management of postpartum haemorrhage and … · page 5 of 23 mat 103 / version 8 / management of...

of 23

MAT 103 / Version 8 / Management of Postpartum Haemorrhage & Massive Obstetric Haemorrhage, September 2014

Document Ref: MAT 0103

WOMEN AND CHILDREN’S HEALTH UNIT

Clinical Guideline

For use in: (Clinical Area) Maternity Department

For use by: (Staff Group) Doctors and Midwives

Distributed to: Staff in the Maternity Department

Author/s: Original Authors: M Judd, Consultant Obstetrician & C Duke,

Consultant Anaesthetist

Reviewed by: L Brignall, Senior Midwife & D Meldrum,


Date of issue: September 2014

Date of review / by: September 2017

Status: APPROVED

Equality impact assessment (HO 2010)

June 2013

Roger Giles

Lead Consultant Obstetrician

Roger Giles

Clive Duke


Clive Duke

Approved by Patricia Davis.

Head of Midwifery

Patricia Davis

Approved by Supervisor of Midwives

Colleen Greenwood

MANAGEMENT OF POSTPARTUM HAEMORRHAGE and MASSIVE OBSTETRIC HAEMORRHAGE

of 23


INDEX

Management of Postpartum Haemorrhage & Massive Obstetric Haemorrhage, August 2014

Section Title Page Number

Front pages Index and Document History 1 - 3

1. Introduction 4

1.1 Purpose of Guideline 4

1.2 Inclusions 4

2. Definition of Postpartum Haemorrhage 4

3. Risk factors for Postpartum Haemorrhage 5

3.1 Antenatal Risk Factors 5

3.2 Diagnosis of Postpartum Haemorrhage 5

3.3 Important Considerations in the Diagnosis of Postpartum Haemorrhage

6

4. Management of Women with Clinically Significant Postpartum Haemorrhage

6

4.1 Communication 6

4.2 Resuscitation / Replacement of Fluid 7

4.3 Intraoperative Cell Salvage 8

4.4 Arresting the Bleeding 9

4.3.1 Bleeding Due to Trauma 10

4.3.2 Excessive Bleeding due to Retained Tissue 10

4.3.3 Excessive Bleeding due to Thrombin / Coagulopathies 10

5. Monitoring and Investigations 10

5.1 Documentation 10

5.2 Observations Whilst Bleeding Persists 11

5.3 Observations when the Bleeding is Controlled 11

5.4 Other Observations / Investigations 12

6. Surgical Options for Controlling Postpartum Haemorrhage 12

7. Anaesthetic Management 13

8. Access to Blood and Transport Arrangements 14

9. Haematological Considerations 14

9.1 Target Levels of Treatment 15

10. Massive blood loss protocol 15

10.1 Activating the Massive blood loss protocol 15

10.2 Responsibilities and Lines of Communication 15

11. Obstetric Haemorrhage Outside Labour Suite 17

of 23


11.1 Midwifery Led Birthing Unit 17

11.2 In the Community 17

12. Aftercare Following Postpartum Haemorrhage 17

13. Debriefing and Support 17

14. Secondary Postpartum Haemorrhage 17

15 Staff Training 18

16 Risk Management 18

17 References 18

18. Associated Documents 18

19 Monitoring / Audit Standards 19

20 Consultation 21

Appendix 1 Obstetric Haemorrhage Proforma 22

2 Procedure for Insertion of B Lynch Suture 23

PREVIOUS DOCUMENT

First issued January 1994

Reference No

Present version number

Reference: Mat 0103

Version No 8

Supersedes

Management of Postpartum Haemorrhage, July 2013

Changes implemented:

Change to the definitions of PPH to reflect EoE Strategic Clinical Network recommendations.

Inclusion of details from trust guidance on activation of massive blood loss protocol.

Inclusion of the bleep cascade.

Amendment to PPH proforma

of 23


MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND

MASSIVE OBSTETRIC HAEMORRHAGE

1. INTRODUCTION

Although there has been a decline in deaths from obstetric haemorrhage in the United Kingdom over the last 50 years, Saving Mothers Lives (CEMACE 2011) highlighted haemorrhage as the sixth leading direct cause of maternal death with nine deaths from 2006-2008 and 6 of these were found to include substandard care. While it is recognised that a fall in the rate of major obstetric haemorrhage is due to improved management of the condition, it is nevertheless essential for maternity services to continue to strive to reduce the risks of obstetric haemorrhage and learn from and improve the management of this complication of delivery.

1.1 Purpose of guideline

The intention of this guideline is to support staff in the prevention and management of postpartum haemorrhage.

The management of a postpartum haemorrhage includes women who give birth in the Midwifery Led Birthing Unit (MLBU) or Labour Suite (LS). Both areas have access to laboratory and blood bank facilities and have skilled obstetric and anaesthetic staff readily available. The guideline also gives details of how to manage a postpartum haemorrhage in the community.

1.2 Inclusions

Any woman from delivery to 12 weeks postpartum.

