Blood Management for the

Obstetric Patient

An overview with recommendations for managing patients

experiencing obstetric hemorrhage

Publication Date: October 2024

For more information, please visit: MPOG

Patient Blood Management Toolkit

Toolkit Overview

• This presentation is part of a Patient Blood Management Toolkit offering an overview of

transfusion practices and considerations for cardiac and pediatric surgery as well as

general recommendations for patient blood management.

• For other patient blood management recommendations please reference additional

toolkit components:

 Perioperative Transfusion - Overview of Incidence, Risks, and Costs Associated with Transfusion

 Patient Blood Management - Transfusion Considerations for Adult Surgical Patient

 Blood Management for the Cardiac Surgical Patient (Coming soon!)

 Blood Management for the Pediatric Surgical Patient (Coming soon!)

Thomas Klumpner, MD – University of Michigan

Brandon Togioka, MD – Oregon Health and Sciences University

Nirav Shah, MD – MPOG

Nicole Barrios, MHA, BSN – MPOG

Kate Buehler, MS, RN - MPOG

Kimberly Finch, MS, RN – Henry Ford Health System

Acknowledgements

Objectives

Provide an overview of obstetric (OB) hemorrhage

Explain the primary causes and risk factors associated with obstetric hemorrhage

Discuss risks and outcomes associated with transfusion in the obstetric population

Share general recommendations when caring for the OB hemorrhage patient based on the

American College of Obstetricians and Gynecologists (ACOG) guidelines

Review massive transfusion / OB hemorrhage protocols

Discuss methods for evaluating and monitoring practices within the healthcare setting to

ensure continuous improvement

Describe MPOG QI measures in this domain

Sections

1. Obstetric Hemorrhage: Incidence and Impact

2. Definitions of OB Hemorrhage

3. Management of Obstetric Hemorrhage

4. Additional Recommendations

5. MPOG Transfusion QI Measures

Section I:

Obstetric Hemorrhage –

Incidence & Impact

References:

1. Pregnancy-related deaths data. (May 2024). Maternity Mortality Prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-

surveillance/?CDC_AAref_Val=https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2020

Pregnancy-Related Mortality Ratio

*Per 1,000 live births

Mortality Ratio

• Postpartum hemorrhage remains a leading cause of maternal mortality

• Many deaths from PPH may be preventable.

Pregnancy Related Mortality in the US

Data from CDC Pregnant Mortality Surveillance System

Maternal Death Rate by Country

• Rates of maternal mortality in the United States are more than double compared to other developed countries

• Black women have the highest maternal death rate

• Studies suggest that positive patient experiences correlate with lower mortality rates

References:

1. Munira Z. Gunja et al., Insights into the U.S. Maternal Mortality Crisis: An International Comparison (Commonwealth Fund, June 2024). https://doi.org/10.26099/cthn-st75

2. Guan, T., Chen, X., Li, J., & Zhang, Y. (2024). Factors influencing patient experience in hospital wards: a systematic review. BMC Nursing, 23(1), 527. https://doi.org/10.1186/s12912-024-02054-0

*Maternal deaths per 100,000 live births

Incidence & Impact of Postpartum Hemorrhage

The prevalence of PPH in the United States is currently at 11% and is on the

rise.

Uterine atony is the primary cause of PPH and accounts for 70-80% of all

hemorrhages.

Approximately 14 million women experience PPH annually, resulting in

approximately 70,000 maternal deaths (globally).

According to the World Health Organization (WHO), many survivors are often

left with lifelong reproductive disability.

References:

1. Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute Postpartum Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

2. Postpartum haemorrhage. (May 29, 2023). Life Saving Solution dramatically reduces severe bleeding after childbirth. https://www.who.int/teams/sexual-and-reproductive-health-and-

research-(srh)/areas-of-work/maternal-and-perinatal-health/postpartum-haemorrhage

Postpartum Hemorrhage - figures and facts

• Primary PPH is 1L of blood loss within 24 hours of delivery or blood loss

accompanied by signs or symptoms of hypovolemia.

