POSTPARTUM HEMORRHAGE MANAGEMENT

POLICY

A physician, Registered Midwife, Registered Nurse initiates care, monitoring and interventions for women experiencing postpartum hemorrhage.

Applicability: Care and monitoring of women experiencing postpartum hemorrhage occurs in the Acute Maternal Gyne Program.

1.1 Overview

• Postpartum hemorrhage (PPH) is a leading cause of maternal mortality and morbidity worldwide. • The average rate of PPH for BCWH from 2009 to 2013 is 10.5%. (BC Women's Hospital Indicator: Postpartum Hemorrhage – 2009/10 FP12 to 2012/13 FP11). • Early identification of PPH is necessary to intervene and prevent major blood loss. • Early intervention requires recognition of risk factors leading to heightened surveillance, standard work in estimating blood loss, and using clinical parameters as triggers for escalating intervention. • Collaborative and interprofessional teamwork and effective communication are essential to the effective delivery of this care.

1.2 Definitions

• PPH is defined as blood loss greater than 500 mL in a vaginal birth and greater than 1000 mL in a caesarean section birth or any blood loss that produces hemodynamic instability. • Severe PPH is defined as blood loss greater than 1500 mL for either vaginal birth or caesarean section birth. • Primary (immediate) PPH is when excessive bleeding occurs within the first 24 hours after birth. • Secondary (late) PPH is when excessive bleeding begins more than 24 hours after birth up to six weeks postpartum.

1.3 Pregnancy physiology

• In pregnancy, maternal plasma volume expands by approximately 42%, and red blood cell volume increases 24%. A greater expansion of plasma volume relative to the increase in hemoglobin mass and erythrocyte volume is responsible for the modest fall in hemoglobin levels (i.e., physiological or dilutional anemia of pregnancy) is seen in healthy pregnant women • Due to the normal physiologic changes of pregnancy, the pregnant woman demonstrates an initial heightened compensatory response to blood loss. Initially, maternal vital signs may be within normal limits. The amount of blood loss required to cause hemodynamic instability depends on the woman’s pre-existing health status.

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1.4 Classification of PPH by stages of blood loss including signs & symptoms

Estimated Blood % of Blood Heart Signs & Symptoms Loss blood Pressure Rate loss Stage 1 >500mL for 15-20% Normal <110 (mild) vaginal birth bpm >1000mL for C/S Stage 2 1000-1500mL 20-30% Postural >110 *May show some (moderate) hypotension bpm signs and symptoms Slight fall of severe PPH SBP 80-100 mm Hg Stage 3 over 1500-2000mL Over 30- Marked fall >120 Diaphoresis (severe or 40% SBP 70-80 bpm Delayed capillary refill massive) mm Hg time Cool extremities Anxiety Tachypnea Oliguria Restlessness Pallor Agitation/confusion Anuria

* Although these signs and symptoms may manifest in some patients, the obstetric patient population may tolerate significant hemorrhage with few signs or symptoms manifesting until severe hemorrhage. This is likely due to the ability of healthy pregnant women to compensate to a loss of circulating volume and to possible underestimation of blood loss.

1.5 Causes of PPH (Commonly called the 4 T’s)

• Tone: uterine atony is the most common cause. May be due to distended bladder, chorioamnionitis, or other factors. • Trauma: uterine, cervical or vaginal injury; uterine rupture; uterine inversion • Tissue: retained placenta or clots • Thrombin: pre-existing or acquired coagulopathy, pre-eclampsia, anti-coagulation

PROCEDURE 1.1 Pre-admission/Time of admission

1.1.1 Prenatal, Admission and Ongoing Risk assessment

• Prenatal Risk Assessment • Identify on antenatal history record patients with antenatal risk factors for PPH such as placenta accreta, percreta, increta; bleeding disorders, severe anemia, or those who decline blood products. • Prepare for care of patients with risk factors through consultation with Anesthesiology, Hematology, and Internal Medicine. Ensure communication with Transfusion Medicine. Senior

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Practice Leader may be consulted to assist with advanced care planning and documentation of the plan of care.

Admission Risk Assessment: Identify risk factors at admission and document on triage record. • Low risk: no previous uterine incision, singleton pregnancy, less than 4 previous vaginal births, no known bleeding disorder, no history of PPH • Medium risk: previous caesarean birth(s) or uterine surgery, over-distended uterus (e.g. multiple gestation, polyhydramnios, estimated fetal weight greater than 4500 grams), 5 or more previous vaginal births, chorioamnionitis, abruption, history of previous PPH, uterine fibroids over 8 cm, morbid obesity (BMI > 38), thrombocytopenia (platelets <75), hemoglobin less than 90 • High risk: placenta previa, low lying placenta, suspected placenta accreta, percreta, or increta, hemoglobin less than 80 and other risk factors, active bleeding (greater than show) on admission, known coagulopathy (including von Willebrand disease; antibodies to Factor VIII; Factor X, XI, XIII deficiencies; anticoagulation therapy; severe Gestational Hypertension; sepsis)