2. DEFINITION OF POSTPARTUM HAEMORRHAGE 2.1 Primary

The traditional World Health Organisation definition of primary postpartum haemorrhage (PPH) is a blood loss greater than 500ml in the 24 hours following delivery. Most mothers in the UK can readily cope with a blood loss of this order and usually need no clinical intervention. In line with the recommendations of the East of England Strategic Clinical Network for Maternity the definition of postpartum haemorrhage use at West Suffolk Hospital is as follows: Minor – 500 – 1,000 mls or Major more than 1,000 mls.

Major is divided to: Moderate 1000–2000 ml or Severe more than 2000 ml

of 23


2.2 Secondary Secondary PPH is defined as abnormal or excessive bleeding from the birth canal between 24 hours and 12 weeks postnatally.

3. RISK FACTORS FOR POSTPARTUM HAEMORRHAGE

3.1 Antenatal Risk Factors Women who fall into the categories listed below are at an increased risk of postpartum haemorrhage:

Asian ethnicity

Age > 40 (Primip)

Grand multiparity

BMI > 35

Multiple pregnancy

Past history retained placenta, abruption or placenta praevia

Previous PPH

Polyhydramnios

Antepartum haemorrhage

Anaemia less than 90g/L (affects myometrial contractility)

Placenta praevia or accrete in current pregnancy

Pre eclampsia and pregnancy induced hypertension

Disorders of coagulation including anticoagulants

These pre-existing risk factors need to be documented at the booking appointment in the woman‟s hand-held notes and white card. These risks must be taken into account when advising about the place of delivery. An appropriate care plan must be documented and all health care providers should be aware. When risks become apparent during labour, the care plan should be modified accordingly. Where a woman has declared her intention to decline blood or blood products, the consultant obstetrician and consultant anaesthetist should be involved antenatally and an individual management plan developed which is then documented in the maternity records. (See guideline on Women Who Decline Blood Products MAT 0104)

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0104-WomenWhoDeclineBloodProducts,Nov2011.pdf

3.2 Diagnosis of postpartum haemorrhage

Most cases of postpartum haemorrhage are not associated with any pre-existing antenatal risk factors and the following aide memoire should be used:

Consider the Four T’s as the causes of primary PPH

TONE

Bleeding as a result of uterine atony, accounts for the majority (80%) of postpartum haemorrhage. In addition to the antenatal risk factors consider the following intrapartum risks:

Induction of labour

Prolonged labour > 12 hrs

Operative vaginal deliveries

TRAUMA

Cuts / tears resulting in bleeding from the genital tract, which can be from any site from the perineum to the broad ligament

Emergency caesarean section

Elective caesarean section

Mediolateral episiotomy



of 23


Baby > 4 kgs

Operative vaginal delivery

Baby > 4kgs

Perineal tear; cervical tear

TISSUE

Bleeding from retained products

Retained placental products.

THROMBIN

Pre-existing coagulopathy or has received recent anticoagulation therapy.

Suspected or proven placental abruption

Pre eclampsia /gestational hypertension

Pyrexia in labour

3.3 Important considerations in the diagnosis of postpartum haemorrhage

The severity of a postpartum haemorrhage is not always easy to assess due to:

(i) Inaccurate assessment of blood loss as it is difficult to measure all blood that is lost. Blood loss is frequently underestimated.

(ii) The uterus and vagina may hold large clots not visible to the eye. (iii) Women of lower body weight will tolerate blood loss less readily. (iv) Women can have significant signs of hypervolemia without any obvious signs

of bleeding. In these instances consider:

Uterine rupture

Broad ligament haematoma

Be alert to other causes of maternal collapse, such as:

Pulmonary embolism

Myocardial infarction

Amniotic fluid embolism

Anaphylactic shock and other rare conditions e.g. local anaesthetic toxicity

4. MANAGEMENT OF WOMEN WITH CLINICALLY SIGNIFICANT POST PARTUM HAEMORRHAGE

Once a clinically significant postpartum haemorrhage has been identified, the management involves four components all of which need to be undertaken simultaneously:

Communication

Resuscitation/replacement of fluid

Arresting the bleeding

Monitoring and investigation

of 23


4.1 Communication

The midwife summons emergency assistance using the emergency buzzer in the room. Stating that a postpartum haemorrhage is in progress.

When assistance arrives the clinical situation is assessed to establish what additional support is required this may include:

Labour Suite Co-ordinator

Obstetric Registrar and Senior House Officer ( ST 1/2)

Obstetric Anaesthetist

2nd midwife

Postpartum Haemorrhage trolley including Obstetric Haemorrhage Proforma to be used on LS & MLBU. (It may be used in theatre if it is deemed appropriate)

A scribe to record events, fluids, drugs, vital signs

Midwifery Care Assistant for delivery of specimens To gain access to medical assistance urgently the midwifery staff phone switchboard on 2222 stating:

‘Labour Suite Obstetric Emergency 1’

Switchboard will place a written message on the bleep Obstetric Emergency 1 and state the location for those staff required. If the on call consultant is required or the emergency theatre team these should be requested at the time the call is made

If the woman has a blood loss of 1500 mls or more or is cardiovascularly compromised the consultant obstetrician is requested to attend and, if required, the consultant anaesthetist on call. If you need to activate the „Massive Blood Loss Protocol please refer to Section 10

4.2 Resuscitation / Replacement of Fluid

Ensure the woman is lying flat. Assess the woman Airway, Breathing, Circulation.