• Uterine atony, the primary cause of PPH, accounts for approximately 80% of PPH.

• Postpartum hemorrhage can cause a reduction in blood pressure and perfusion to

the brain and other vital organs.

• Many deaths from PPH are likely preventable.

2-3

References:

1. Menard MK, Main EK, Currigan SM. Executive summary of the reVITALize initiative: standardizing obstetric data definitions. Obstet Gynecol 2014;124:150–3.

2. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

3. A Roadmap to combat postpartum haemorrhage between 2023 and 2030. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.

MPOG Data: Transfusion during cesarean delivery

For MPOG sites where cesarean deliveries are performed, 1-4% of cases received a blood

transfusion in the perioperative time period.

• Across MPOG sites, more than half of cesarean hysterectomies received a blood transfusion.

• A common indication for unplanned cesarean hysterectomy is uterine atony, which can lead to PPH.

Higher rates of transfusion for this patient population is expected due to the patient's acuity.

MPOG Data: Transfusions during Cesarean Hysterectomy

Section II:

Obstetric Hemorrhage Defined

Obstetric Hemorrhage Categories

Antepartum hemorrhage (APH) -

before delivery

•Primary vs. Secondary

•Severe vs. Life-threatening

Postpartum hemorrhage (PPH) -

after delivery

References:

1. Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute Postpartum Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

2. Munoz, M., Stensballe,. J., Ducloy-Bouthors, A., Bonnet, M., DeRobertis, E., Fornet, I., Goffinet, F., Hofer, S., Holzgreve, W., Manrique, S., Nizard, J., Christoru, F., Samama, C., Hardy, J. (2019) Blood Transfusion Vol 17; 112-

36. “Patient Blood Management in Obstetrics: Prevention and Treatment of Postpartum Haemorrhage. A NATA Consensus Statement.

3. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

4. Bellamy, C. (2024, February). Black women may prefer Black OBs due to fear of discrimination, dying during pregnancy. NBC News. https://www.nbcnews.com/health/health-news/black-woman-may-prefer-black-obs-

due-fear-discrimination-dying-pregnan-rcna138456

Antepartum Hemorrhage Considerations

• Common causes of APH include placenta previa, cervical bleeding and placental abruption

• Treatment may include antenatal corticosteroid (once bleeding is controlled) between 24 and

32 weeks if preterm birth is anticipated

. Type and crosscheck should be completed at

admission to avoid delays in receiving blood if needed.

• Immediate delivery of fetus if fetal or maternal health is compromised/suspected

• The OB anesthesia team will plan for PPH and may notify the blood bank for potential

Massive Transfusion Protocol

Types of Placenta Previa

Placental abruption

References:

1. Linder, Grace E., and Tina S. Ipe. 2022. “Pregnancy and Postpartum Transfusion.” Annals of Blood 7 (March): 12–12

2. Hacker NF, Moore JG, editors: Essentials of obstetrics and gynecology, 2nd ed. Philadelphia, WB Saunders, 1992, p 156.

3. Casanova R, Beckmann CRB, Ling FW, et al. Beckmann and Ling’s Obstetrics and Gynecology. 8th ed. Philadelphia, PA: Wolters Kluwer; 2018.

PPH: Primary vs. Secondary

 Primary (PPH): Blood loss > 1000 ml regardless of mode of delivery or

bleeding associated with signs of hypovolemia

within 24 hours of the birth

process.

 Secondary PPH: Blood loss of more than 500ml > 24 hours after delivery

References:

1. Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute Postpartum Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

ACOG states that blood loss > 500 ml at time of delivery is abnormal and may

warrant intervention.

PPH: Severe vs. Life-threatening

 Severe: Ongoing blood loss of >

1,000 mL within 24 hours or blood

loss accompanied by

signs/symptoms of hypovolemia.

 Life-threatening: Ongoing blood

loss of >2,500 mL, or hypovolemic

shock, no matter the mode of

delivery.