Ongoing Risk Assessment: Evaluate for development of additional risk factors in labour. Document assessment and communicate plan with patient, Primary Care Provider (PCP) and obstetrical team. • Precipitous labour and birth • Prolonged 2nd stage > 3 hours • Prolonged oxytocin use (greater than 12 hours) • Active bleeding • Chorioamnionitis • Operative vaginal delivery (forceps or vacuum) • Caesarean delivery • Retained placenta

1.1.2. Based on risk assessment

Low risk • Evaluate for development of additional risk factors in labour

Medium risk • Insert IV • Draw type & screen, CBC and differential • Review PPH protocol and discuss increased level of risk and anticipated care with woman and team

High risk • Type & crossmatch 2 units PRBCs • Notify OB of admission • Notify anesthesia of admission • Consent woman for blood products • Review PPH protocol and discuss increased level of risk and anticipated care with woman and team

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1.2 All Births

1.2.1 Active Management of the Third Stage of Labour (AMTSL) decreases the incidence and severity of PPH. For all women, AMTSL includes the following

• Oxytocin 10 units intramuscularly given after the delivery of the fetus’s anterior shoulder • Delayed cord clamping (see policy) • When the signs and symptoms of placental separation are evident, deliver the placenta (no cord traction) • After delivery of the placenta, assess fundal tone and location. • AMTSL is our standard of care for every birth. If a woman declines AMTSL, an informed refusal of care form is signed antenatally. If risk factors develop during labour, there is a discussion with the woman regarding increased level of risk and AMTSL. • For elective caesarean births, women with 1 or more risk factors for PPH should be given carbetocin 50 micrograms as an IV bolus over at least 1 minute for prevention of PPH and to decrease the need for therapeutic uterotonics. Carbetocin 50 micrograms IV bolus over at least 1 minute may be repeated if needed for bleeding. • For urgent or emergent caesarean births, consider giving carbetocin 50 micrograms as an IV bolus over at least 1 minute for prevention of PPH and to decrease the need for therapeutic uterotonics.

1.2.2 Monitor blood loss in order to identify PPH early; quantify blood loss and determine the source of bleeding. Weigh all sponges for both vaginal birth, assisted vaginal birth, and caesarean birth.

1.2.3 Quantification of blood loss

• Blood loss estimation is performed through objective methods including direct measurement of blood volume in containers (e.g. suction canisters, under buttocks drape) and weighing all blood soaked materials. Subjective visual estimation is used only when objective methods are not feasible.

1.3 Obtain supplies and PPH cart

• PPH carts located on: • Delivery Suite main desk • OR equipment area by OR 2 • SRMC in Holly medication room • Arbutus cart is across from room 2 (shared between Arbutus and Balsam) • Dogwood cart is across from room 2 (shared between Dogwood, Evergreen and Fir) (see equipment lists in Appendix) • Medications (hemabate and ergometrine) in refrigerators in the medication rooms on individual units and PAR refrigerator • Scale • Under Buttock drape (delivery cart or operating room cupboard) • Overhead directed light • Bair Hugger (in PAR) • Rapid infuser (in OR) • Cell saver (on call from the perfusionist as needed) • Surgical instrument sets: WW.08.16 Fetal Maternal Newborn and Family Health Policy & Procedure Manual Effective Date: 21-OCT-2013 Page 4 of 9 Refer to online version – Print copy may not be current – Discard after use POSTPARTUM HEMORRHAGE MANAGEMENT

• Hysterectomy set • Dilation and curettage set • Cervical inspection set • Suture set

1.4 Stage 1: Blood Loss >500mL Vaginal Birth or >1000mL Caesarean Birth

1) Assess maternal Circulation, Airway, and Breathing (CAB). 2) Call for help and notify additional personnel including the Primary Care Provider, a second Nurse, and consider consult to an obstetrician (if PCP not an obstetrician; at discretion of PCP). 3) Start an IV using a large-bore catheter (#16 or 18 gauge) with Normal Saline mainline (if not already in place). 4) Assess vital signs, including level of consciousness (document according to sedation scale on Partogram) and SpO2 level at least every 5 minutes. Titrate oxygen by facemask to keep SpO2 above 95%. 5) Place woman in supine position and lower the head of the bed to less than 30 degrees. 6) Give nothing by mouth. 7) Keep woman warm by covering with warm blankets or Bair Hugger. 8) Perform interventions specific to the source of bleeding: • Assess fundal tone • Perform fundal massage. Once the uterus is firm, use one hand to express clots by applying firm but gentle pressure on the fundus toward the vagina. Use other hand to support the uterus suprapubically during the fundal massage. • Ensure the woman’s bladder is empty and catheterize if needed. • Assess for cervical or vaginal lacerations or hematoma • Apply pressure to laceration, if visible, with sterile gauze/sponge. • Repair of laceration. • Assess for retained placenta or clots • Assess for coagulopathy by assessing serum coagulation profile 9) Administer secondary uterotonics as per PCP orders:

• If Oxytocin 30 Units in 500 ml IV already running, then increase rate to bolus remainder of the bag. If no Oxytocin, then start Oxytocin 40 Units in 1 Litre of Normal Saline and give 500 ml bolus then 125 ml/hr. Oxytocin 20 Units in 1 Litre can be given and rate titrated to blood loss in the absence of a PCP (see PSBC DST for PPH). Further dosing requires a provider order. • Ergometrine (ergonovine maleate) 0.25 milligrams IM or IV (by physician only, over 1 minute) once. May repeat once at 15 minutes but only IM. Further doses may be repeated every 4 hours. Maximum of 1.5 milligrams (5 doses) in 24 hours. Note: This medication is contraindicated in hypertension and with concomitant use of certain drugs used to treat HIV. • Hemabate (carboprost) 250 micrograms IM. May repeat every 15 minutes to a maximum cumulative dose of 2 milligrams (8 doses) in 24 hours. Use caution in patients with asthma. Give Hemabate concurrently with antidiarrheal agent (loperamide 4 milligrams ODT (Oral Dissolving Tablet) orally once) to prevent side effect of diarrhea. If needed, give loperamide 2 milligrams orally after each loose stool to a maximum of 16 milligrams in 24 hours to prevent the side effect of diarrhea. Note: ODT tablet formulations crumble easily and are affected by moisture (e.g. on fingers/hands). 9) Draw CBC, coagulation studies, type and screen if not already done.

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1.5 Stage 2: Blood Loss 1000-1500mL 1) Notify additional personnel. Update charge nurse regarding patient status. Call obstetrician and anaesthesiologist at attend and assess woman. 2) Continue to quantify blood loss by weighing blood soaked materials. Communicate estimated blood loss totals to the obstetric team. 3) Continue assessment of vital signs, including level of consciousness and SpO2 level at least every 5 minutes. 4) Obstetric management

Vaginal: • Insert indwelling foley catheter (if not already in place). • Continued bimanual massage • Consider subsequent doses of uterotonic agents • If retained products of conception (POC) suspected and bleeding ongoing, then proceed to D&C and communicate with the OR team • If continued atony persists, then insert intrauterine balloon tamponade • Treat laceration/hematoma as required. Caesarean Section: • If continued atony persists, then continue surgical compression • Consider subsequent doses of uterotonic agents • Insert intrauterine balloon tamponade • If continued hemorrhage, then consider cell saver and/or uterine artery ligation 5) Start a second IV access using large-bore catheter (#16 gauge or greater). 6) Draw CBC and coagulation panel if not already done in stage 2. 7) Administer ongoing IV fluid resuscitation. Consider the use of Plasmalyte, a crystalloid recommended for large fluid volume resuscitation beyond 2 litres, as directed by anaesthesiologist. 8) Administer prophylactic antibiotics as per orders. 9) Anticipate and prepare patient for transfer to the Operating Room or to Delivery Suite if the woman is on a Postpartum unit. 10) Crossmatch 2 Units Packed Red Blood Cells (PRBCs). 11) Transfuse 2 Units PRBCs as per clinical signs (do not wait for lab values).

1.6 Stage 3: Blood Loss >1500mL

1) Continue to quantify blood loss by weighing blood soaked materials. Communicate estimated blood loss totals to the obstetric team at least every 10 minutes. 2) Continue assessment of vital signs, including level of consciousness and SpO2 level at least every 5 minutes

3) Bleeding Ongoing and Uncontrolled

• Transfer to the Operating Room (if in any other patient care area) • Call Transfusion Medicine to activate Obstetric Massive Transfusion Protocol (provide patient name, Medical Record Number, and location) (see Appendix: Obstetric Massive Blood Transfusion Protocol)

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• Notify additional personnel of massive PPH, including charge nurse, second obstetrician (maternal-fetal-newborn medicine if obstetrician unavailable), and laboratory services. Consider consultation with intensive care and/or Gynecology Oncologist • Consider ongoing use of uterotonic agents • Consider use of tranexamic acid 1000 milligrams IV over 10 minutes (undiluted by physician or diluted in 50-100 mL IV fluid over at least 10 minutes by RN). Rate not to exceed 100 mg/minute. May repeat 1 gram dose after 2 hours if needed. See BCW Parenteral Manual for more information. • Surgical management: • Laparotomy • B-Lynch or Cho suture • Uterine Artery Ligation • Consider embolization • Consider hysterectomy • Consider Gynecology Oncology consult

4) Bleeding controlled

• Crossmatch 4 Units PRBCs • If full hemostasis is not imminent, consider thawing Fresh Frozen Plasma 2 Units.

