident(s) OB Resident(s) Anesthesia Attending Anesthesia Attending Anesthesia Resident(s) Anesthesia Resident(s) 2 Circulating RNs 2 Circulating RNs 1 Scrub Tech/RN 1 Scrub Tech/RN Gyn-Onc Surgeon (prn) Gyn-Onc Surgeon (prn) Interventional Radiology (prn) Interventional Radiology (prn) Cell Saver Personnel (prn) Cell Saver Personnel (prn)

31. MANAGEMENT: Surgical OR Equipment Trays Trays –Gyn Long Tray –Hysterectomy Tray –Gyn Surgery Tray Cell Saver Equipment Cell Saver Equipment Preparation of fibrin glue Preparation of fibrin glue (1-30 ml syringe with 2 vials Topical Thrombin + 0.5 ml of 10% CaCl, 1-30 ml syringe with 30 ml of cryoprecipitate, both attached to 18 g angiocaths)

32. MANAGEMENT: Surgical ANESTHESIA Team Coordinator Team Coordinator Airway management Airway management Hemodynamic Monitoring Hemodynamic Monitoring Fluids Fluids Blood Products Blood Products Output Output

33. MANAGEMENT: Surgical OBSTETRICIAN/SURGEON Control Source of Hemorrhage Control Source of Hemorrhage Perform indicated Procedure: Perform indicated Procedure: –REPAIR LACERATION –BILATERAL UTERINE ARTERY LIGATION –BILATERAL HYPOGASTRIC ARTERY LIGATION –HYSTERECTOMY Utilize additional resources if surgery continues and emergency transfusion is occurring (Gyn- Onc Surgeon) Utilize additional resources if surgery continues and emergency transfusion is occurring (Gyn- Onc Surgeon) Consider Interventional Radiology Consider Interventional Radiology

34. MANAGEMENT: Surgical NURSING Assist anesthesia as needed Assist anesthesia as needed Assist with surgery (scrub/circulate) Assist with surgery (scrub/circulate) Assess for the need for further additional surgical expertise Assess for the need for further additional surgical expertise Ongoing surgery with emergency transfusion continuing Obtain NICU as needed if infant undelivered Obtain NICU as needed if infant undelivered Obtain/administer medications as needed Obtain/administer medications as needed

35. Post-op Disposition Anesthesiologist and obstetrician will determine post op disposition of the patient and call appropriate consults ( i.e. SICU attending) Anesthesiologist and obstetrician will determine post op disposition of the patient and call appropriate consults ( i.e. SICU attending) All intubated patients must go to the SICU All intubated patients must go to the SICU Other patients at anesthesiologist’s discretion Other patients at anesthesiologist’s discretion Nursing to give report to SICU Nursing to give report to SICU

36. Summary Maternal hemorrhage remains the number one cause of maternal death in NYS Maternal hemorrhage remains the number one cause of maternal death in NYS Identification of high risk patients can prevent severe complications Identification of high risk patients can prevent severe complications Early intervention for the low risk patient who starts to bleed is also crucial Early intervention for the low risk patient who starts to bleed is also crucial Proper communication between nursing, OB, anesthesia and neonatology will provide best outcome for mother and baby Proper communication between nursing, OB, anesthesia and neonatology will provide best outcome for mother and baby