OPQIC – Oklahoma Perinatal Quality Improvement Collaborative



Stage 0 Routine Postpartum Recovery and Care (All Births)TEAM MEMBERSROLES AND ACTIONSMEDICATIONS AND PROCEDURESPrimaryNurseAssess for risk factors for hemorrhageOngoing Quantitative Evaluation of Blood LossVital signs and fundal massage q 15 minutes for 2 hoursOxytocin infusion: 20-40 units oxytocin/1000 ml solution or 10 units IM; Do not give oxytocin as IV pushTitrate infusion rate to uterine tonePhysicianActive management of 3rd Stage:Oxytocin 20-40 units in 1000ml at 150cc/hr. or 10units IM after deliveryFundal massage 15 seconds minimumUmbilical Cord Traction Risk Factors – (Not a complete list)Early Recognition of Signs of PPH May Include but not limited to:Uterine atony (boggy uterus)Displaced uterus after bladder emptiedVaginal bleeding that gushes or constantly tricklesVital sign changes: pulse, resp., BP., O2 sat. If any of the above conditions are present and not correctable, proceed to Stage 1 OB HemorrhageMacrosomiaMagnesium administrationProlonged use of oxytocin in laborPrecipitous laborCesarean sectionRetained placental fragmentsVBACUterine fibroidsGrand multiparousProlonged laborHistory of PPHTrauma to genital tractStage 1 OB Hemorrhage Cumulative Blood loss > 1000 mL OR Vital Signs Unstable: HR >110 OR Increased Bleeding during with continued bleeding BP < 85/45 recovery or postpartum ( if > 500mL vaginal delivery investigate cause) SaO2 < 95%TEAM MEMBERSROLES AND ACTIONSMEDICATIONS AND PROCEDURESPrimaryNurseMay require additional nurse(s)Call for help: Notify Charge Nurse & OB provider Activate Postpartum Hemorrhage Guidelines/ChecklistAssure primary IV access is > 18 gauge and patentVital signs, oxygen saturation, and level of consciousness every 5-10 minutes Administer Oxygen to maintain oxygen saturation > 95%Vigorous fundal massageQuantitative Blood Loss measured, announced and recorded every 15 min. (1gram = 1milliliter)Place Foley with urimeter -If already in place empty and begin documenting hourly urine output Keep patient warm: warmed blankets or air-flow warmerIncrease IV Oxytocin rate; titrate to uterine toneAdminister uterotonics as directed by physician Methergine 0.2mg IM (if no response, move on to second line drugs below, if good response, may repeat every 2h prn) Avoid with hypertensionMisoprostol 800-1000 mcg sublingual or p.o.Hemabate 250 mcg IM Avoid with asthma or hypertensionType & Cross for 2 units PRBC-assure proper labelingIf available at your facility, consider administering Tranexamic Acid (TXA) 1 gram IV over 10 minutes within 3 hours of birth after failure of uterotonics and surgical repair. TXA is not used as an initial treatment.PhysicianBimanual uterine massageConsider etiology of hemorrhage and take corrective action Tone, Tissue, Trauma, ThrombinIf open C/S: Inspect for uncontrolled bleeding at surrounding sitesAtony: uterotonics, intrauterine balloon, B-Lynch suture if C/STissue retained: D&CTrauma/Laceration: visualize and repair, correct inversion with anesthesia/uterine relaxants, evacuate hematomaCoagulopathy: replace coag factors aggressively If available at your facility, consider administering Tranexamic Acid (TXA) 1 gram IV over 10 minutes within 3 hours of birth after failure of uterotonics and surgical repair. TXA is not used as an initial treatment.Charge Nurse(or designee)Bring PPH Kit to patient bedside Notify anesthesia Obtain portable lighting as needed for visualization Obtain needed medications Facilitate labwork Facilitate requisition of blood products as neededPatients may move rapidly from one stage to another. DO NOT DELAY. If Continued bleeding or Vital Signs unstable, and < 1500 mL cumulative blood loss proceed to STAGE 2Once Stabilized: modified postpartum management with increased surveillanceStage 2 OB Hemorrhage Continued bleeding with blood loss > 1000mL up to 1500mL Vital Signs Unstable: HR > 110 OR BP < 85/45 SaO2 < 95% TEAM MEMBERSROLES AND ACTIONSMEDICATIONS AND PROCEDURESPrimaryNurseMay require additional nurse(s)Start secondary IV access -14 or 16 guage Vital signs, oxygen saturation, cumulative blood loss and level of consciousness every 5- 10 minutes Administer Oxygen to maintain saturation > 95%Move patient to OR Ready blood administration set and blood warmer for transfusionPlace Foley w/urimeter if not already done, document hourly urine outputKeep patient warm: warmed blankets or air-flow warmer Apply sequential compression device to legs Observe for s/s of DIC including bleeding from the mouth, gums, needle puncture sites or surgical sites Increase IV Oxytocin rate Administer uterotonics as directed by physician Methergine 0.2mg IM (if no response, move on to second line drugs below, if good response, may repeat q2h prn). Avoid with hypertensionMisoprostol 800-1000 mcg sublingual or p.o.Hemabate 250 mcg IM Avoid with asthma or hypertensionSTAT Labs: CBC, Platelets, Chemistry, Coagulation panel, ABG. Repeat with each MTP pack or as clinically