Obstetric Hemorrhage: Event Planning and Training

1. Obstetric Hemorrhage:Event Planning and Training Developed by HealthEast and Memorial Blood Centers Funding provided by: Foundation for America’s Blood Centers Principal Author: Jed B. Gorlin MD, MBA

2. Training Goals • Discuss clinical importance of issue • Explain the 4 R’s: Readiness, Recognition, Response, Reporting • Describe tools for response to hemorrhage • Discuss hemorrhage care guidelines • Discussion facilitated by video segments • Awareness of additional resources and materials

3. Content Areas-Emergent Tx • Emergency/Massive Transfusion • Communication: SBAR • Situation, Background, Assessment, Recommendation • Assessing adequacy of preparedness • Eliminating roadblocks • Medical Emergency transfusion concepts: • Emergent release of uncrossmatched blood • O negative vs. type specific • Massive transfusion issues

4. Malpractice lawsuit nets $4.6 million awardA woman bled to death after giving birth at a hospital in Wright County, MN • The family of a woman who bled to death after delivering her first child was awarded $4.6 million. • C. C. began hemorrhaging and died hours after her son was born on Jan. 18, 2008. Her doctors were unable to perform surgery because the hospital failed to provide blood for transfusion in time, even though it was "sitting right in their refrigerator," an attorney for C.'s family argued. • (The patient was A- and identical type blood was requested. Because the only Rh negative blood the small hospital stocked was O-, the physician tried to have her transferred.) Source: http://www.startribune.com/105580653.html

5. Doctor’s Company ReviewClosed Claim Review of Maternal Deaths from PPH • DENIAL: “Catch up” phenomenon: Initial manifestations of hemorrhage were VS changes (hypotension and/or tachycardia) NOT frank vaginal bleeding. • DELAY: in delivery of products from the blood bank to the labor and delivery operating room. • DELAY: of administration to patient once products arrived at L+D. • DELAY: Mobilization of equipment. • DELAY: Waiting for cross-matched blood instead of utilizing O negative or type specific blood. • “Underutilization”-- DELAY in administering additional amounts and types of blood products (i.e. FFP, platelets, and cryoprecipitate)

6. Doctor’s Company Review (con’t) COMMUNICATION BREAKDOWNS Among Team Members… For example: • Obstetrician and anesthesiologist regarding efficacy of intervention(s) and need to escalate care or change strategy. • Operating room and blood bank concerning urgency of situation. • Among support personnel concerning delivery of products and location of specialized equipment (i.e., rapid infusion devices or specialized kits). SOURCE: Doctors Company Reviews Maternal Arrests Cases (Reprinted with permission from The Doctors Company); APSF NEWSLETTER Summer 2007; page 28; Ann Lofsky, MD.

7. WHO worldwide data SOURCE: Taking stock of MATERNAL, NEWBORN and CHILD SURVIVAL 2000–2010 decade report, http://www.countdown2015mnch.org/documents/2010report/CountdownReportOnly.pdf

8. Statistics • Postpartum hemorrhage (PPH) is responsible for 35% of maternal mortality worldwide (WHO, 2007), reaching as high as 60% in developing countries • PPH can also be a cause of long-term severe morbidity, and approximately 12% of women who survive PPH will have severe anemia (Abou-Zahr, 2003; WHO, 2006) • Additionally, women who have severe PPH and survive (“near misses”) are significantly more likely to die in the year following the PPH (Impact International, 2007) SOURCE: http://www.pphprevention.org/pph.php

9. Causes and Risk Factors • More than one of these can cause postpartum hemorrhage in any given woman: • Uterine atony (failure of the uterus to contract properly after delivery) • Trauma (cervical, vaginal, or perineal lacerations) • Retained or adherent placental tissue • Clotting disorders • Inverted or ruptured uterus • Two-thirds of women who have PPH have no risk factorsrecognizable before delivery(Jhpiego, 2001) SOURCE: http://www.pphprevention.org/pph.php

10. UK SHOT Program(Serious Hazards of Transfusion) • UK National program for transfusion-related adverse events • More death and morbidity was attributed to lack of or miscommunication during transfusion emergencies than adverse effects of transfused blood components • During the period October 2006 to September 2010, the National Patient Safety Agency (NPSA) received reports of 11 deaths and 83 incidents in which a patient was harmed as a result of delays in the provision of blood in an acute situation. • Awareness of this problem prompted a review and Rapid Response Report (RRR) • This Rapid Response Report (RRR) focuses attention of hospitals on the systems and human factors that impact provision of blood in emergencies. SOURCE: http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=83659

