Readiness, recognition, response, and reporting.
- Implementing a standardized safety bundle can reduce the likelihood of patient harm from hemorrhage.
- Working as a team during uncontrolled hemorrhage is essential for optimal maternal outcomes.
- Conducting multidisciplinary review of hemorrhage can increase effectiveness of the response team.
During childbirth, 3% to 5% of women experience maternal hemorrhage, the leading cause of maternal death around the world. In 2010, the California Maternal Quality Care Collaborative (CMQCC) released its first Hemorrhage Toolkit aimed at reducing maternal morbidity and death. The toolkit focuses on the 4 Rs: Readiness, Recognition, Response, and Reporting. In 2015, CMQCC published Hemorrhage Toolkit 2.0, which is aligned with the National Partnership for Maternal Safety Consensus Bundle on Obstetric Hemorrhage, with the goal of optimizing maternal hemorrhage prevention and management. Hospitals that have implemented these bundles have significantly reduced maternal morbidity from hemorrhage. Effective use of a guideline based on the three stages of hemorrhage can improve perinatal team recognition, communication, and situational awareness.
Definitions and causes
In 2017, the American College of Obstetricians and Gynecologists (ACOG) defined maternal hemorrhage as a cumulative blood loss of greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia that occurs within 24 hours after the birth process.
Although blood loss of 500 mL after vaginal birth is abnormal and requires prompt attention, to help standardize management approaches and improve data collection, the new definition emphasizes cumulative blood loss. Essential physiologic changes during pregnancy are normal, but they create vulnerability for the mother. For example, at term, pregnant women are hypervolemic with approximately 5.5 L of total body blood volume. Blood composition is hemodiluted (low in red blood cells) and hypercoagulated from a 35% plasma increase that occurs during pregnancy. To meet the demands of the growing fetus, cardiac output increases by 50%, and during pushing and birth it increases by 80%, making the cardiovascular system hyperdynamic to meet this challenge. These normal protective changes give rise to vulnerability during hemorrhage beyond 1,000 mL. The 4 Ts mnemonic—Tone, Trauma, Tissue, and Thrombin—summarizes causation of hemorrhage in order of prevalence.
- Tone: Uterine atony (accounts for about 80% of maternal hemorrhage)
- Trauma: Birth canal lacerations, concealed blood vessels, and uterine inversion
- Tissue: Retained placental tissue or membranes
- Thrombin: Thrombin depletion and inadequate clot formation.
Obstetric emergencies are relatively uncommon, and many of the lifesaving interventions required during hemorrhage are rarely needed for most obstetric patients who receive routine care. However, maternal hemorrhage is difficult to predict and can occur without warning. According to The Joint Commission, up to 20% of obstetric hemorrhage occurs in women with no risk factors. The unpredictability of maternal hemorrhage requires obstetric units to maintain a constant state of readiness, with standardized protocols for maternal hemorrhage.
An emergency is not the time to search for rarely used supplies or obtain expensive equipment from locked cabinets or closets. Not having medications and equipment readily available when obstetricians and anesthesiologists request them during an emergency can be nerve-racking for nursing staff. Well-equipped and maintained mobile obstetric hemorrhage carts are essential for prompt availability of equipment necessary to treat maternal hemorrhage. The cart should contain transfusion lines, surgical instruments, sutures, and tamponade balloons, as well as consent forms, algorithms, and checklists. (See Hemorrhage cart at the ready.)
In addition to the emergency supplies on the hemorrhage cart, these medications should be easily accessible:
- uterotonics (oxytocin, methylergometrine, misoprostol, carboprost)
- antifibrinolytic (tranexamic acid)
- calcium replacement (calcium chloride, calcium gluconate)
- after transfusion of ≥ 6 units of packed red blood cells: Consider administering calcium chloride via central venous line and calcium gluconate via peripheral venous line.
Leaders of obstetric units should ensure staff receive education so they can recognize and respond to maternal hemorrhage. In addition, a rapid response team should be established with each member having defined roles for maternal hemorrhage, such as who is responsible for rapid blood product administration. Annual multidisciplinary hemorrhage drills (followed by debriefings) can help ensure the unit’s readiness.
The perinatal team should establish a hemorrhage order-set that includes a massive transfusion protocol (MTP). For women with known hemorrhage risk, the provider should develop a written collaborative management plan and review it with all specialty services before hospitalization. For centers caring for women with morbidly adherent placenta, specialized percreta carts can be useful.
During labor and delivery, all women are at risk of uncontrolled hemorrhage that can quickly progress to hypovolemic shock if untreated. Early recognition is key to timely correction and management of the underlying cause. Three pillars of early recognition are risk assessment, early-warning criteria, and quantification of blood loss (QBL).