If the airway is compromised owing to impaired conscious level, anaesthetic assistance should be sought urgently, if not already present. Turn the patient into the lateral position.

Administer high flow oxygen via a mask with a reservoir bag at 10-15 litres per minute.

Gain intravenous access x 2, minimum 16 gauge (grey), and commence intravenous fluid. Send blood samples as outlined below:

o Group and cross match 4-6 units

o Urea and Electrolytes

o Full blood count

o Coagulation screen, specifically requesting fibrinogen

of 23


o Renal and liver function test for baseline

Monitor heart rate, blood pressure, respirations, temperature and pulse oximetry as indicated in section 5.2.

Commence intravenous fluids (see fluid replacement section 4.2)

Initial fluid management:

o Estimate blood loss by weighing pads, clots, and swabs as far as possible.

o Either crystalloid or colloid may be used, but frequently up to 2 litres of warmed Hartmann‟s solution is given followed by up to a further 1.0 litre of warmed colloid, to maintain blood pressure whilst waiting for blood.

o Consider O-negative blood if fully crossed matched blood is not available

and the mother remains cardiovascularly compromised. See note below if the woman has anti-c. If a woman has the results of 2 group and screen samples on the blood bank computer record she can have group specific blood in 5-10 minutes. Always ensure the blood bank has an in date sample to crossmatch.

Note: If a woman has anti-c antibodies it is preferable not to use emergency

blood as it will not be c antigen negative. However the clinician needs to assess the level of urgency & balance the risk of transfusion reaction/antibody development versus cardiovascular compromise of the woman. O neg blood can be used if the risk of not giving blood immediately is too great.

Group compatible blood will be available within 20 minutes of receipt of request/sample.

Fully cross matched blood will be available within 60 minutes of receipt of request/sample.

Fluid and blood management is the responsibility of a senior clinician.

Maintain the mother's temperature to reduce the development of coagulopathy

o Use a forced air warming blanket available from theatre.

o Use fluid warmer for all intravenous fluids (including blood and fresh frozen plasma) where rapid transfusion is required

Consider activating the Massive Blood Loss Protocol (WSH CG10089)

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10089MassiveBloodLossGuideline.pdf

also See Section 10

4.3 Intraoperative Cell Salvage

For massive obstetric haemorrhage (excluding cases where there is likely contamination of the blood by infection) consider use of cell salvage to provide reinfusion with autologous blood with additional donor units used as required.


of 23


In cases where there could be possible contamination with amniotic fluid a Pall leucocyte depletion filter should be used.

Cell salvage should only be used by healthcare teams who use it regularly and have the necessary expertise and experience.

Perform coagulation tests regularly as re-infused blood will not contain clotting factors. (See also Trust guidelines on cell salvage (WSH CG 10189)

Refer to WSH Trust guidelines on the safe administration of blood and blood products. (WSH CG 100101-11) and remember to change the administration sets every 12 hours and between different blood products or intravenous fluids.

Document all fluids and blood on the obstetric haemorrhage chart, fluid prescription chart and the blood prescription and administration chart as appropriate.

4.4 Arresting the bleeding

The most common cause of primary postpartum haemorrhage is uterine atony. However a clinical examination must be undertaken to exclude other or additional causes.

Initially assume uterine atony as this is by far the most common cause of excessive bleeding and is suggested by the presence of a boggy, soft uterus.

Massage the uterus to stimulate a uterine contraction.

Ensure the bladder is emptied by inserting a Foleys Self Retaining catheter

Administer a second dose of Syntometrine 1 ml (if not hypertensive) or 10 units of Syntocinon intramuscularly (if hypertensive)

Perform bimanual compression if bleeding persists

If bleeding persists consider using the following drugs sequentially, with assessment of the uterine contraction between each drug administration.

Ergometrine 500micrograms by slow intravenous or intramuscular injection (contraindicated if hypertension is present)

Syntocinon infusion (40 units in 500mls Hartmann‟s solution at 125mls/hour)

(If fluid is restricted Syntocinon infusion by adding 40 units of Syntocinon to 36mls of Normal Saline and infuse at a rate of 10 mls per hour over 4 hours,)

Carboprost 250 micrograms (Haemabate) by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses. Contraindicated with women who have asthma or hypertension.

Misoprostol 1000 micrograms (200 micrograms x 5 tablets) rectally (stat dosage)

Further medical options for controlling postpartum haemorrhage:

of 23


Ensure coagulopathy has been investigated and vigorously treated with fresh frozen plasma, platelets or cryoprecipitate in consultation with haematologists.

Correct coagulopathies with appropriate blood products. See 10.1 for targets for platelets, Hb and fibrinogen.

Reverse anticoagulant using vitamin K and Octaplex for warfarin and protamine for heparin.

