Why is There a Focus on Maternal Hemorrhage?

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality, accounting for an estimated 3 percent of deliveries in the United States, or more than 100,000 births a year. A recent study from the CDC Foundation postulated that up to 70% of hemorrhage-related obstetric deaths are preventable. That means that we can drastically reduce the most common cause of maternal death by developing the right strategies.

Postpartum hemorrhage is more bleeding than normal after the birth of a baby. About 3 in 100 women have postpartum hemorrhage, which is defined as cumulative blood loss greater than or equal to 1,000mL or blood loss accompanied by the signs or symptoms of hypovolemia within 24 hours. However, blood loss >500mL in a vaginal delivery is abnormal and should be investigated and managed according to the American College of Obstetricians and Gynecologists (ACOG). Heavy bleeding, after the birth of a baby, can quickly cause a severe drop in blood pressure, and may lead to shock and death if not treated. The most common causes of postpartum hemorrhage are uterine atony, trauma, retained placenta or placental abnormalities, and coagulopathy.

Prenatal factors that should be considered prior to delivery include suspected previa, accreta, increta or percreta; pre-pregnancy BMI greater than 50; clinically significant bleeding disorders; and other significant medical or surgical risks, as well as, those who would decline blood transfusion.

The Joint Commission recently issued new accreditation requirements, PC.06.01.01 and PC .06.03.01, effective July 2020 that focus on organizations reviewing, developing or refining their processes to reduce maternal harm and:

• Select, adopt, and implement evidence-based protocols for maternal hemorrhage.
• Implement assessment of hemorrhage risks
• Educate staff and patients regarding risk of maternal hemorrhage and treatment
• Provide drills for implementation of your maternal hemorrhage protocols

See pre-publication standards at: https://www.jointcommission.org/standards/prepublication-standards/new-standards-for-perinatal-safety/

The National Partnership for Maternal Safety developed by official representatives from the American Association of Blood Banks, the American Academy of Family Physicians, the American College of Nurse‐Midwives, the American College of Obstetricians and Gynecologists (the College), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), the Society for Maternal‐Fetal Medicine, and the Society for Obstetric Anesthesia and Perinatology, created an Obstetric Hemorrhage Safety Bundle. The Safety Bundle focuses on four key domains to reduce the national maternal mortality and morbidity rate. These domains include:

1. Readiness

a. Stocked hemorrhage cart with emergency supplies
b. Checklist and instruction cards for intrauterine balloons and compression sutures
c. Immediate access to hemorrhage medications
d. Rapid response team
e. Massive transfusion protocols
f. Unit education and drills on protocols

2. Recognition and Prevention:

a. Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times) for every patient
b. Measurement of cumulative blood loss (formal, as quantitative as possible)
c. Active management of the 3rd stage of labor (department-wide protocol)

3. Response:

a. Unit-standard, stage-based obstetric hemorrhage emergency management plan with checklists for every patient
b. Support program for patients, families, and staff for all significant hemorrhages

4. Reporting and Systems Learning:

a. Establish a culture of huddles for high-risk patients
b. Provide post-event debriefs to identify successes and opportunities
c. Create multidisciplinary review of serious hemorrhages for systems issues
d. Monitor outcomes and process metrics in perinatal quality improvement committee

ACOG and AWHONN emphasize the importance of the development of a Massive transfusion Protocol and a Hemorrhage Ready Cart with the following items:

• IV supplies and fluids
• Urinary catheter supplies
• Rapid access to medications (oxytocins / uterotonics)
• Lab supplies for type & crossmatch, CBC, coagulation, fibrinogen
• Systems to place OR on alert
• Having. two units RBCs ready to hang
• Prepare for Intrauterine Balloon Placement and Compression Sutures
• Continue monitoring for signs of bleeding

In addition, evidence-based options to assess risk before, during and after delivery are available through ACOG, as part of its Safe Motherhood Initiative. The June 2019 Maternal Hemorrhage Checklist is available for download at: https://www.acog.org/-/media/Districts/District-II/Public/SMI/v2/SMIHemorrhageChecklistREVISEDJUNE2019.pdf?dmc=1&ts=20200224T1718319975

With a few critical strategies, we can improve the management of maternal hemorrhage by recognizing early opportunities to assess risk, anticipate, and plan in advance of an obstetric hemorrhage. Interdisciplinary coordination and preparation, particularly with ongoing readiness, the blood bank, and rapid access to emergency supplies is critical in providing safe obstetrical care. In addition, implementing a standardized approach to obstetric hemorrhage includes a clearly defined, practiced approach to assure appropriate actions are taken throughout pregnancy to assess potential risk before, during and after delivery to manage emergency situations and improve patient outcomes.

Helpful References:
• The Joint Commission Comprehensive Accreditation Manual for Hospitals, 2020
• The joint Commission, Quick Safety Issue 51: Proactive Prevention of Maternal Death from Maternal Hemorrhage, 10/29/2019
• The American College of Obstetricians and Gynecologists at www.acog.org
• The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) at www.awhonn.org

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