Lyndon and colleagues categorize hemorrhage risk as low, medium, or high. (See Hemorrhage risk.) The prenatal record and the patient condition on admission establish the initial hemorrhage risk, which can increase as labor progresses. For example, the initial admission hemorrhage risk may be low, but after a long labor induction, prolonged labor, or cesarean birth, the risk increases. Intrapartum factors that increase hemorrhage risk include oxytocin infusion for more than 18 hours, chorioamnionitis, and prolonged second stage of labor (pushing). Reassessing and communicating hemorrhage risk during shift report and at all patient handoffs or department transfers ensures that perinatal team members can identify high-risk patients, remain vigilant, and are prepared for a potential emergency.
Maternal hemorrhage risk is categorized as low, medium, or high.
• Fewer than four previous deliveries • No hemorrhage history
• Singleton pregnancy
• Unscarred uterus
• Greater than four previous deliveries
• Large uterine fibroids
• Magnesium sulfate use
• Multiple pregnancy
• Prior cesarean delivery or uterine surgery • Prolonged use of oxytocin
• Abnormal vital signs (e.g., tachycardia, hypotension) • Bleeding on admission
• Hematocrit < 30%
• History of hemorrhage
• Known coagulant disorder
• Placenta previa, accreta, increta, percreta
Adapted from the California Maternal Quality Care Collaborative Obstetric Hemorrhage Toolkit 2.0.
Loss of situational awareness and denial that a problem exists are two common reasons perinatal teams fail to recognize the severity of blood loss. Teams frequently normalize abnormal findings because the patient “looks good” and fail to recognize maternal hemorrhage. Most pregnant women are young adults in relatively good health who can tolerate 2,000 mL of blood loss before vital signs begin to deteriorate. However, after 1,000 mL of blood loss, the patient requires a heightened level of surveillance.
Incorporating an alert system can draw team members’ attention to early-warning criteria (heart rate ≥ 110 beats per minute, blood pressure ≤ 85/45 mmHg or 15% drop, mean arterial pressure [MAP] < 60 mmHg [MAP is the most specific and sensitive criterion], oxygen saturation < 96%, temperature < 36° C [96.8° F], urine output < 30 mL/hr). The warning criteria correlate with severe blood loss and require immediate bedside evaluation by the provider to further assess and manage the hemorrhage.
Failing to recognize and respond to impending cardiovascular collapse is a common causal factor associated with maternal death from obstetric hemorrhage. If warning criteria are met and a rapid response isn’t called, the rationale for omission should be documented in the electronic health record (EHR).
Quantification of blood loss
ACOG’s 2019 committee opinion on QBL states that quantitative methods of measuring blood loss are more accurate than visual estimations. The Association of Women’s Health, Obstetric and Neonatal Nurses also issued a practice brief on QBL as a best practice recommendation to help perinatal teams recognize the severity of maternal blood loss during childbirth.
QBL can be calculated from blood in suction canisters, under-buttock drapes, and in surgical sponges, bed pads, and sanitary napkins. Total blood-soaked items should be weighed (1 g = 1 mL of fluid loss) and then the dry weight subtracted. The remaining difference is the net weight or QBL.
After calculating the QBL, the nurse should announce it to the other members of the perinatal team, who should then verbally acknowledge awareness of the blood loss. The nurse enters and timestamps the QBL in the EHR, making the QBL an essential metric and providing a baseline measurement for hemorrhage.
QBL as standard work allows for cumulative measurement of ongoing blood loss and ensures time-sensitive skillful action in emergencies. It improves situational awareness, ensures accurate communication for arriving rapid response staff, and can reduce maternal morbidity and death associated with hemorrhage. If QBL is measured only in emergent situations, the unit risks not having a reliable effective workflow at all times. QBL should continue through immediate postpartum recovery until hemostasis has been achieved and critical postpartum recovery elements are met.
Stages of hemorrhage
Vital signs, the patient’s clinical condition, and QBL provide criteria to categorize and communicate hemorrhage as either Stage 1, Stage 2, or Stage 3. (See 3 stages of hemorrhage.)
Stage 3 hemorrhage may represent as much as 35% of total blood volume lost. Managing Stage 3 hemorrhage frequently requires participation from interprofessional care team members, including intensivists, critical-care staff, radiologists, and hematologists. Blood loss from uterine atony can be brisk (up to 300 mL per minute if uncontrolled), so time is of the essence, and the team must provide a quick response, effectively mobilize resources, and manage the hemorrhage in a stepwise fashion to avoid hypovolemic shock. If shock persists, end organ hypoperfusion results, with widespread cellular dysfunction, metabolic acidosis, disseminated intravascular coagulation (DIC), and eventually death.
Maternal hemorrhage can be staged based on patient vital signs, clinical condition, and quantification of blood loss (QBL).
• Activate hospital maternal hemorrhage guideline and continue to monitor closely.