References:

1. Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute Postpartum Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

“Patient Blood Management in Obstetrics: Prevention and Treatment of Postpartum Haemorrhage. A NATA Consensus Statement.” Accessed April 17, 2024.

3. Clinical Odyssey: Interactive case study. (November 29, 2020.). Retrieved October 7, 2024, from https://clinicalodyssey.com/lm/pd-after-birth-postpartum-hemorrhage

Signs of hypovolemia

Stages of Postpartum Hemorrhage (PPH)

Stage 1:

Blood Loss > 500 mL

vaginal or > 1000 mL

cesarean with normal

labs and vitals

1,2

Stage 2:

Continued bleeding (up

to 1500 mL or > 2

uterotonics) with

normal labs and vitals

Stage 3:

Continued bleeding EBL

>1500 mL or > 2 RBCs

administered or risk for

occult bleeding

coagulopathy or abnormal

vitals/labs/oliguria

Stage 4:

Cardiovascular collapse

(massive hemorrhage,

profound hypovolemic

shock)

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. ACOG. Practice Bulletin #183. Obstet & Gynecol 2017;130(4):e168-186.

Obstetric hemorrhage care guidelines flowchart: CMQCC Toolkit

Section III:

Management of Obstetric

Hemorrhage

Overview of Management of OB Hemorrhage

1. Assessment & management of risk factors in each phase of pregnancy

2. Care of Patients Refusing Blood Products

3. Preparation of hemorrhage cart and checklist

4. Readiness among team members to prepare for obstetric hemorrhage

 Recognizing stages of hemorrhage

 Familiarity with interventions associated with each stage.

5. Culture of learning.

 Host team debrief sessions after hemorrhage event.

 Conduct multidisciplinary review after severe and life-threatening hemorrhage events.

 Monitor outcomes associated with obstetric hemorrhage.

Labor and Delivery teams have developed policies and processes to manage OB hemorrhage.

#1 Assessment of Risk Factors

Clinical Assessment

Antepartum

+ Imaging reviewed to assess

patient for placenta previa,

accreta, increta, or precreta.

+ Plan developed to admit patient

to higher lever of care if placenta

accreta spectrum disorders are

identified.

+ Anemia assessed and treated as

appropriate.

2-5

Upon Admission

+ Coagulation disorders and

anemia assessed. Risk

stratification performed. Blood

bank notified as indicated for

scheduled or unscheduled birth.

+ Multidisciplinary consultation

for patients with hematologic

disorders for delivery and

anesthetic planning.

Postpartum

+ Uterine atony assessed: will

feel soft, boggy, non-contracted.

6-7

+ Genital lacerations or retained

placenta assessed which may be

source of bleeding.

Ongoing surveillance after

hemostasis is achieved to identify

worsening/delayed PPH.

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. Smith, C, Teng, F., Branch, E., Chu, S., and K. S. Joseph. 2019. “Maternal and Perinatal Morbidity and Mortality Associated With Anemia in Pregnancy.” Obstetrics and Gynecology 134 (6): 1234–44.

3. ASCLS. August 2022. Volume 36, Number 4. “Improving Obstetric Patient Safety with Better Massive Transfusion Protocols - ASCLS.” Accessed December 22, 2023. https://ascls.org/improving-obstetric-patient-safety-with-better-massive-transfusion-protocols/.

4. Iron. (2023). Retrieved May 13, 2024, from https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

5. Qassim, A., Grivell, R. M., Henry, A., Kidson-Gerber, G., Shand, A., & Grzeskowiak, L. E. (2019). Intravenous or oral iron for treating iron deficiency anemia during pregnancy: systematic review and meta-analysis. The Medical Journal of Australia, 211(8), 367–373.

https://doi.org/10.5694/mja2.50308

6. Gill, P., Patel, A., & Van Hook, J. W. (2023). Uterine Atony. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493238/

7. Wormer, K. C., Jamil, R. T., & Bryant, S. B. (2023). Acute Postpartum Hemorrhage. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499988/

Risk Assessment during pregnancy

Placenta Accreta Spectrum

• Assess patient for possible placenta previa/accreta/increta/precreta- these conditions increase

patients’ risk for PPH. Obtain necessary imaging studies for the conditions. Transfer to

appropriate level of care if accreta is suspected.