11. Reducing the risk of harm Local organizations should ensure that: • The hospital transfusion committee reviews local protocols and practices for requesting and obtaining blood in an emergency (including out of hours), ensuring that they include all actions required by clinical teams, laboratories and support services, e.g. portering and transport staff/drivers and any specific actions for sites without an on-site transfusion lab. • Local protocols enable the release of blood and blood components without the initial approval of a hematologist although they should be advised of the situation at the earliest opportunity. SOURCE:http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=83659

12. Prevention • Active management of the third stage of labor (AMSTL): intramuscular administration of 10 IU of oxytocin, controlled cord traction (CCT) and fundal massage after delivery of the placenta • In the absence of a skilled birth attendant who can provide all of the components of AMTSL, oxytocin (10 IU) or misoprostol (400-600 mcg orally) should be given by a health worker trained in its use to prevent PPH. SOURCE: http://www.pphprevention.org/pph.php

13. Prevention (con’t) Other preventive measures may increase survival or avoid PPH • During labor: • Monitor and guide management of labor and quickly detect unsatisfactory progress, encourage bladder emptying, limit induction or augmentation use for medical and obstetric reasons, do not encourage pushing before the cervix is fully dilated, perform selective episiotomy for medical/obstetric reasons only, control delivery of the baby’s head and shoulders to help prevent tears. • During third stage of labor: • Provide active management of the third stage of labor (AMTSL) do not massage the uterus prior to delivery of the placenta, do not use fundal pressure to assist the delivery of the placenta, do not perform controlled cord traction (CCT) without administering a uterotonic drug, or without providing countertraction to support the uterus. • After delivery of the placenta: • Routine inspections to identify genital lacerations, assess the placenta and membranes for completeness, evaluate and, if necessary, massage the uterus at regular intervals after placental delivery (at least every 15 minutes for the first two hours after birth), monitor for vaginal bleeding and uterine hardness every 15 minutes for at least the first two hours SOURCE: http://www.pphprevention.org/pph.php

14. Reducing the risk of harmLocal organizations should ensure that: • All clinical, laboratory and support staff know how to access the massive blood loss protocol and are familiar with it • Supported by training and regular drills • The blood transfusion laboratory staff are informed of patients with a massive hemorrhage at the earliest opportunity • Clinical teams dealing with patients with massive hemorrhage nominate a specific member of the team to coordinate communication with the laboratory and support services staff for the duration of the incident SOURCE:http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=83659

15. Example of OB Specific MTP SOURCE: Handout: RCH ER Massive Transfusion Protocol March 2010, Massive OB Hemorrhage Presentationby: Wendy MacLeod and Kallie HoneywoodAn Update on Rural Obstetric Anesthesia held on June 15, 2011 in Kelowna, BC

16. Reducing the risk of harm (con’t)Local organizations should ensure that: • There is a clear and well understood trigger phrase to activate the massive blood loss protocol, including location • E.g. “I want to trigger the massive blood loss protocol in the delivery suite” • All subsequent communications should include a trigger phrase • E.g. “This call relates to the massive blood loss protocol in the delivery suite” • All incidents where there are delays or problems in the provision of blood in an emergency are reported and investigated locally, and reported to the NPSA and the Serious Hazards of Transfusion (SHOT) scheme (www.shotuk.org) • Each event triggering the massive blood loss protocol is recorded and reviewed by the hospital transfusion committee to ensure local protocols are applied appropriately and effectively SOURCE:http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=83659

17. Diagnostic aid for assessment of excessive OB hemorrhage

18. Obstetric Hemorrhage: New Strategies, New Protocol This project was supported by Title V funds received from the California Department of Public Health; Maternal, Child and Adolescent Health Division www.cmqcc.org/ob_hemorrhage 16

20. California Pregnancy-related Mortality ReviewComposite Case Example: 24yo G2 P1 at 38 wks gestations induced for “tired of being pregnant”: • After 8hr active phase and 2 hr 2nd stage, had a NSVD of an 8lb 6oz infant. • After placental delivery, she had an episode of atony that firmed with massage. A second episode responded to IM methergine and the physician went home (now 1am). • The nurses called the physician 30 min later to report more bleeding and further methergine was ordered. • 60min after the call, the physician performed a D&C with minimal return of tissue. More methergine was given. • 45 min later a second D&C was performed, again with minimal returns. EBL now >2,000 ml. • Delays in blood transfusion because of inability to find proper tubing. • Anesthesia is delayed, but a second IV started for more crystaloid. VS now markedly abnormal, P=144, BP 80/30. • One further methergine given and patient taken for a 3rd D&C. Now has gotten 2u PRBCs • After D&C is complete, she had a cardiac arrest from hypovolemia /hypoxia and was taken to the ICU when she succumbed 3 hours later.