Consider Tranexamic Acid 10-20 mg / kg (initial dose usually 1 gram). Discuss with Anaesthetist

Activated Factor VIIa following discussion with Consultant Haematologist.

Calcium chloride 10 mls if signs of hypocalcaemia following massive blood product transfusion. Discuss with Anaesthetist.

4.4.1 Bleeding due to Trauma

Place the woman into the lithotomy position and examine the lower genital tract for trauma using a good light source.

If bleeding persists arrange a transfer to theatre for examination under anaesthesia. Where possible discuss management of care with the mother and her partner, including the possibility of the need to perform a hysterectomy.

4.4.2 Excessive Bleeding due to Retained Tissue

Find out if there were any difficulties in delivering the placenta and whether the placenta is complete.

Arrange to transfer the mother to theatre for examination under anaesthesia and possible evacuation of retained products.

4.4.3 Excessive Bleeding due to Thrombin / Coagulopathies

Clotting studies (specifically request fibrinogen) are obtained to ascertain the severity of coagulopathy. (see section 10.1 for haematological target levels)

Consider if the patient has been receiving LMWH or heparin containing products antenatally. Routine clotting studies will not detect coagulation abnormalities after LMWH, so discuss further investigations and management with a Consultant Haematologist.

Is there any pre-existing coagulation abnormality e.g. von Willebrand's. Discuss with Consultant Haematologist.

5. MONITORING AND INVESTIGATIONS

5.1 Documentation

In the event of a postpartum haemorrhage documentation is performed in the emergency situation on the Obstetric Haemorrhage Proforma (Appendix 1).

Detailed clinical notes must be written after the emergency has been treated.

of 23


5.2 Observations whilst bleeding persists

All observations are documented on the on the MEOWS CHART after the first 15 minutes

Blood pressure recordings (using an automated machine)

Every 5 minutes

Pulse (using pulse oximeter) Every 5 minutes

Continuous oximetry ( O2 sats) Record every 15 minutes

Respiratory rate* Every 15 minutes

Temperature Every 15 minutes

Level of consciousness Every 15 minutes

Full completion of MEOWS score Every 15 minutes

Urine output Hourly

Fluid input Hourly

Blood loss assessment (weighing swabs, incontinent sheets, towels)

Continual monitoring and record hourly

*Increased respirations can be indicative of deterioration in the woman’s clinical condition and may be a more sensitive indicator of deterioration than pulse and blood pressure measurements. Note: observations must also comply with transfusion guidelines if blood is being administered. (WSH CG 10010-13) http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10010BloodPolicyandAdministration.pdf

5.3 Observations when the bleeding is controlled Note: observations must also comply

with transfusion guidelines if blood is being administered.

Blood pressure recordings (using an automated machine)

Every 15 minutes for 1 hour Every 30 minutes for 2 hours Hourly for 2 hours 4 hourly for 24 hours

Pulse (using pulse oximeter)

Respiratory rate

Level of consciousness

Urine output Hourly for 24 hours

Fluid input Hourly for 24 hours

Blood loss assessment (weighing swabs, incontinent sheets, towels)

Hourly for 24 hours

Temperature 4 hourly for 24 hours, or more frequently, if abnormal

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10010BloodPolicyandAdministration.pdf


of 23


5.4 Other Observations / Investigations

Regular estimations of haemoglobin, urea and electrolytes and clotting studies are performed according to the clinical condition or in line with the Massive Blood Loss Protocol.

Pain scores should be undertaken alongside MEOWS scoring as persistent pain, in spite of having had appropriate analgesia, should be regarded with suspicion, as it could be indicative of internal bleeding.

Women who have had a significant postpartum haemorrhage secondary to uterine atony requiring medical intervention should have two lines drawn across their abdomen to indicate the level of the fundus. (The fundal height is palpated and

a line is drawn either side of the ulnar surface of the hand to indicate precisely where the hand has been laid on the abdomen.

Clinicians should ensure the fundal height is not rising, as this can indicate

internal bleeding. At the same time the amount of lochia is assessed.

If there are any deviations from normal, either physiological as indicated on the MEOWS chart, or if there are any obstetric concerns these need to be reported to the obstetric registrar and / or obstetric anaesthetist.

6. SURGICAL OPTIONS FOR CONTROLLING POST PARTUM HAEMORRHAGE

If pharmacological measures fail to control the haemorrhage, surgical haemostasis should be initiated sooner rather than later. (RCOG 2009) Surgical interventions may include:

Parallel vertical compression sutures: used to control bleeding from placenta praevia/accreta

Insertion of Bakri Tamponade Balloon (intrauterine balloon) to apply pressure and arrest bleeding. A syntocinon infusion should be continued to augment uterine contractions.

Insertion of a B-Lynch suture: (B-Lynch et al 1997) see description of insertion on Appendix 2

Bilateral Uterine artery ligation: the procedure is effective, safe and technically easier than ligation of the internal iliac artery. There are few associated complications.