Anemia

• Early treatment of anemia can reduce morbidity and mortality.

• Anemia in pregnancy is a worldwide health concern. WHO estimates 40% of pregnant women

are anemic.

• During pregnancy women experience physiologic anemia, due to an increase in plasma volume

that causes a dilutional effect.

• During pregnancy and lactation, the recommended daily allowance for Iron is 27 mg. This can be

obtained by eating a whole foods diet and taking prenatal vitamins.

• Qassim et al found no significant difference in first line therapy with IV iron vs oral

administration for treating Iron Deficiency Anemia (IDA) in pregnancy.

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

better-massive-transfusion-protocols/.

4. Iron. (2023). Retrieved May 13, 2024, from https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

Journal of Australia, 211(8), 367–373. https://doi.org/10.5694/mja2.50308

Risk Factors for OB Hemorrhage

References:

1. Linder, Grace E., and Tina S. Ipe. 2022. “Pregnancy and Postpartum Transfusion.” Annals of Blood 7 (March): 12–12.

36. “Patient Blood Management in Obstetrics: Prevention and Treatment of Postpartum Haemorrhage. A NATA Consensus Statement.” Accessed April 17, 2024.

Before Pregnancy Antepartum Intra/Post-Partum

•

Grand Multiparity

(≥ 5 births)

• Maternal Age <19

• Maternal Age >35

• Prior Cesarean

Delivery

• Placenta accreta spectrum

• Diabetes

• Fibroids

• Hypertensive Disease of

Pregnancy

• Infection

• Macrosomia (>4,000g)

• Multiple Gestation

• Placenta Previa/Abruption

• Polyhydramnios

• Cesarean Delivery

• Instrumental Vaginal

Delivery

• Medical Induction of

Labor

OB Hemorrhage Risk Assessment Tools

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. Colalillo EL, Sparks AD, Phillips JM, Onyilofor CL, Ahmadzia HK. Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity. Sci Rep. 2021 Jul 19;11(1):14709. doi: 10.1038/s41598-021-93413-3. PMID: 34282160; PMCID:

PMC8289851.

3. ACOG. January 2019. Obstetric Hemorrhage. Risk Assessment Tables. https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-ob-hemorrhage-bundle-risk-assessment-ld-admin-intrapartum.pdf

California Maternal Quality Care

Collaborative

Association of Women’s Health,

Obstetric and Neonatal Nurses

(AWHONN)

American College of Obstetricians

and Gynecologists Safe Motherhood

Initiative

California

Maternal Quality

Care

Collaborative

Reference

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response

to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

Association of

Women’s Health,

Obstetric and

Neonatal Nurses

(AWHONN)

Reference:

1. Colalillo EL, Sparks AD, Phillips JM, Onyilofor CL, Ahmadzia HK. Obstetric hemorrhage

risk assessment tool predicts composite maternal morbidity. Sci Rep. 2021 Jul

19;11(1):14709. doi: 10.1038/s41598-021-93413-3. PMID: 34282160; PMCID:

PMC8289851.

American College

of Obstetricians

and

Gynecologists

Safe Motherhood

Initiative

Reference:

1. ACOG. January 2019. Obstetric Hemorrhage. Risk Assessment Tables.

https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-

ob-hemorrhage-bundle-risk-assessment-ld-admin-intrapartum.pdf

#2: Care of Patients Refusing

Blood Products

 Detailed discussion and

documentation of each blood product

as accepted or refused

 Plan for blood conservation

techniques and hemorrhage discussed

early among OB, anesthesia, and

nursing teams

 Early intervention to prevent

bleeding, hypothermia, and fluid

deficits

 May need to move to surgical

management quicker in this

population.

