maternal hemorrhage risk assessment presentation

8/9/2019 Maternal Hemorrhage Risk Assessment Presentation

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MATERNALMATERNALHEMORRHAGEHEMORRHAGE


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Prevention of MaternalPrevention of Maternal

DeathDeath High Rate of Maternal Death due to hemorrhageHigh Rate of Maternal Death due to hemorrhage

Most women who died of hemorrhage (97%) wereMost women who died of hemorrhage (97%) werehospitalized at the time of their deathhospitalized at the time of their death

To reduce the risk of death the ACOG/DOHTo reduce the risk of death the ACOG/DOH

recommends:recommends: Effective guidelines for maternal hemorrhageEffective guidelines for maternal hemorrhage

Prompt recognition and response to hemorrhagePrompt recognition and response to hemorrhage

DO NOT DELAY TRANSFUSION WHILEDO NOT DELAY TRANSFUSION WHILEAWAITING LAB RESULTS OR HEMODYNAMICAWAITING LAB RESULTS OR HEMODYNAMIC

INSTABILITYINSTABILITY


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Prevention of Maternal DeathPrevention of Maternal Death

RecommendationsRecommendations

Effective guidelines to respond,Effective guidelines to respond,including emergency transfusion, withincluding emergency transfusion, with

coordination among obstetricians,coordination among obstetricians,nurses, anesthesia and Blood Banknurses, anesthesia and Blood Bank

Be vigilant to blood loss, if clinicalBe vigilant to blood loss, if clinicaljudgment indicates transfusion,judgment indicates transfusion, do notdo not

delay awaiting lab resultsdelay awaiting lab results, slow blood, slow bloodloss can be life threateningloss can be life threatening


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Prevention of Maternal DeathPrevention of Maternal Death

RecommendationsRecommendations

Use fluid resuscitation and transfusion basedUse fluid resuscitation and transfusion based

on estimated blood loss and expectation ofon estimated blood loss and expectation of

continued bleedingcontinued bleeding

Work with Labor and Delivery on MaternalWork with Labor and Delivery on Maternal

Hemorrhage DrillsHemorrhage Drills

Conduct Continuing Medical Education for theConduct Continuing Medical Education for the

entire medical teamentire medical team


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Informed ConsentInformed Consent

Identify patients who express concernsIdentify patients who express concernsabout receiving blood products for anyabout receiving blood products for anyreason (i.e Jehovah Witness)reason (i.e Jehovah Witness)

Ensure that the patient has adequateEnsure that the patient has adequateopportunity to speak to an obstetrician andopportunity to speak to an obstetrician andan anesthesiologist regarding her concernsan anesthesiologist regarding her concernsand the risks/benefitsand the risks/benefits

Ensure that the Consent/Refusal to BloodEnsure that the Consent/Refusal to BloodProducts form is signedProducts form is signed


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Risk AssessmentRisk Assessment

for Hemorrhagefor Hemorrhage


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Low RiskLow Risk

First or early second trimester D&CFirst or early second trimester D&Cwithout history of bleeding (scheduled)without history of bleeding (scheduled)

CerclageCerclage

Vaginal BirthVaginal Birth No previous uterine incisionNo previous uterine incision

No history of bleeding problemsNo history of bleeding problems

No history of PP hemorrhageNo history of PP hemorrhage

Four or less previous vaginal birthsFour or less previous vaginal births

Singleton pregnancySingleton pregnancy


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Low RiskLow Risk

Send Hold specimen to the Blood BankSend Hold specimen to the Blood Bank

If patients status changes, notify bloodIf patients status changes, notify blood

bank to perform type and screen and/orbank to perform type and screen and/or

type and cross matchtype and cross match Examples include need for c/section, PPExamples include need for c/section, PP

hemorrhage, chorioamnionitis, prolongedhemorrhage, chorioamnionitis, prolonged

labor and exposure to oxytocinlabor and exposure to oxytocin


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Moderate RiskModerate Risk

VBACVBAC

Cesarean sectionsCesarean sections

Multiple gestations or macrosomiaMultiple gestations or macrosomia

History of prior post partum hemorrhageHistory of prior post partum hemorrhage

Uterine fibroidsUterine fibroids

Mid to late second trimester D&Es orMid to late second trimester D&Es or

induced vaginal birthsinduced vaginal births Other increased risks as designated byOther increased risks as designated by

physicianphysician


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Moderate RiskModerate Risk

Type and screen to Blood BankType and screen to Blood Bank

CBC with plateletsCBC with platelets

Additional labs as per OBAdditional labs as per OB Consider cell saver for JehovahConsider cell saver for Jehovah