Bilateral Internal iliac artery ligation: postpartum success rates for this technique are poor at about 42%. Significant operative morbidity is associated with the technique and includes nerve injury, gluteal necrosis, inadvertent ligation of common iliac artery, cardiac arrest and prolonged blood loss and operative time.

Hysterectomy: if this intervention is anticipated it is recommended that a second consultant obstetrician should be involved in the decision making. Resorting to hysterectomy should be taken sooner rather than later, especially in cases of placenta accreta or uterine rupture. (RCOG 2009)

Emergency Interventional radiology is not provided at the West Suffolk Hospital. If interventional radiology is necessary for an elective case, a referral to a tertiary centre must be made.

of 23


7. ANAESTHETIC MANAGEMENT

Regional anaesthesia should only be considered if the mother is fully resuscitated and cardiovascularly stable. In virtually all cases where there has been significant obstetric haemorrhage, a general anaesthetic is the technique of choice.

A consultant anaesthetist must be informed prior to the transfer of a woman to theatre and would normally be expected to attend.

A medical, surgical and obstetric history is obtained and the anaesthetic technique to be used is explained.

Ensure the following has been carried out:

Cannulation with two 16 gauge (minimum) cannulae

Blood is available (at least 4 units)

Fluid/blood warming equipment is available

Mother is kept warm with a warming blanket

An antacid prophylaxis regime is given of Ranitidine 50mgs intravenously (if oral Ranitidine has not been given within the last 6 hours) and Sodium Citrate 30mls orally.

Induce anaesthesia in theatre with the mother fully monitored with a non-invasive blood pressure, pulse oximetry, and electro cardio graph (ECG). Invasive monitoring may need to be instituted intra-operatively.

Rapid sequence induction. Lower doses of induction agent are generally required. The use of Ketamine is useful in the severely collapsed mother.

Maintain – oxygen, nitrous oxide and a volatile agent. Keep the minimum alveolar concentration (MAC) to around 1.0 (excess volatile agent will predispose to uterine atony).

If there is continued uterine atony despite oxytocics, consider changing to Propofol infusion to maintain anaesthesia.

A 5 unit Syntocinon bolus can cause acute hypotension and collapse in the already cardiovasculary compromised patient; therefore extreme caution should be exercised in its use.

Dilute 5 units to 5mls in normal saline and give 1ml every few minutes depending on the blood pressure.

Alternatively, omit the bolus of Syntocinon and start the standard infusion of 40 units Syntocinon in 36 mls of normal saline over 4 hours, which is used in all cases of PPH unless there is a contraindication. The obstetrician should be informed if a bolus of Syntocinon has been omitted and asked to “rub up” a physiological contraction.

See drug regimes for managing major haemorrhage (section 4.3)

of 23


Insert invasive pressure monitoring as appropriate.

Transfer to a Level 3 Critical Care Area if post operative ventilation is required. 8. ACCESS TO BLOOD AND TRANSPORT ARRANGEMENTS

Ring 2222 and state „massive blood loss – blood required in ….(location). This activates a bleep to the Portering Supervisor and Duty Clinical Manager to summon immediate assistance to the ward/dept. to collect the prescription chart for collection of group compatible/cross matched blood

If the Emergency O Rhesus negative blood is required bleep 959 then key in **07# - this conveys a message to the Portering Supervisor “O NEG Blood required on Labour Suite” so that the job can be assigned immediately. The Porter will be sent straight to Blood Bank as a prescription chart is not needed to collect the Emergency blood.

In an extreme emergency, where there is no time to await assistance, send a “runner” to Blood Bank to collect the blood - having preferably first communicated the need to the Biomedical Scientist (BMS) on extension 3316 (bleep 526 17:30-09:00hrs) for him/her to release blood products to a non-BARS trained member of staff.

Note it is preferable to use the BARS trained Porters where possible as the BMS will be diverted from preparing essential blood products when requested to release products for a “runner”

Refer to WSH Trust guidelines on the safe administration of blood and blood products. (WSH CG 100101-11).

Refer to WSH Trust Guidelines in the case of when requested to release products for a Major Blood Loss http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10010BloodPolicyandAdministration.pdf See Laminated Algorithm displayed in clinical areas.

9. HAEMATOLOGICAL CONSIDERATIONS

If a woman is known to have red cell antibodies the blood should be negative for the corresponding antigens if at all possible. In an emergency where delay in transfusion would be life-threatening and no antigen negative blood is available, antigen positive blood may need to be used but the clinicians need to be aware of the risk of transfusion reaction. This applies to O neg blood in women with anti-c and or anti-e.

Kell – negative blood should be used for transfusion in women of childbearing age to prevent alloimmunisation and subsequent risk of haemolytic disease of the newborn (unless a woman is known to be Kell positive).

Cytomegalovirus seronegative (CMV) negative products are required for elective transfusions during pregnancy. (WSH CG 10208) With the current practice of



of 23


leucodepletion of blood, it is no longer necessary to insist on Cytomegalovirus seronegative red cells and platelets in the emergency transfusion situation.

If RhD positive platelets have to be used for a RhD negative woman she should

be given 1500iu of anti-D as soon as practicable and the incident documented.