References:

1. Maternal Safety Bundle for OB Hemorrhage. American College of Obstetrician and Gynecologists. (2020). https://www.acog.org/community/districts-and-sections/district-ii/programs-and-

resources/safe-motherhood-initiative/obstetric-hemorrhage

Standard Protocols and Processes

#3: Preparation of Hemorrhage Cart

& Checklist

• Oxytocin: administered via infusion (10-40 units

in 500 mL or 20-60 in 1000 mL solution) or

• IV Bolus -1-3 units to initiate tone, followed by an infusion

of 30 units in 500 mL at 125 mL/hr.

• If no IV access: Oxytocin 10 units IM

1,2

Note: Oxytocin dosing strategies are varied and will differ

based on patient needs/presentation.

• 15-methyl PGF2a (Carboprost / Hemabate): 250

mcg/ml IM. Avoid in patients with severe asthma.

• Misoprostol (Cytotec): 200 mcg tablets

administered in 600 mcg or 800 mcg doses

sublingually. (Rectal administration is no longer

recommended due to late onset of action).

• Methylergonovine (Methergine): 0.2

mg/mL IM. Avoid in patients with poorly

controlled hypertension

• Calcium: consider 1 gram IV infused over

10 minutes after cord clamping

• Tranexamic acid (TXA): 1 gram IV, can

repeat in 30 minutes, max dose: 2 grams in

24 hours

4,5

• Hysterectomy Tray and Intrauterine

Balloon

Standard Medications and Supplies

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. Jones AJ, Federspiel JJ, Eke AC. Preventing postpartum hemorrhage with combined therapy rather than oxytocin alone. Am J Obstet Gynecol MFM. 2023 Feb;5(2S):100731. doi: 10.1016/j.ajogmf.2022.100731. Epub 2022 Aug 24. PMID: 36028160; PMCID: PMC9941051.

3. Ansari, Jessica R., Alla Ya rmo sh, Guillermina Michel, Deirdre Lyell, Haley Hedlin, David N. Cornfield, Brendan Carvalho, and Brian T. Bateman. 2024. “Intravenous Calcium to Decrease Blood Loss During Intrapartum Cesarean Delivery: A Randomized Controlled Trial.” Obstetrics and

Gynecology 143 (1): 104–12.

4. Shakur, H., Roberts, I., Fawole, B., Chaudhri, R., El-Sheikh, M., Akintan, A., Qureshi, Z., Kidanto, H., Vwalika, B., Abdulkadir, A., Etuk, S., Noor, S., Asonganyi, E., Alfirevic, Z., Beaumont, D., Ronsmans, C., Arulkumaran, S., Grant, A., Afsana, K., … Faye, G. E. (2017). Effect of early tranexamic

acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. The Lancet, 389(10084), 2105–2116.

https://doi.org/10.1016/S0140-6736(17)30638-4

5. Chauncey, J. M., & Wieters, J. S. (2023). Tranexamic Acid. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532909/

6. Maternal Safety Bundle for OB Hemorrhage. American College of Obstetrician and Gynecologists. (2020).

https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage

Hemorrhage Cart

A well stocked Hemorrhage Cart should contain:

• Emergency hemorrhage supplies:

 IV start supplies

 hemorrhage balloons and supplies

 urinary catheters

 sutures

 pressure infuser bags

 policy and procedure binder and laminated handouts that are

easy to read easily accessible

• Associated equipment

 stepstool

 bright task light on wheels

 ultrasound machine

 crash cart- stocked and routinely checked by staff responsible

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. Designating an Effective Emergency Coordinator Environment of Care. (2021). The Joint Commission. Emergency Management, 24(7). https://store.jcrinc.com/assets/1/7/ECN_24_2021_07.pdf

Treating Uterine Atony

The rule of threes was developed due to variation in initial doses of oxytocin, lack of an

existing protocol for step-wise increase in uterotonic agents, and normalization of

deviance from standard dosages of oxytocin.

