In this update:

• New definition for postpartum hemorrhage from the American College of Obstetricians and Gynecologists
• Tranexamic acid as first-line medication
• 1:1 ratio of packed red blood cells (PRBC) to fresh frozen plasma (FFP)

Postpartum hemorrhage is defined as cumulative blood loss greater than or equal to 1,000 mL or bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process, regardless of delivery route (ACOG Practice Bulletin 183, October 2017). It is one of the top three leading causes of maternal death in industrialized nations. Of equal concern are “near miss” patients who suffer with morbidities from obstetrical hemorrhage.

Many organizations (World Health Organization, California Maternal Quality Care Collaborative and the American College of Obstetricians and Gynecologists) have fervently worked to reduce the maternal mortality and morbidity of hemorrhage.

Planning:

1.) Identifying patients at risk

Predelivery

• Abnormal placentation (previa, accrete, etc.)
• Pre-eclampsia, HELLP syndrome
• Large for gestational age fetus
• Polyhydramnios
• Bleeding disorders
• Anticoagulant use
• Intrauterine fetal demise

Postdelivery

• Retained placenta/membranes
• Lacerations
• Prolonged induction of labor
• Failure to progress in the second stage of labor

In a retrospective analysis of massive blood transfusion in New York state, the four highest risk factors for massive transfusion were abnormal placentation, placental abruption, severe pre-eclampsia and intrauterine fetal demise.

2.) Hemorrhage protocols and order sets – Each facility should have a protocol in place and have it posted on the labor and delivery unit. (CMQCC.org)

3.) Postpartum hemorrhage kits – A list of suggested items from the California Maternal Quality Care Collaborative (CMQCC.org/resources-tool-kits)

4.) Training and simulation drills (This is the most important step!) – All staff participate in drills and perform debriefings after drills and after an event occurs to share and learn.

Management

1.) Objective management of blood loss – Collecting blood and measuring in graduated cylinders, weighing drapes and sponges, visual aids that correlate amount of blood with saturated items.

2.) Early intervention – Use an algorithm/protocol for all staff (nursing, blood bank, obstetricians, midwives, anesthesiologists). This includes timing for measuring vital signs, labs, transfusion and administration of medications.

New recommendation

Transexemic acid 1 gram IV over 10 minutes should be considered as a first-line therapy in a stage 2 or 3 hemorrhage. It may be repeated in 30 minutes if bleeding persists. The World Maternal Antifibrinolytic (WOMAN) Trial
showed that administration improved mortality, decreased morbidity, caused no adverse events but also did not prevent hysterectomy.

Teamwork

Engagement of staff from labor and delivery, operating room, blood bank, pharmacy, and physicians and midwives leads to success.

Our experience

In the past three years, our team has cared for more than 30 patients with significant risk for obstetrical hemorrhage from placenta accrete, increta and percreta. Less than half of these patients have required blood transfusion or ICU admission. This success is due to a collaborative team
effort of obstetricians, maternal-fetal medicine specialists, gynecologic oncologists, anesthesiologists, urologists, labor and delivery staff, operating room staff, blood bank and pharmacy.

Refer a patient

To refer a patient to Norton Children’s Maternal-Fetal Medicine, click here for the online referral form, make a referral through Epic or call (888) 4-U-NORTON.