• Consider blood product prep time and medical record order entry process.
• QBL 1,200 mL to 1,500 mL
• May result in tachycardia, tachypnea, and ortho-static hypotension
• Sequentially advance through hemorrhage guide- line.
• Administer medications and begin corrective procedures.
• Call for 2 units of packed red blood cells in a cooler to arrive at patient’s bedside.
• Evaluate need for blood transfusion based on clinical condition.
• QBL > 1,500 mL or if more than 2 units of packed red blood cells have been given or if disseminated intravascular coagulation is suspected
• Maternal symptoms usually worsen, vital signs trend down and may become abnormal
• Activate massive transfusion protocol.
• Activate rapid response team, obstetrician, anesthesiologist, perinatologist, and other specialists as needed.
The Council on Patient Safety in Women’s Health Care (which represents major women’s healthcare organizations in the United States) recommends using a standardized, stage-based hemorrhage emergency plan with checklists. The council’s obstetric hemorrhage safety bundle and the CMQCC Hemorrhage Toolkit 2.0 describe detailed strategies for reducing maternal morbidity and death from hemorrhage. Time-sensitive interventions beyond fundal massage, include:
- quick access to uterotonic medication and tranexamic acid
- uterine balloon placement
- establishing a second I.V. line dedicated to blood product administration
- serum coagulation evaluation
- uterine curettage
- arterial blood gas analysis
- MTP activation.
The lethal triad of coagulopathy (hypotension, hemodilution, and hypothermia) are precursors to DIC and should be avoided. Other response considerations include MTP, hypothermia, and acidosis.
MTP is intended to replace whole blood loss with a combination of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and single-donor apheresis pooled platelets. Recommended MTP blood product ratios vary, but one suggested ratio is 1:1:1 (for example, one unit each of PRBCs, FFP, and platelets). For suspected placental abruption or amniotic fluid embolism, or if serum fibrinogen is less than 100 to 125 mg/dL, the perinatal team should consider transfusing six to 10 units of pooled cryoprecipitate. Rapidly replacing red blood cells and adequate clotting factors are key interventions aimed at avoiding hypovolemic shock and consumptive coagulopathy.
Hypothermia can lead to platelet dysfunction, so the patient’s core temperature should be monitored and maintained above 36° C (96.8° F). Using a blood and fluid warming device for rapid blood transfusion or a warming blanket can help maintain normal temperature.
Acidosis from hypoperfusion to multiple organs results in elevated lactic acid levels. It’s also important to monitor arterial blood gas pH, which should be greater than 7.25.
A dedicated nurse or technician can assist the anesthesiologist with central and arterial line setup, placement, and monitoring. If amniotic embolism is suspected, vasopressor support may be needed to maintain mean arterial pressure greater than 60 mmHg. The nurse should remain with the patient during hemorrhage for continuous assessment and team communication.
The labor and delivery nurse should remain with the mother for at least 2 hours postpartum and perform an ongoing assessment of her physical condition, vital signs, and general well-being. If assessment results become abnormal, the nurse should notify the charge nurse, the obstetric provider, and the anesthesiologist. If the nurse receives orders to administer two or more additional uterotonic medications for persistent bleeding, the provider should perform an immediate bedside evaluation to determine the etiology of ongoing bleeding. If the provider is unavailable or refuses to perform the evaluation, the nurse should notify the charge nurse, the hospital nurse supervisor, and, if needed, the medical director. This chain of communication should not be used lightly, but it should be activated by the direct care nurse if there’s concern about potential harm due to treatment delay, biases, or lapses in time-sensitive care. The nurse is responsible for communicating hemorrhage severity to the obstetric provider and confirming or clarifying the management plan.
Hemorrhage protocols that require activating the communication chain facilitate prompt bedside response and promote patient safety. The communication chain also promotes situational awareness, effective resource use, and clear team communication. During Stage 3 hemorrhage with uncontrolled bleeding, anesthesia and obstetric providers should be at the bedside to assess and comanage the patient. Additional staff—gynecology/obstetric surgeon, hospitalist/intensivist, perinatologist, and intervention radiologist—should be called as needed for specialized procedures.
After the mother and baby are stable, the nurse-to-patient ratio can change from 1:1 (one nurse for the mother and one nurse for the baby) to 1:2 (one nurse for both mother and baby). The immediate postpartum 1:1 staffing recommendation allows for continued mother and baby surveillance for at least 2 hours. After that, the stable couplet can be transferred to the mother baby unit, where the recommended nurse-to-patient ratio is one nurse for no more than three stable, low-risk couplets.