References:

1. Tsen, L. C., & Balki, M. (2010). Oxytocin protocols during cesarean delivery: time to acknowledge the risk/benefit ratio? International Journal of Obstetric Anesthesia, 19(3), 243–245.

https://doi.org/10.1016/j.ijoa.2010.05.001

Oxytocin protocol for cesarean delivery: Rule of threes

3 IU oxytocin intravenous loading dose administered no faster than 15 seconds

3 min assessment intervals. If inadequate uterine time, give 3- IU oxytocin intravenous rescue dose.

3 total doses of oxytocin (initial load + 2 rescue doses)

3 IU oxytocin intravenous maintenance dose (3 IU/L at 100 mL/hr)

3 Pharmacologic options (e.g. ergonovine, carboprost and misoprostol) if inadequate uterine tone persists

**An initial dose of 3 IU oxytocin is sufficient for effective uterine contractions for both non-laboring and laboring women.

Preferably this dose should be administered in the form of a rapid infusion, rather than a bolus. Maintenance oxytocin

infusion can be administered for up to 8 hr following delivery.

#4: Ensure Readiness of Team Members

Team Readiness

#1: Understanding stages of hemorrhage

#2: Familiarity with interventions associated with each stage

# 3: Evaluation and monitoring practices available within

team’s healthcare setting

#4: Regular review of hospital’s policy on massive transfusion

protocol and PPH treatment

Stage 1: blood loss > 500 mL vaginal or > 1000 mL cesarean

with normal labs and vitals

Initial steps:

1. Ensure 16- or 18-gauge IV access.

2. Increase IV fluid (crystalloid without oxytocin)

3. Insert urinary catheter.

4. Begin fundal massage

Medications:

1. Increase oxytocin if indicated

2. Consider Methylergonovine, 15-methyl PGF or Misoprostol

Contact Blood Bank:

1. Contact Blood Bank- (early)

2. Type and Crossmatch 2 units RBCs

Action:

1. Determine cause and treatment. Continually assess tone, trauma, tissue and thrombin, or coagulation

dysfunction.

2. Prepare for OR if clinically indicated

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. ASCLS. August, 2022. Volume 36, Number 4. “Improving Obstetric Patient Safety with Better Massive Transfusion Protocols - ASCLS.” Accessed December 22, 2023. https://ascls.org/improving-obstetric-patient-

safety-with-better-massive-transfusion-protocols/.

Stage 2: continued bleeding up to 1500 mL or > 2

uterotonics with normal labs and vitals

Initial steps

1. Request additional help/resources (RRT, Anesthesiologist, OB, RN, Hemorrhage cart, record scribe, assign one person to communicate with

blood bank and one person to communicate with family)

2. Place second IV

3. Draw stat labs (CBC, coags, fibrinogen), use point of care viscoelastic testing if available.

4. Prepare OR

Medications (See slide 32)

1. Continue stage 1 medications: consider TXA

2. TXA dose: 1 gram over 10 minutes. Add 1 gram vial to 10 mL NS or 100 ml NS and give over 10 minutes, may be repeated once after 30 min

Blood Bank

1. Patient currently bleeding and at risk for uncontrollable bleeding

i. Review steps of MTP and call Blood bank and initiate massive transfusion protocol

ii. Nursing/anesthesia draw stat labs

a. Immediate need for transfusion (type and crossmatch not yet available)

Action

1. Uterine Atony: consider uterine balloon or packing, possible surgical intervention.

2. Consider moving patient to OR

3. Escalate therapy with goal of hemostasis

All obstetric units need a massive transfusion protocol for the initial management of life threatening PPH and

consider early therapy of RBCs and FFP.

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

2. ASCLS. August 2022. Volume 36, Number 4. “Improving Obstetric Patient Safety with Better Massive Transfusion Protocols - ASCLS.” Accessed December 22, 2023. https://ascls.org/improving-obstetric-patient-safety-with-better-

massive-transfusion-protocols/.