21. California Pregnancy-related Mortality ReviewQI Opportunities and Learning Points from the above composite case: How to reduce Mortality and Morbidity from OB Hemorrhage? • Need a medical indication for induction • No documentation of actual blood loss, e.g., what does “more bleeding” mean? • Only a few treatments tried, e.g., Methergine and D&C, and repeated even when they were ineffective • Underestimation of blood loss • Delay in administration of blood • Lack of working equipment • Delay in response from other team members • Delays in adequate resuscitation • Lack of an organized approach

22. Summary: Key Survey Findings • 40% of hospitals DO NOT have a hemorrhage protocol • Inconsistent definitions • 70% of hospitals DO NOT perform drills (MDs are not regularly participating in drills) • Most have access to all 4 uterotonics (More specific data will be released after complete analysis) • Many hospitals report they do not have access to alternative treatment methods, e.g., Balloons (More specific data will be released after complete analysis)

23. Denial Delay Quality Improvement Opportunities for OB Hemorrhage • Reduce risks of hemorrhage • Perform admission risk assessments • Reduce Denial, Delay… • Quantify blood loss • Follow a step-by-step plan • Increase use of non-pharmacologic treatments • Improve treatments with blood products • “Too little, too late”—Resuscitation v. Treatment • “Old wine in new bottles”—“Whole blood” v. PRBCs • Enhance Teamwork and Communications!

24. Four Major Recommendations for California Birth Facilities: • Improve readiness to hemorrhage by implementing standardized protocols (general and massive). • Improve recognitionof OB hemorrhage by performing on-going objective quantification of actual blood loss during and after all births. • Improve response to hemorrhage by performing regular on-site multi-professional hemorrhage drills. • Improve reporting of OB hemorrhage by standardizing definitions and consistency in coding and reporting.

25. Denial Delay What’s New? • Quantification of blood loss (QBL) for all births • Active management of the 3rd stage for all • Vital sign triggers • “Move along” on uterotonic medications • Bakri intrauterine balloon / B-Lynch suture • A rational approach to blood components • The value of a formal protocol With kind permission of Bev VanderWal, CNS

26. Methods to Estimate Blood LossRecommended methods for ongoing quantitative measurement of blood loss: • Formally estimate blood loss by recording percent (%) saturation of blood soaked items with the use of visual cues such as pictures/posters to determine blood volume equivalence of saturated/blood soaked pads, chux, etc. • Formally measure blood loss by weighing blood soaked pads, chux • Formally measure blood loss by collecting blood in graduated measurement containers

27. Methods to Estimate Blood LossQuantifying blood loss by weighing • Establish dry weights of common items • Standardize use of pads • Build weighing of pads into routine practice • Develop worksheet for calculations With kind permission of Bev VanderWal, CNS

28. Methods to Estimate Blood LossQuantifying blood loss by measuring • Use graduated collection containers (C/S and vaginal deliveries) • Account for other fluids (amniotic fluid, urine, irrigation) With kind permission of Bev VanderWal, CNS

29. Methods to Estimate Blood LossDevelop Training Tools: Visual aids displayed in Labor & Delivery and/or Postpartum areas are guides for more accurate visual estimation (visual aids can be displayed discreetly for clinicians) With kind permission of Bev VanderWal, CNS

30. Denial Delay Recommendations • Teach clot size using posters showing known blood quantities on common materials or compared to common volumes (e.g., a Coke can=350ml) • Weigh wet materials (with known dry weight); this can be done by gathering a group of pads and weighing them all together • Measure what can be suctioned at CS (less irrigation+AF) • Use calibrated under-buttock drapes (at vaginal birth, note the volume of amniotic fluid, urine and stool after birth but before the placenta) • What we don’t know: How to estimate the blood loss that we don’t see… (i.e., intra- abdominal)

31. Denial Delay Recommendations • Many centers will customize their approach to quantification using a combination of approaches for different settings • Vaginal deliveries • Cesarean sections • Minimal loss • Greater than usual loss • Massive loss • The process is intentional—a formal effort! • No more vague “Guesstimates” • Continues and is cumulative

32. Denial Delay Who should determine QBL? • Anesthesia is at the head of the table and often does not see it all • OB’s aren’t looking at the suction bottles or at the collective sponges • No one is doing it in a standardized manner—we obstetricians need help! Collaboratively! • We should be able to answer: • How much blood is in the suction bottle (after amniotic fluid)? • How much blood is on sponges? • How much blood is on the floor/on the table? • In a big case, hourly and cumulatively

33. Active management of the third stage of labour • Active management of the third stage of labour consists of interventions designed to facilitate the delivery of the placenta by increasing uterine contractions and to prevent PPH by averting uterine atony. The usual components include: • Administration of uterotonic agents • Controlled cord traction • Uterine massage after delivery of the placenta, as appropriate. SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO) http://www.figo.org/files/figo-corp/docs/PPH%20Joint%20Statement.pdf