If the mother declines to have a blood transfusion / products refer to individual management plan and Trust and maternity guidelines for further guidance. http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10013TreatmentofJehovahswitnesses.pdf http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0104-ManagementofWomenwhoDeclineBloodProducts,Nov2013.pdf

9.1 Target levels of treatment

Haematology levels Target levels of treatment, aim for:

Haemoglobin levels Greater than 80 g/L

Haematocrit levels 0.35

Fibrinogen levels

Should be maintained above 1.0 g /l by the use of fresh frozen plasma or two pools of cryoprecipitate.

Prothrombin time Normal range 24 – 35 seconds

Prothrombin time normal range 10 – 14 seconds

Aim to keep prothrombin time less than 18 seconds

Platelet count

Should not be allowed to fall below

50 x109 /l in the acutely bleeding patient.

Platelet transfusion A platelet transfusion trigger of 75 x 109 /l is

recommended to provide a margin of safety.

10. MASSIVE BLOOD LOSS PROTOCOL 10.1 Activating the Massive Blood Loss Protocol

By ringing Blood Bank on #6444 stating “I want to trigger the massive blood loss protocol in …… (location)”.

This initiates the supply of blood products without the need to discuss with a Consultant Haematologist and therefore minimises delay in availability.

Refer to WSH Trust (WSH CG 10089) for full details or see laminated algorithm displayed in clinical areas. http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10089MassiveBloodLossGuideline.pdf

10.2 Responsibilities and lines of communication

Early involvement of senior obstetric and anaesthetic staff as well as laboratory specialists is fundamental to the management of a massive postpartum haemorrhage.

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10013TreatmentofJehovahswitnesses.pdf


http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0104-ManagementofWomenwhoDeclineBloodProducts,Nov2013.pdf

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0104-ManagementofWomenwhoDeclineBloodProducts,Nov2013.pdf



of 23


Once the massive blood loss protocol is activated then a designated member of the team who understands the ongoing clinical situation is delegated to take responsibility for communicating the clinical condition and the amount of blood products needed between blood bank, the consultant haematologist and members of the resuscitating team.

Staff Member

Clinical Communication Organisational (staff)

Organisational (equipment)

Attending midwife

Recognises the critical situation

Activates emergency buzzer

Senior Midwife /

Coordinator

Instigates initial emergency measures

Ensures all necessary staff contacted obstetricians / anaesthetists / blood bank / theatre

Ensures 2nd midwife / MCA / scribe appointed

Ensures drugs and equipment available

2nd Midwife Assists with patient management

Assists with contacting relevant staff

Assists with drug and equipment provision

Scribe Documents all events with times on Obstetric Haemorrhage Proforma.

Accurate timing of drug / fluid / blood administration

Obstetric SpR

(670)

Assesses and instigates further clinical management of mother

Will request consultant obstetric attendance if indicated.

May call Massive blood loss protocol.

If patient transferred to theatre request

any specific surgical equipment

On Call Consultant Obstetrician

Overall clinical management, but not necessarily Team Leader

Overall communication with other health care groups, patient and partner.


If patient transferred to theatre request

any specific surgical equipment

Anaesthetic SpR (770)

Assist with immediate resuscitation.

Assist with blood and fluid transfusion.


Assist communication with theatres and blood bank

May request ODP if not already present

If patient transferred to theatre, request cell saver

On Call Consultant Anaesthetist

Leads ongoing resuscitation and Anaesthetic

management


Assists with communication with theatres and blood bank

If patient transferred to theatre, request cell saver

* Many of these events can happen simultaneously

of 23


11. OBSTETRIC HAEMORRHAGE OUTSIDE LABOUR SUITE

12.1 Midwifery Led Birthing Unit:

Midwife activates emergency buzzer, which is heard within the Labour Suite.

Midwives who are safely able to attend should assist immediately.

The Labour Suite Coordinator should attend immediately, or as soon as is clinically safe on Labour Suite.

Until she is able to attend, the midwife in charge of MLBU co-ordinates management (see above table).

Senior medical staff will decide when the woman is sufficiently stable to be moved to Labour Suite, theatres or a critical care area.

A bed from the Labour Suite is taken to the Midwifery Birthing unit for transfer of the woman

12.2 In the Community:

The attending midwife institutes first aid measure which includes:

Call 999 ambulance, requesting ambulance with paramedic.

Inform Labour Suite Co-coordinator at West Suffolk Hospital.

Accompany woman in ambulance. Refer to WSH Maternity Guidelines: Arrangements for Planned Home Birth. http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079ArrangementsforPlannedHome-Birth,May2013.pdf

12. AFTERCARE FOLLOWING POSTPARTUM HAEMORRHAGE

Once the bleeding is controlled and initial resuscitation is complete, monitoring of the clinical condition should continue in the High Dependency Room on the Labour Suite (Room E) or if indicated transferred to Critical Care Services. Refer to: Identification of the Seriously Ill Woman and for those requiring Critical Care http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0091-SeriouslyillWoman(MEOWS),Jan2012.pdf

13. DEBRIEFING AND SUPPORT

Major haemorrhage is traumatic to the woman, her family and birth attendants, therefore debriefing is recommended by a senior member of the team who was present at the time. This should be undertaken at the earliest opportunity.