Stage 3: bleeding > 1500 mL or > 2 RBCs or at risk for occult

bleeding/coagulopathy or abnormal vitals/labs/oliguria

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

massive-transfusion-protocols/

Initial steps

1. Request additional help and resources/staff

i. continue communication with family.

ii. Reidentify team leadership

2. Move patient to OR

3. Announce clinical status (vitals, cumulative blood loss, etiology)

4. Outline and communicate plan

Medications (See slide 32)

1. Continue stage 1 medications; consider TXA

Contact Blood Bank

1. Clinical signs of blood loss > 1500

1. Hypotension, narrowed pulse pressure, marked tachycardia, tachypnea, pale, cool extremities, restlessness, decreased urine output

2. Initiate Massive Transfusion protocol

3. If clinical coagulopathy, add cryoprecipitate, consult for additional agents

Action

1. Achieve hemostasis, intervention at this stage will be based on the cause of bleeding.

2. Escalate interventions and prevent hypothermia

Possible interventions:

1. Bakri balloon

2. Compression suture/B-Lunch suture

3. Uterine artery ligation

4. Hysterectomy

Stage 4: cardiovascular collapse (massive hemorrhage,

profound hypovolemic shock)

Initial Step

1. Request additional help and resources (Additional provider, charge RN, RRT Staff)

Medications

1. ACLS Medications

Blood Bank

1. Clinical signs/symptoms: profound hypotension, worsening tachycardia and tachypnea,

negligible urine output or anuria, altered level of consciousness

2. Simultaneous aggressive massive transfusion

Action

1. Immediate surgical intervention to ensure hemostasis- possible hysterectomy

Post-hemorrhage management

1. Determine disposition of patient

2. Debrief with entire team

3. Debrief with patient and family (continuous through event)

4. Document events

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

massive-transfusion-protocols/

Viscoelastometric Testing

Rotational Thromboelastometry (ROTEM)

• Point of care testing device

• Provides a global assessment of hemostasis by using a whole blood sample to

demonstrate how platelets, coagulation factors, RBCs, and other elements work

together to:

 initiate a clot

 determine clot strength; and

 investigate if there is any fibrinolysis

• Used in the management of bleeding because it can quickly assess the state of

hemostasis and can direct care.

References:

1. Drotarova M, Zolkova J, Belakova KM, Brunclikova M, Skornova I, Stasko J, Simurda T. Basic Principles of Rotational Thromboelastometry (ROTEM®) and the Role of ROTEM-Guided Fibrinogen Replacement

Therapy in the Management of Coagulopathies. Diagnostics (Basel). 2023 Oct 16;13(20):3219. doi: 10.3390/diagnostics13203219. PMID: 37892040; PMCID: PMC10606358.

Viscoelastometric Testing

Used to analyze various aspects of

clotting cascade.

• INTEM

• Intrinsic system screening test

• EXTEM

• Extrinsic system screening test

• FIBTEM

• Isolated fibrinogen contribution to clot firmness

Point-of-care viscoelastic testing (ROTEM) helps reduce unnecessary transfusions

MPOG TEG & ROTEM Concepts

References:

1. Gonzalez E, Moore EE, Moore HB. Management of Trauma-Induced Coagulopathy with Thrombelastography. Crit Care Clin. 2017 Jan;33(1):119-134. doi: 10.1016/j.ccc.2016.09.002. PMID: 27894492; PMCID: PMC5142763

Department of Anesthesiology

#5: Foster a Culture of Learning

Organizational Preparedness

• Establish a culture of debriefs/huddles and

multidisciplinary reviews.

• Monitor outcomes and trends for your

department and patient population.

• Conduct drills at least once a year to

ensure staff are prepared for an OB

emergency.