indicatedClot tube at bedside to evaluate clotting time Send for 2 units PRBC and transfuse: may begin with O-negative in emergencyPhysicianFocus is on advancing through medications & procedures, and keeping ahead with volume and blood products Bimanual uterine massageCall additional OB/Surgeon for assistanceConsider etiology of hemorrhage and take corrective actionTone, Tissue, Trauma, ThrombinIf open C/S: Inspect for uncontrolled bleeding at surrounding sitesConsider possibility for Massive Transfusion Protocol (MTP)Atony: uterotonics, intrauterine balloonTissue retained: D&CTrauma/Laceration: visualize and repairCoagulopathy: replace coag factors aggressivelyProcedures: B-Lynch suture, intrauterine balloon, uterine artery ligation, selective embolizationCharge Nurse(or designee)Bring PPH Kit to patient location Notify blood bank of possibility of massive transfusion Notify anesthesia Bring transfusion supplies/equipment to bedsideBring Crash Cart to roomConsider Rapid Response Team or get assistance of ICU nurse, RT and House Supervisor Notify OR team of PPH in progress /set up as neededAssign scribe to document clinical eventsAssign runner for transport of lab specimens and supplies Assemble invasive mon. equip. as needed by anesthesia (i.e. art-line)Delegate newborn’s careUpdate family on patient conditionObtain medication as needed by primary nurseFacilitate requisition of blood products as neededFacilitate lab workAnesthesiaAssess patient hemodynamic stability Invasive hemodynamic monitoring as indicatedManage IVs, medication and blood administration Ensure adequate anesthesia for proceduresPatients may move rapidly from one stage to another. DO NOT DELAY. If cumulative blood loss > 1500ml, > 2 units PRBCs given, Vital Signs unstable or suspicion for DIC, proceed to STAGE 3Once Stabilized: modified postpartum management with increased surveillanceStage 3 OB Hemorrhage Continued bleeding with blood loss > 1500ml Vital Signs Unstable: HR > 110 > 2 units PRBCs given, BP < 85/45 suspicion for DIC SaO2 < 95% Team MembersRoles and ActionsMedications and ProceduresPrimaryNurseMay requireadditional nurse(s)Move patient to ORVital signs, oxygen saturation, cumulative blood loss and level of consciousness every 5-10 minutes Administer Oxygen to maintain saturation > 95% Use fluid warmer and rapid infuser for blood products and fluidsDocument hourly urine outputKeep patient warm, warmed blankets or air-flow warmer Apply sequential compression device to legsObserve for s/s of DIC including: bleeding from the mouth, gums, needle puncture sites or surgical sites 85725534035Transfuse blood products per MTP Alternate transfusing one unit PRBCs with one unit FFP for a total of 10 units of eachThenTransfuse 1 aphaeresis unit platelets400000Transfuse blood products per MTP Alternate transfusing one unit PRBCs with one unit FFP for a total of 10 units of eachThenTransfuse 1 aphaeresis unit plateletsSTAT Labs: CBC, Platelets, Chemistry, Coagulation panel, ABG if not already done. Repeat with each MTP pack or as clinically indicatedPhysicianFocus is on MTP & invasive procedures to control bleeding191770244475Aggressively transfuse based on blood loss and VSAlternate transfusing one unit PRBCs with one unit FFP for a total of 10 units of each???????ThenTransfuse 1 aphaeresis unit platelets 400000Aggressively transfuse based on blood loss and VSAlternate transfusing one unit PRBCs with one unit FFP for a total of 10 units of each???????ThenTransfuse 1 aphaeresis unit platelets Initiate Massive Transfusion Protocol (MTP)Send for second MTP pack as neededAdditional OB/surgeon for assistanceArtery embolization (interventional radiology)If hemorrhage not controlled by prior measures consider hysterectomy. Consider consult with or transfer to higher level of careCharge Nurse(or designee)Notify blood bank of MTP initiation Notify anesthesiaBring PPH Kit to patient locationBring transfusion supplies and equipment to roomBring Crash Cart to roomConsider Rapid Response Team or get assistance of ICU nurse, RT and House Supervisor if patient condition worsens Notify OR team of PPH in progress /set up as neededAssign scribe to document clinical eventsAssign runner for transport of lab specimens and supplies Assemble invasive mon. equip. as needed by anesthesia (i.e. art-line)Delegate newborn’s careUpdate family on patient conditionObtain medication as needed by anesthesia and primary nurseFacilitate lab work Facilitate requisition of blood products as neededAnesthesiaAssume care of patients hemodynamic statusPrevent hypothermia, acidemiaCentral hemodynamic monitoring as indicatedCall additional anesthesia provider for assistance Administer medications and bloodVasopressor support Calcium replacementAdequate anesthesia for procedure: General anesthetic as indicated Once Stabilized: modified postpartum management with increased surveillance. Consider ICU ................
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