34. 62% fewer PPH in Active Management group versus Expectant Management Meta Analysis of Active vs. Expectant 3rd Stage Management at vaginal birth: Outcome of postpartum EBL ≥ 500 ml SOURCE: Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev 2000; 3: CD000007

35. Every attendant at birth needs to have the knowledge, skills and critical judgment to carry out active management of the third stage of labour and access to needed supplies and equipment. In this regard, national professional associations have an important and collaborative role to play in: • Advocacy for skilled care at birth; • Public education about the need for adequate prevention and treatment of post-partum haemorrhage; • Address legislative and other barriers that impede the prevention and treatment of post-partum haemorrhage; • Incorporation of active management of the third stage of labour in national standards and clinical guidelines, as appropriate; • Incorporation of active management of the third stage into pre-service and in-service curricula for all skilled birth attendants; • Working with national pharmaceutical regulatory agencies, policymakers and donors to assure that adequate supplies of uterotonics and injection equipment are available. SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO) http://www.figo.org/files/figo-corp/docs/PPH%20Joint%20Statement.pdf

36. HOW TO USE UTEROTONIC AGENTS Within one minute of the delivery of the baby, palpate the abdomen to rule out the presence of an additional baby(s) and give: • Oxytocin 10 units IM. Oxytocin is preferred over other uterotonic drugs because it is effective 2-3 minutes after injection, has minimal side effects and can be used in all women. • If oxytocin is not available, other uterotonics can be used such as: ergometrine 0.2 mg IM, syntometrine (1 ampoule) IM or • Misoprostol 400-600 mcg orally. Oral administration of misoprostol should be reserved for situations when safe administration and/or appropriate storage conditions for injectable oxytocin and ergot alkaloids are not possible. • Uterotonics require proper storage: • Ergometrine: 2-8°C and protect from light and from freezing. • Misoprostol: room temperature, in a closed container. • Oxytocin: 15-30°C, protect from freezing • Counseling on the side effects of these drugs should be given.Warning! Do not give ergometrine or syntometrine (because it contains ergometrine) to women with pre-eclampsia, eclampsia or high blood pressure. SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO) http://www.figo.org/files/figo-corp/docs/PPH%20Joint%20Statement.pdf

37. HOW TO DO CONTROLLED CORD TRACTION • Clamp the cord close to the perineum (once pulsation stops in a healthy newborn) and hold in one hand. • Place the other hand just above the woman’s pubic bone and stabilize the uterus by applying counter-pressure during controlled cord traction. • Keep slight tension on the cord and await a strong uterine contraction (2-3 minutes). • With the strong uterine contraction, encourage the mother to push and very gently pull downward on the cord to deliver the placenta. Continue to apply counter-pressure to the uterus. • If the placenta does not descend during 30-40 seconds of controlled cord traction do not continue to pull on the cord: • Gently hold the cord and wait until the uterus is well contracted again; • With the next contraction, repeat controlled cord traction with counter-pressure. • Never apply cord traction (pull) without applying counter traction (push) above the pubic bone on a well-contracted uterus. • As the placenta delivers, hold the placenta in two hands and gently turn it until the membranes are twisted. Slowly pull to complete the delivery. • If the membranes tear, gently examine the upper vagina and cervix wearing sterile/disinfected gloves and use a sponge forceps to remove any pieces of membrane that are present. • Look carefully at the placenta to be sure none of it is missing. If a portion of the maternal surface is missing or there are torn membranes with vessels, suspect retained placenta fragments and take appropriate action (ref Managing Complications in Pregnancy and Childbirth). SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO) http://www.figo.org/files/figo-corp/docs/PPH%20Joint%20Statement.pdf

38. HOW TO DO UTERINE MASSAGE • Immediately massage the fundus of the uterus until the uterus is contracted. • Palpate for a contracted uterus every 15 minutes and repeat uterine massage as needed during the first 2 hours. • Ensure that the uterus does not become relaxed (soft) after you stop uterine massage. SOURCE: Joint Statement, Management of the Third Stage of Labour to Prevent Post-partum Haemorrhage, International Confederation of Midwives (ICM), International Federation of Gynaecologists and Obstetricians (FIGO) http://www.figo.org/files/figo-corp/docs/PPH%20Joint%20Statement.pdf

39. Denial Delay Vital Signs are Often IgnoredConcept of “Triggers” • Triggers identify patients that need more attention (from on-call physician, in-house physician, or rapid response team (RRT)) • Prevent such patients from being ignored • Independent of diagnosis, useful for all OB emergencies • Used in many areas of hospital medicine • Do not wait for lab results before acting

40. NHS Trigger Tool for Obstetrics:graphical display of vital signs: “Contact doctor if one red or two yellows” With kind permission of Fiona McIlveney, PhD