References:

1. Lagrew D, McNulty J, Sakowski C, Cape V, McCormick E, Morton CH. Improving Health Care Response to Obstetric Hemorrhage, a California Maternal Quality Care Collaborative Toolkit, 2022.

protocols/

3. World Health Organization “WHO Policy Brief.” 2021 https://iris.who.int/bitstream/handle/10665/346655/9789240035744-eng.pdf?sequence

Educational Resources for Clinicians and Patients

• Center for Disease Control and Prevention – Hear Her Campaign

 Resources available for people who are pregnant or post-partum, their

care takers or healthcare workers.

 Aim: Raise awareness regarding maternal warning signs during and

after pregnancy and improve communication between health care

providers and patients.

 18 languages available

• Association of Women’s Health, Obstetric and Neonatal Nurses

(AWHONN) –

Post-Birth discharge education program for

clinicians

 Online course with resources to educate nurses and clinicians about

postpartum maternal morbidity and mortality in the US.

• Alliance for Innovation on Maternal Health (right)

• Quality Improvement initiative identifying best practices to make birth

safer & improve maternal health outcomes.

• 80 languages available.

References:

1. CDC. (2024, May 20). Hear Her Campaign: An Overview. HEAR HER Campaign. https://www.cdc.gov/hearher/about/index.html

2. Doolin, S. (2020, January 5). POST-BIRTH Warning Signs Education Program. AWHONN. https://www.awhonn.org/education/hospital-products/post-birth-warning-signs-

education-program/

3. Urgent Maternal Warning Signs. (2024, August 6). AIM. https://saferbirth.org/aim-resources/aim-cornerstones/urgent-maternal-warning-signs-2/

Section IV:

Additional Recommendations

References:

1. Maternal Safety Bundle for OB Hemorrhage. American College of Obstetrician and Gynecologists. (2020). https://www.acog.org/-/media/project/acog/acogorg/files/forms/districts/smi-ob-hemorrhage-bundle-

slides.pdf

ACOG Maternal Safety Recommendations

Society for Obstetric Anesthesia and Perinatology

(SOAP) Guidelines

References:

1. Bollag L, Lim G, Sultan P, Habib AS, Landau R, Zakowski M, Tiouririne M, Bhambhani S, Carvalho B. Society for Obstetric Anesthesia and Perinatology: Consensus Statement and Recommendations for Enhanced

Recovery After Cesarean. Anesth Analg. 2021 May 1;132(5):1362-1377. doi: 10.1213/ANE.0000000000005257. PMID: 33177330

In 2019, SOAP published a summary of their Enhanced Recovery After Cesarean Delivery (ERAC) protocol, developed

by six providers and approved by the SOAP Board of Directors. The goal of the consensus statement was to provide

practical and evidence-based recommendations regarding ERAC. The recommendations are as follows

1. Use the lowest effective dose of oxytocin for cesarean delivery:

a. Scheduled Cesarean Delivery: 1 unit bolus + 2.5-7.5 U/hr

b. Intrapartum Cesarean Delivery: 3 U bolus + 7.5-15 U/hr

2. Limit IV fluids to < 3 L for routine cases.

Council on Patient Safety in Women’s Health Care

Recommendations from the

Alliance for Innovation on

Maternal Health

• Prepare hemorrhage cart

• Ensure emergency release blood

available

• Perform regular risk assessments for

hemorrhage

Reference

1. Obstetric Emergency Readiness Resource Kit. (2023). https://saferbirth.org/wp-content/uploads/FINAL_AIM_OERRK.pdf

Summary

• Maternal mortality rates in the US continue to rise while it is decreasing in

other developed countries.

• Early identification of PPH is important in reducing maternal mortality

because many deaths are preventable.

• Point-of-care viscoelastic testing (ROTEM) helps reduce unnecessary

transfusions.

• Review your hospitals Blood Bank and Emergency Release policies to ensure

staff are prepared to treat PPH

• Establish a process to review your site’s MPOG specific outcome and process

measures

• For more information, please visit the Patient Blood Management Transfusion

Toolkit

page on the MPOG website