14 SECONDARY POST PARTUM HAEMORRHAGE

Secondary postpartum haemorrhage is associated with endometritis and the use of antibiotics is recommended. The use of co-amoxiclav (or clindamycin if penicillin allergic) and metronidazole are to be prescribed for uncomplicated clinical cases. Surgical measures should be undertaken if there is excessive or continual bleeding, irrespective of ultrasound findings.

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079ArrangementsforPlannedHome-Birth,May2013.pdf

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079ArrangementsforPlannedHome-Birth,May2013.pdf

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0091-SeriouslyillWoman(MEOWS),Jan2012.pdf


of 23


A consultant obstetrician should always be involved in the decision making process prior to the performing of any evacuation of retained products of conception. This procedure carries a high risk of uterine perforation.

15. STAFF TRAINING

Training is undertaken annually for all midwives and obstetric medical staff in the management of postpartum haemorrhage as described in the training needs analysis. This is included in PROMPT training.

In addition multidisciplinary skills drills are undertaken on the Labour Suite regularly which includes postpartum haemorrhage

A register of attendance at skills drills in the management of postpartum haemorrhage is maintained.

16. RISK MANAGEMENT

A Datix report must be completed if the following has occurred

Blood loss of 2,000mls or more

Blood loss that requiring immediate medical management.

Transfer to a Critical Care Area was required.

Hysterectomy performed following a postpartum haemorrhage.

A delay with the availability of blood products (to support reporting to Serious

Hazards of Transfusion (SHOT ))

17. REFERENCES

CEMACH (2008) Saving Mother’s Lives: Reviewing Maternal Deaths to make Motherhood Safer Centre for Maternal and Child Enquires, Wiley-Blackwell B-Lynch et al (1997) The B-Lynch Surgical Technique for the Control of Massive Postpartum Haemorrhage: an Alternative to Hysterectomy? Five cases reported. British J Obstet Gynecol 111:284-7 Bakri et al 2001. Tamponade-balloon for Obstetrical Bleeding Int J Gynaecol Obstet 74:139-142 RCOG (2009) Prevention and Management of Postpartum Haemorrhage Green-top Guideline No 52, RCOG London. O‟Brien et al 1998 Rectally Administered Misoprostol for the Treatment of Postpartum Haemorrhage Unresponsive to Oxytocin and Ergometrine: A Descriptive Study Obstet Gynecol 92:212-214

18. ASSOCIATED DOCUMENTS

West Suffolk Hospital NHS Foundation Trust CG11010-12 Blood Policy and Administration Guidelines http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10010BloodPolicyandAdministration.pdf



of 23


West Suffolk Hospital NHS Foundation Trust CG 10089-7 Massive Blood Loss Guideline http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10089MassiveTransfusion.pdf West Suffolk Hospital NHS Trust Maternity Guideline MAT 0104 Women who Decline Blood Products http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0104-WomenWhoDeclineBloodProducts,Nov2011.pdf West Suffolk Hospital NHS Trust Maternity Guideline MAT 0079 Arrangements for Planned Home Birth http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079-ArrangementsforPlannedHome-Birth,Nov2011.pdf

West Suffolk Hospital NHS Trust Maternity Guideline MAT 0091 Identification of the Seriously Ill Woman and for those requiring Critical Care http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0091-SeriouslyillWoman(MEOWS),Jan2012.pdf Trust guideline on Jehovah’s Witnesses CG10013 http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10013TreatmentofJehovahswitnesses.pdf

19. MONITORING / AUDIT STANDARDS

Responsibility of: Inpatient Service Manager

Standard to be assessed:

Compliance with the management postpartum haemorrhage and massive obstetric haemorrhage, according to the guidelines stipulated within this document. In particular will be assessed:

Agreed criteria for postpartum haemorrhage.

Management of postpartum haemorrhage according to present guideline.

Evidence of communication between Labour Suite Co-ordinator, Consultant Obstetrician, Consultant Anaesthetist, Haematologist, and Blood Bank department.

Assessment of availability and accessing of blood in a timely manner.

Evidence of accessing of massive blood loss guideline..

Documentation of observations performed.

Documentation of transfer arrangements to Obstetric unit or theatre

Documentation of fluid balance.

Documentation of individual management plan present in the maternal health records of any women who decline blood products.

Observations carried out according to the present guideline.

Documented communication with the obstetric unit for those on Midwifery Birthing Unit.

Use of intra operative cell salvage.

Review of women referred to a tertiary centre for interventional radiology.

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10089MassiveTransfusion.pdf

http://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10089MassiveTransfusion.pdf



http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079-ArrangementsforPlannedHome-Birth,Nov2011.pdf

http://staff.wsha.local/Intranet/MaternityGuidelines/docs/MAT0079-ArrangementsforPlannedHome-Birth,Nov2011.pdf





of 23


Evidence of staff training in postpartum haemorrhage as described in the training needs analysis.

