Challenge 11A

Postpartum Hemorrhage (PPH)

Executive Summary Checklist

Obstetric Hemorrhage is the most common complication in pregnancy leading to severe maternal morbidity and preventable mortality. The National Partnership for Maternal Safety, an alliance of the professional organizations of maternity care professionals and advocates, selected this safety topic for priority development and national implementation. Representative experts from these organizations developed the bundle to outline critical clinical practices that should be implemented in every maternity unit. To underscore the importance of this work. In depth description of this bundle has been simultaneously published in 5 peer-reviewed journals representing the involved organizations. As will all maternal safety bundles, the Obstetric Hemorrhage bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources to assist with implementation.

Prevention of PPH-related maternal mortality

  • Commitment from hospital governance and senior administrative leadership to support maternal safety initiatives like PPH in their healthcare system.

Readiness in Every Unit

  • Create a hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches based on the recommendations referenced1,2,3,4,5,6,7
  • Ensure teams have immediate access to hemorrhage medications (kit or equivalent)1,2,3,4,5,6,7,8 9,10
  • Establish a response team – who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services)1,2,3,4,5,6,7,8,9,11
  • Establish massive and emergency release transfusion protocols (type-O negative/uncross-matched)1,2,3,4,5,6
  • Unit education on protocols, unit-based drills (with post-drill debriefs1,2,3,4,5,6,8,9,10

Recognition & Prevention in Every Patient

  • Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)1,2,3,4,5,6,7
  • Assessment of:1,2,3,4,5,6,7,9
    • Retained placenta
    • Failure to progress during the second stage
    • Lacerations
    • Morbidly adherent placenta
    • Instrumental delivery
    • Large for gestational age newborn (>4000 gm)
    • Hypertensive disorders
    • Induction of labor
    • Prolonged 1st or second stage of labor
  • Measurement of cumulative blood loss (formal, as quantitative as possible1,2,3,4,5,6,7,9
    • Weigh the pads for quantitative measurement
  • Active management of the 3rd stage of labor (department-wide protocol)1,2,3,4,5,6,7,8,9,10

Response

  • Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists1,2,3,4,5,6,8,9
    • Obstetric rapid response teams, Team Stepps.
  • Support program for patients, families, and staff for all significant hemorrhages1,2,3,4,5,6,8

Reporting

  • Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities1,2,3,4,5,6,7
  • Multidisciplinary review of serious hemorrhages for systems issues1,2,3,4,5,6,7
  • Monitor outcomes and process metrics in perinatal quality improvement (QI) committee1,2,3,4,5,6,7

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.

References
  1. Postpartum hemorrhage. ACOG practice bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039-47. Available until 4/17/16.
  2. American College of Obstetricians and Gynecologists. Safe motherhood initiative. Available at: http://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-Registration. Retrieved September 22, 2014.
  3. Lyndon A, Lagrew D, Shields L, Melsop K, Bingham B, Main E. (Eds). Improving health care response to obstetric hemorrhage. Stanford, CA: California Maternal Quality Care Collaborative; 2010.
  4. Preparing for clinical emergencies in obstetrics and gynecology. Committee opinion No. 590. American College of Obstetricians an d Gynecologists. Obstet Gynecol 2014;123:722-5.
  5. Florida Perinatal Collaborative. Obstetric hemorrhage initiative (OHI) tool kit for hospital implementation. Available at: https://www.dropbox.com/sh/1jz1mn3tllmsrtm/GsbzbCxMXn. Retrieved September 22, 2014.
  6. Association of Women’s Health, Obstetric and Neonatal Nurses. AWHONN postpartum hemorrhage project. 2014. Available at: http://www.pphproject.org/resources.asp on 8/28/14. Retrieved September 22, 2014.
  7. Bingham D, Melsop K, Main E. CMQCC Obstetric hemorrhage hospital level implementation guide. Stanford, CA: California Maternal Quality Care Collaborative; 2010.
  8. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva, Switzerland: World Health Organization; 2012.
  9. Evanson A, Anderson J. Postpartum hemorrhage: Third stage pregnancy. In: Leeman L, editor. Advanced life support in obstetrics provider syllabus. Leawood, KS: American Academy of Family Physicians; 2014.
  10. Association of Women’s Health, Obstetric and Neonatal Nurses. Oxytocin administration for management of third stage of labor. Practice brief number 2, May 2014. Available at: http://www.pphproject.org/downloads/awhonn_oxytocin.pdf. Accessed September 22, 2014
  11. The Joint Commission. Preventing maternal death. Sentinel event alert issue 44. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_44_preventing_maternal_death/. Retrieved September 22, 2014.

Parent Challenge

  1. Challenge 11: Optimizing Obstetric Safety