Witness or any other patient whoWitness or any other patient who

refuses blood productsrefuses blood products


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High RiskHigh Risk

Placenta previaPlacenta previa

Suspected placenta accretaSuspected placenta accreta

Hematocrit less than 26Hematocrit less than 26 Vaginal bleeding on admissionVaginal bleeding on admission

Coagulation defectsCoagulation defects

Other high risks as designated by theOther high risks as designated by thephysicianphysician


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High RiskHigh Risk

Type and screen and cross match for 4 unitsType and screen and cross match for 4 units

CBC, PT, PTT, FibrinogenCBC, PT, PTT, Fibrinogen

Second large bore IVSecond large bore IV

Anesthesia to prepare Hot LineAnesthesia to prepare Hot Line Cell saver team on stand-byCell saver team on stand-by

1-800-235-57281-800-235-5728

(****especially for Jehovahs Witness****)(****especially for Jehovahs Witness****)


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MATERNAL BLOOD VOLUMEMATERNAL BLOOD VOLUME

Non pregnant femaleNon pregnant female

3600 ml3600 ml

Pregnant female (near term)Pregnant female (near term) 54005400

mlml


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DEGREES OF BLOOD LOSSDEGREES OF BLOOD LOSS

VolumeEstimate

Percent Type

500 ml or > 10-15% compensated

1000-1500 ml 15-25% mild

1500-2000 ml 25-35% moderate

2000-3000 ml 35-50% severe


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Caveats for the PregnantCaveats for the Pregnant

PatientPatient If the Obstetric Staff is consideringIf the Obstetric Staff is considering

transfusing a pregnant patient anesthesiatransfusing a pregnant patient anesthesiashould be notifiedshould be notified

Blood loss is almost alwaysBlood loss is almost always underestimatedunderestimated(especially after vaginal birth)(especially after vaginal birth) Pregnant patients can lose up to 40% ofPregnant patients can lose up to 40% of

their blood volume (compared to 25% intheir blood volume (compared to 25% in

non-pregnant patients) before showingnon-pregnant patients) before showingsigns of hemodynamic instabilitysigns of hemodynamic instability

Dont wait for hypotension to startDont wait for hypotension to startreplacing volumereplacing volume


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Causes of PP HemorrhageCauses of PP Hemorrhage

Uterine AtonyUterine Atony

Lacerations to the cervix and genitalLacerations to the cervix and genital

tracttract

Retained placenta and otherRetained placenta and other

placental abnormalitiesplacental abnormalities

Coagulation disordersCoagulation disorders


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Risk Factors for UterineRisk Factors for Uterine

AtonyAtony Multiple gestationMultiple gestation MacrosomiaMacrosomia PolyhydramniosPolyhydramnios

High ParityHigh Parity Prolonged labor especially if augmentedProlonged labor especially if augmentedwith oxytocinwith oxytocin

Precipitous laborPrecipitous labor

ChorioamnionitisChorioamnionitis Use of tocolytic agentsUse of tocolytic agents Abnormal placentationAbnormal placentation


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Trauma to the Genital TractTrauma to the Genital Tract

Large episiotomy, including

extensions

Lacerations of perineum, vagina orcervix

Ruptured uterus


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Placental AbnormalitiesPlacental Abnormalities

Retained placentaRetained placenta

Abnormal placentationAbnormal placentation

AccretaAccreta

PercretaPercreta

IncretaIncreta

PreviaPrevia


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Coagulation AbnormalitiesCoagulation Abnormalities

DIC (may result from excessive blood loss)

Thrombocytopenia

abruption

ITP

TTP

Pre-eclampsia including HELLP Syndrome

Anticardiolipin/Antiphospholipid Syndrome


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IDENTIFICATION ANDIDENTIFICATION AND

EVALUATIONEVALUATION

Assessment:Assessment:

Mental StatusMental Status

Vital Signs including BP, Pulse and OVital Signs including BP, Pulse and O22

saturationsaturation

Intake: Blood Products and FluidsIntake: Blood Products and Fluids

Output: Urine and Blood LossOutput: Urine and Blood Loss

Hemoglobin and HematocritHemoglobin and Hematocrit Assess uterine tone and vaginal bleedingAssess uterine tone and vaginal bleeding


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Identify Team LeadersIdentify Team Leaders

(MD/RN)(MD/RN)

Call Code Noelle

MFM on-call

AnesthesiaAttending

Blood BankDirector

Antepartum Back-

up (if MFM isprimary OB)

L&D NurseManager

ADN


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MANAGEMENTMANAGEMENT

Non-surgicalNon-surgical

IDENTIFY CAUSE OF BLEEDING

Examine :

Uterus to r/o atony

Uterus to r/o ruptureVagina to r/o laceration


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MANAGEMENTMANAGEMENT

Non-surgicalNon-surgical ManagementManagement

Atony:Atony: Firm Bimanual Compression

Order

Oxytocin infusion

15-methyl prostaglandin F2alpha IM

Second line:

(methergine (if BP normal), PGE1, PGE2)

MANAGEMENT: NonMANAGEMENT: Non


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MANAGEMENT: Non-MANAGEMENT: Non-

surgicalsurgical

Hypovolemic ShockHypovolemic 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 O2 at 8-10 L Non re-breather mask



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surgicalsurgical

NursingNursing Registered Nurses: Administer O2 at 8-10 L face mask

Cardiorespiratory, BP and SAO2 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



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surgicalsurgical

NursingNursing Nursing Station Clerks:

Enter Lab and Blood Bank Orders

Page all members of MaternalHemorrhage team

Await addition instructions for: Cell Saver Team

Gyn-Oncology Surgeon



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surgicalsurgical

NursingNursing 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


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MANAGEMENT: SurgicalMANAGEMENT: Surgical

OR PersonnelOR Personnel

OB AttendingOB Attending

MFM Back upMFM Back up

OB Resident(s)OB Resident(s) AnesthesiaAnesthesia

AttendingAttending

AnesthesiaAnesthesia

Resident(s)Resident(s)

2 Circulating RNs2 Circulating RNs

1 Scrub Tech/RN1 Scrub Tech/RN

Gyn-Onc SurgeonGyn-Onc Surgeon

(prn)(prn) InterventionalInterventional

Radiology (prn)Radiology (prn)

Cell SaverCell Saver

Personnel (prn)Personnel (prn)


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OR EquipmentOR EquipmentTraysTrays

Gyn Long TrayGyn Long Tray

Hysterectomy TrayHysterectomy Tray

Gyn Surgery TrayGyn Surgery Tray

Cell Saver EquipmentCell Saver Equipment

Preparation of fibrin gluePreparation of fibrin glue

(1-30 ml syringe with 2 vials Topical Thrombin + 0.5 ml of 10% CaCl, 1-(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 g30 ml syringe with 30 ml of cryoprecipitate, both attached to 18 g

angiocaths)angiocaths)


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ANESTHESIAANESTHESIA

Team CoordinatorTeam Coordinator

Airway managementAirway management

Hemodynamic MonitoringHemodynamic Monitoring FluidsFluids

Blood ProductsBlood Products

OutputOutput


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OBSTETRICIAN/SURGEONOBSTETRICIAN/SURGEON Control Source of HemorrhageControl Source of Hemorrhage Perform indicated Procedure:Perform indicated Procedure:

REPAIR LACERATIONREPAIR LACERATION

BILATERAL UTERINE ARTERY LIGATIONBILATERAL UTERINE ARTERY LIGATION

BILATERAL HYPOGASTRIC ARTERY LIGATIONBILATERAL HYPOGASTRIC ARTERY LIGATION

HYSTERECTOMYHYSTERECTOMY

Utilize additional resources if surgeryUtilize additional resources if surgerycontinues and emergency transfusion iscontinues and emergency transfusion is

occurring (Gyn-Onc Surgeon)occurring (Gyn-Onc Surgeon) Consider Interventional RadiologyConsider Interventional Radiology


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NURSINGNURSING Assist anesthesia as neededAssist anesthesia as needed

Assist with surgery (scrub/circulate)Assist with surgery (scrub/circulate)

Assess for the need for further additionalAssess for the need for further additionalsurgical expertisesurgical expertise

Ongoing surgery with emergencyOngoing surgery with emergency

transfusion continuingtransfusion continuing

Obtain NICU as needed if infant undeliveredObtain NICU as needed if infant undelivered

Obtain/administer medications as neededObtain/administer medications as needed


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Post-op DispositionPost-op Disposition

Anesthesiologist and obstetrician willAnesthesiologist and obstetrician will

determine post op disposition of thedetermine post op disposition of the

patient and call appropriate consultspatient and call appropriate consults

( i.e. SICU attending)( i.e. SICU attending) All intubated patients must go to theAll intubated patients must go to the

SICUSICU

Other patients at anesthesiologistsOther patients at anesthesiologistsdiscretiondiscretion

Nursing to give report to SICUNursing to give report to SICU


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SummarySummary

Maternal hemorrhage remains the numberMaternal hemorrhage remains the number

one cause of maternal death in NYSone cause of maternal death in NYS

Identification of high risk patients canIdentification of high risk patients can

prevent severe complicationsprevent severe complications Early intervention for the low risk patientEarly intervention for the low risk patient

who starts to bleed is also crucialwho starts to bleed is also crucial

Proper communication between nursing,Proper communication between nursing,OB, anesthesia and neonatology willOB, anesthesia and neonatology will

provide best outcome for mother and babyprovide best outcome for mother and baby

maternal hemorrhage risk assessment presentation

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