Frequency and method of monitoring:

Continuous audit of maternal health records of all postpartum haemorrhage of 2,500mls and above or maternal compromise.

Audit using Obstetric Haemorrhage proforma and maternal records.

Reviewed Multidisciplinary review via the Clinical Governance Steering Group

Meeting and subsequent monitoring of action plans.

of 23


20. CONSULTATION HISTORY

Name Title Date Sent Comments received

Included in document

M Judd Consultant Obstetrician

22nd

July 2014

R Giles Consultant Obstetrician

22nd

July 2014

S Gull Consultant Obstetrician

22nd

July 2014

P Harris Consultant Obstetrician

22nd

July 2014

D Ross Consultant Obstetrician

22nd

July 2014

M Prasad Consultant Obstetrician

22nd

July 2014

J Reeve Consultant Obstetrician

22nd

July 2014

M Vella Consultant Obstetrician

22nd

July 2014

C Beatty Consultant Haematologist

22nd

July 2014

Consultant Anaesthetists

22nd

July 2014

P Davis Head of Midwifery/General Manager

22nd

July 2014

S Stone Inpatient Services Manager

22nd

July 2014

A Littler Outpatient Service Manager

22nd

July 2014

Supervisor of Midwives

22nd

July 2014

Senior midwives 22nd

July 2014

S Rush Hall Project Midwife 22nd

July 2014 25/7/14 Typo‟s – amended

S Wyatt Practise Development Midwife

22nd

July 2014

G Bass Transfusion Nurse Specialist

22nd

July 2014 24/7/14 Comments on Massive Blood Loss guidance included

J Hoyle Transfusion Nurse Specialist

22nd

July 2014

of 23


Appendix 1: Obstetric Haemorrhage Proforma

Time of call out: Midwife: Location: Date: Time:

Team member Name Time arrived Drug Dose Time

On-call Obstetric Consultant Syntometrine (2nd) 1 amp IM (if BP not raised)

On-call Obstetric SpR (670) Syntocinon 5 units IV or 10 units IM

On-call Obstetric SHO Ergometrine 500 micrograms IM/IV (if BP not raised)

On-call Anaes Consultant Syntocinon 40 units in 500mls Hartmann‟s IV 125ml/hr

On-call Obstetric SpR (770)

Theatre ODP (840) Hemabate 250 micrograms IM Not less than 15 minute intervals

Labour Suite Co-ordinator Hemabate 250 micrograms IM

2nd Midwife Hemabate 250 micrograms IM

Appointed Scribe Hemabate 250 micrograms IM

Runner Hemabate 250 micrograms IM

Porter (959) Hemabate 250 micrograms IM

Informed?

Blood Bank Hemabate 250 micrograms IM

Consultant Haematologist Hemabate 250 micrograms IM

Placenta delivered? Yes / No Time:

Misoprostol 200 micrograms x 5 tablets (1 mg)PR

Blood Sent Time 5 min obs during active bleeding Ranitidine 50 mg IV, if no dose in last 6 hours

FBC Time Pulse B/P Sodium Citrate 30 mls orally pre operatively

Crossmatch …… units

Clotting + fibrinogen Fluid Volume Time

U&E/LFT

Haemacue ……. g/L After 15 minutes transfer to MEOWS Chart

Management Time

Oxygen given

IV Cannula (1)

IV Cannula (2)

Urinary catheter + urimeter

Hourly urine volume

Fluid warmer

Bair hugger warmer Transferred to: Time informed Time Transferred Handover sheet Y/N

Bi-manual compression Theatre

Uterine balloon Total Blood Loss Critical Care

MOH guideline triggered? Room E (LS) Adapted from RCOG Green top Guideline No 52 (2009)

of 23


Appendix 2 PROCEDURE FOR INSERTION OF B-LYNCH SUTURE

1. Open uterus if caesarean has not been performed.

2. Cavity is swabbed out and examined.

3. Exteriorise uterus.

4. Bi-manual compression to assess the likelihood of success of the B-Lynch suture.

5. 70mm round bodied hand needle with a No.2 vicryl suture.

6. Puncture uterus 3cm below the right lower edge of the uterine incision and 3cm medial to the right lateral border.

7. Bring needle back out 3cm above the upper incision margin and about 4cm medial to lateral border.

8. Pass over fundus about 3-4cm from the right corneal border.

9. Pull suture under moderate tension assisted by manual compression by the assistant.

10. Pass the needle through the posterior wall of the uterus at the same level as the upper entry point and place a suture across the posterior wall exiting at the same position on the left side.

11. Pass the suture over the fundus about 3-4cm from the left corneal border and enter the uterus above and below the incision as for the first side.

12. Pull the two ends of the suture.

13. Tie with a double throw on the first knot followed by two further knots.

14. Close lower transverse uterine incision.

Figure 1: parts (a) and (b) demonstrate the anterior and posterior views of the uterus showing the application of the B-Lynch Brace suture. Part (c) shows the anatomical appearance after competent application. (B-Lynch et al 1997)