Peripartum Hemorrhage

Peripartum hemorrhage is the most common cause of maternal mortality worldwide and the most common preventable cause of maternal mortality in the United States.[1] Defined as cumulative blood loss during delivery greater than or equal to 1000 mL or blood loss associated with signs or symptoms of hypovolemia within 24 hours of delivery, hemorrhage occurs in 4% to 6% of all deliveries.[2] The Alliance for Innovation on Maternal Health Program, a national alliance to promote safe and consistent maternity care and to reduce maternal morbidity and mortality, offers a safety bundle addressing obstetric hemorrhage, which includes suggestions for readiness, recognition, prevention, response, and reporting.[3] OB/GYN hospitalists have an important role in decreasing morbidity and mortality related to hemorrhage by promoting adoption of the Alliance for Innovation on Maternal Health Program guidelines and hemorrhage protocols; offering provider education; facilitating simulation training in the labor and delivery unit; coordinating a team-based response; and maintaining a detailed knowledge of medications, procedures, and personnel.

Knowledge

OB/GYN hospitalists should be able to:

  • Identify risks factors associated with peripartum hemorrhage.
  • List causes of peripartum hemorrhage.
  • Describe methods for the prevention of peripartum hemorrhage.
  • Describe active management of the third stage of labor.
  • Define a management plan for peripartum hemorrhage.
  • Discuss the dosing, mechanism of action, contraindications, and adverse effects of uterotonic medications.
  • Review repair techniques for lacerations associated with childbirth.
  • Explain management of hematomas associated with childbirth.
  • Describe surgical modalities for the management of peripartum hemorrhage, including uterine tamponade and uterine compression sutures.
  • Review management of the inverted uterus.
  • Describe use and indication for arterial embolization for peripartum hemorrhage.
  • Explain the use of pelvic umbrella pack for treatment of intractable pelvic hemorrhage.
  • List signs and symptoms of disseminated intravascular coagulopathy.
  • List signs and symptoms of hypovolemic shock due to blood loss.
  • Discuss use of tranexamic acid in peripartum hemorrhage.
  • Explain the indications for transfusion of blood products and activation of massive transfusion protocols.
  • Review use of emergency transfusion of uncross-matched blood and blood products.
  • Describe the use of prothrombin complex and fibrinogen concentrates for component replacement.

Skills

OB/GYN hospitalists should be able to:

  • Perform a peripartum hemorrhage risk assessment.
  • Quantify blood loss.
  • Develop systematic approach to evaluation and treatment of peripartum hemorrhage.
  • Select appropriate uterotonic agents for the treatment of atony.
  • Demonstrate manual or curette extraction for retained placenta.
  • Perform repair of cervical, vaginal, and perineal lacerations.
  • Demonstrate uterine tamponade techniques such as uterine compression suturing and uterine vascular ligation.
  • Manually and/or surgically replace the inverted uterus.
  • Manage surgical exploration of puerperal hematomas and intraperitoneal or retroperitoneal bleeding after cesarean delivery.
  • Engage consultants and coordinate a multidisciplinary approach, including the patient, those who care for the patient, nursing staff, anesthesiologists, and critical care specialists, when indicated.
  • Communicate with patients and families regarding the risks and benefits of blood transfusion and obtain informed consent for any procedure.
  • Select appropriate blood components for resuscitative efforts.
  • Stabilize patients for transfer to higher level of care.
  • Perform or mobilize the appropriate team to perform emergent hysterectomy.
  • Ensure close follow-up through the patient’s hospitalization and postpartum visits, including treatment of anemia.
  • After stabilization, inform the patient, her family, and primary OB/GYN provider of the etiology of the hemorrhage and of the steps taken to resolve the bleeding, including the risk of recurrence with any future pregnancies.
  • In the medical record, appropriately document the medical history, physical examination findings, relevant imaging and test results, and discussion with the patient regarding the diagnosis, care options, and management plan.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

  • Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who care for the patient, nursing staff, anesthesiologists, and critical care specialists, to ensure a patient-centered, comprehensive response to peripartum hemorrhage.
  • Keep abreast of evolving management strategies, medications, and techniques for peripartum hemorrhage through continuing medical education and simulation training and share knowledge with colleagues, nursing staff, and administration.
  • Respect the patient’s desires, values, and autonomy, including in scenarios when the patient refuses blood products.
  • Lead debriefing activities after peripartum hemorrhage events to optimize team response.

System Organization and Improvement

OB/GYN hospitalists should be able to:

  • Lead, coordinate, and/or participate in the development and use of patient safety bundles for postpartum hemorrhage.
  • Lead, coordinate, and/or participate in the development and use of a comprehensive peripartum hemorrhage management plan inclusive of patients who refuse blood products.
  • Promote and maintain checklists and/or protocols for management of peripartum hemorrhage.
  • Champion use of obstetric hemorrhage carts for labor and delivery units.
  • Lead, coordinate, and/or participate in formulating a plan for managing patients with morbidly adherent placentas, including establishing relationships with facilities with appropriate resources and developing guidelines and processes for transferring to appropriate facilities.
  • Lead, coordinate, and/or participate in the development and use of massive transfusion protocols for life-threatening hemorrhage.
  • Lead, coordinate, and/or participate in unit-based education regarding management of peripartum hemorrhage including stimulation drills for postpartum hemorrhage, implement before and after knowledge testing, and track team performance such as stipulated in Joint Commission obstetric metrics.
  • Implement methods for tracking quality of care related to postpartum hemorrhage to improve outcomes, such as reduction in use of blood products, hysterectomy rate, intensive care unit admission, and length of stay.

References

  1. Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.  [PMID:25103301]
  2. Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186.  [PMID:28937571]
  3. Council on Patient Safety in Women’s Health Care. Patient Safety Bundle: Obstetric Hemorrhage (+AIM). Available at: https://safehealthcareforeverywoman.org/patient-safety-bundles/obstetric-h... . Accessed for verification April 2019.
Last updated: August 27, 2021