1.7 Woman and family education

Antenatal and Intrapartum: • Ensure woman and family understand risks of PPH • Review plan of care and necessary potential interventions with woman and family

Postpartum: The woman may have significant needs for information after a PPH. • Encourage and support frequent breastfeeding (stimulation of endogenous oxytocin facilitates uterine contraction) • Teach woman what is normal to expect with respect to bleeding and clots. Ask her to call for assistance when ambulating in the hospital or if she notices signs and symptoms of increased bleeding. • Encourage frequent voiding to prevent bladder distension, or discuss need for foley catheter. • Teach what to expect from physical recovery, including how to restore hemoglobin levels, normal bleeding over the first 6 weeks postpartum, • Discuss the woman’s plan for follow up with consultants, internal medicine and own family physician medicine) • Discuss the woman’s emotional recovery, and provide an opportunity for debriefing as necessary. This may include available support services, coping with grief over loss of anticipated birth experience, coping with possible experience of trauma from difficult birth/life-threatening complications, coping with possible impact on future fertility, and coping with possible initial separation from baby. Possible resources include primary nurse, social work, spiritual care, primary physician.

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1.8 Care of the Woman Postpartum Consider the following factors for assessment and monitoring after a PPH:

• Antibiotics • Pain management • VTE prophylaxis • Iron supplementation/infusion • Breastfeeding support • Internal medicine follow up • Psychosocial care

DOCUMENTATION • Labour Partogram • Postpartum Clinical Path • Interprofessional Progress Notes • Special Clinical Record • Detailed Fluid Balance Record - BCW 324 • 12 Hour Fluid Balance Record – 00055400

REFERENCES Cordovani, D., Balki, M., Farine, D., Seaward, G., & Carvalho, J. C. A. (2012). Carbetocin at elective Cesarean delivery: A randomized controlled trial to determine the effective dose. Canadian Journal of Anesthesia, 59, 751-757. doi:10.1007/s12630-012-9728-2

Dupont, C. et al. (2009). Incidence and management of postpartum haemorrhage following dissemination of guidelines in a network of 16 maternity units in France. International Journal of Obstetric Anesthesia, 18, 320-327. doi:10.1016/j.ijoa.2009.02.017

Lyndron, A., Lagrew D., Shields, L., Melsop, K., Bingham, B., Main E. (Eds). Improving health care response to obstetric hemorrhage. (California Maternal Quality Care Collaborative toolkit to transform maternity care). (2010). Developed under contract #08-85012 with the California Department of Public Health; Maternal Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative.

Harvey, C. J. & Dildy, G. A. (2012). Obstetric Hemorrhage. Washington, D. C.: Association of Women’s Health, Obstetric and Neonatal Nurses.

Leduc, D., Senikas, V., Lalonde, A. B. (2009). Active management of the third stage of labour: Prevention and treatment of postpartum hemorrhage. JOGC, No 235, 980-993.

Providence Health Care. (2012). Practice Standard Postpartum Hemorrhage. (IDG6109 – PPH). Vancouver, BC.

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Royal College of Obstetricians and Gynaecologists. (2009). Prevention and management of postpartum haemorrhage. RCOG Green-top Guideilne, 52, 1-24.

R. Preston, personal communication, in press data, October 1, 2013.

Salus Global Corporation. (2013). Postpartum Hemorrhage. Retrieved from http://moreob.com/

Thompson, J. F., Ford, J. B., Raynes-Greenow, C. H., Roberts, C. L., & Ellwood, D. A. (2011). Women’s experiences of care and their concerns and needs following a significant primary postpartum hemorrhage. Birth, 38, 327-335. doi: 10.1111/j.1523-536X.2011.00491.x

APPENDICES

Appendix A Obstetric Hemorrhage Algorithm- Birthing Appendix B Obstetric Hemorrhage Algorithm- Postpartum Appendix C Antepartum Hemorrhage Algorithm Appendix D Obstetric Massive Blood Transfusion Protocol: Blood product replacement package and timeframes for release of blood products Appendix E Checklist for Massive Hemorrhage Appendix F Roles and responsibilities of team members in a PPH-TBD Appendix G Pre-printed orders for PPH and Postpartum care checklist Appendix H PPH cart checklists I DS II SRMC III OR IV PP units Appendix I Woman Who Refuses Blood Products--TBD Appendix J Patient pamphlet (Caring for Yourself After a PPH & Active Management of Third Stage Labour)-TBD Appendix K PPH case audit tool Appendix L Teaching tools (estimation of blood loss, rapid infuser Eduquick)-TBD

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