Although not common, delayed hemorrhage may occur. If the patient’s clinical condition worsens or bleeding resumes, the nurse should immediately notify the charge nurse and obstetric provider. If the nurse administers additional uterotonic medications per protocol and bleeding continues, the provider should be notified for immediate bedside evaluation. Time-sensitive procedures (such as intrauterine balloon placement for uterine atony, cervical dilatation with curettage for retained placental fragments, or uterine artery embolization) are stepwise interventions that may be ordered. The charge nurse may consider readjusting the staffing ratio back to 1:1, which provides the nurse with time for heightened surveillance, additional assessments, QBL resumption, targeted procedure assistance, and real-time documentation.
Severe hemorrhage during childbirth is physically and emotionally stressful for patients and families. Bonding, breastfeeding, concern for future pregnancies, and long-term emotional health also pose coping challenges. Comprehensive postpartum care should be sensitive to the patient’s and family’s physical and psychological needs. Postpartum nurses should provide education that includes written discharge instructions as well as community and national resources for women recovering from hemorrhage. An early follow-up appointment 2 weeks after discharge should include targeted postpartum depression and posttraumatic stress syndrome assessment.
Review and reporting
Hospitals should establish criteria to review maternal hemorrhage cases, evaluate care effectiveness, and learn from the experience. Criteria that should be reviewed for low-risk patients include receiving four or more units of blood products or unexpected admission to a higher level of care or the intensive care unit.
Each case review should have an interprofessional team charged with evaluating care, treatment, and services provided by the rapid response team. A rigorous, nonpunitive review serves as an excellent forum to examine perinatal team errors, develop skills, and identify strategies to improve future care. Well-run interprofessional case reviews can create a culture of safety and empower staff to work together to develop safe and effective procedures and processes.
Black women have a three times higher chance of death during childbirth than White women, and denial and delay occur at a higher frequency and duration when Black women seek medical care. Every organization should examine how structural racism and racial disparity may have been a factor in each maternal hemorrhage case. Identifying factors of racism will promote better understanding of the circumstances of severe morbidity and death in Black women and other disproportionately affected populations.
A team approach
Successfully managing maternal hemorrhage is a team effort that requires well-coordinated completion of numerous tasks in a short time frame. The patient’s primary nurse is responsible for recognizing hemorrhage in real time and communicating the patient assessment to the rest of the perinatal team. All team members should adhere to a preapproved department-specific hemorrhage guideline to identify bleeding etiology, implement corrective measures, and avoid pitfalls that contribute to denial and delay of treatment. (See 13 keys to maternal hemorrhage management.)
The CMQCC and the Council on Patient Safety in Women’s Health Care provide many customizable resources to help organizations and teams implement the 4 Rs approach. In addition, The Joint Commission issued a new standard effective July 1, 2020, to further address maternal hemorrhage complications.
The perinatal team’s maternal hemorrhage guidelines should include the following key points.
- Use existing hemorrhage prevention resources from the California Maternal Quality Care Collaborative or the Council on Patient Safe- ty in Women’s Health Care.
- Provide staff education about the complexity of maternal hemor- rhage and management.
- Conduct routine maternal hemorrhage drills to build competency and a shared response framework.
- 4 Establish a department guideline specific to maternal hemorrhage that includes a massive transfusion protocol.
- Assess hemorrhage risk of all obstetric patients on admission and update their risk throughout hospitalization, at shift change, pa- tient transfers, and patient handoffs.
- Implement quantification of blood loss for all births as standard process and classify hemorrhage as Stage 1, 2, or 3.
- Escalate care during Stage 2 hemorrhage and consider activating chain of communication resolution to avoid denial and delay.
- At Stage 3 hemorrhage with signs and symptoms of ongoing bleeding, activate massive transfusion protocol.
- Provide routine postpartum care only if critical elements have been met and bleeding is controlled.
- Activate a rapid response alert for postpartum patients with new- onset hemorrhage.
- Review and report all low-risk patient cases that meet hemorrhage criteria to gain insight into best practices.
- During case reviews, examine how racism and bias may have been a factor in hemorrhage recognition and management.
- Educate and support patients who experience severe maternal hemorrhage and their families.
A role for all nurses
All nurses play a vital role in maintaining and sustaining hemorrhage bundle implementation. Direct care nurses must provide vigilant patient surveillance and advocacy, and nurse educators can build team competencies and prevent skill degradation with novel hemorrhage drills, simulations, and team training exercises. Charge nurses must be ready to deploy emergency resources in a timely manner and escalate communication up the chain of authority when individual biases contribute to care denial and delay. Nurse leaders can strive to create reliable hospital systems where all pregnant women receive safe, equitable, and respectful care.
Finally, nurses can collaborate with the entire perinatal team in rigorous maternal hemorrhage case reviews to identify best practices and areas for improvement so that the best possible outcomes are achieved.
Valerie Yates Huwe is a perinatal outreach educator at the University of California San Francisco Benioff Children’s Hospital and a direct care nurse in labor and delivery at El Camino Hospital in Mountain View, California.
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