Executive Summary Checklist
Obstetric Hemorrhage is the most common complication in pregnancy leading to severe maternal morbidity and preventable mortality. The National Partnership for Maternal Safety, an alliance of the professional organizations of maternity care professionals and advocates, selected this safety topic for priority development and national implementation. Representative experts from these organizations developed the bundle to outline critical clinical practices that should be implemented in every maternity unit. To underscore the importance of this work. In depth description of this bundle has been simultaneously published in 5 peer reviewed journals representing the involved organizations. As will all maternal safety bundles, the Obstetric Hemorrhage bundle is organized into 4 domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources to assist with implementation. (
http://www.safehealthcareforeverywoman.org/)
Prevention of PPH-related maternal mortality
- Commitment from hospital governance and senior administrative leadership to support maternal safety initiatives like PPH in their healthcare system.
Readiness in Every Unit
- Create a hemorrhage cart with supplies, checklist, and instruction cards for intrauterine balloons and compressions stitches based on the recommendations referenced \cite{2006,safemotherhood,ob3,american2014preparing,collaborative2013florida,postpartum18hemorrhage,bingham2010cmqcc}
- Ensure teams have immediate access to hemorrhage medications (kit or equivalent) \cite{world2014recommendations,evanson2014postpartum,warningguidelines}
- Establish a response team - who to call when help is needed (blood bank, advanced gynecologic surgery, other support and tertiary services)\cite{joint2010sentinel}
- Establish massive and emergency release transfusion protocols (type-O negative/uncrossmatched)
- Unit education on protocols, unit-based drills (with post-drill debriefs)
Recognition & Prevention in Every Patient
- Assessment of hemorrhage risk (prenatal, on admission, and at other appropriate times)
- Assessment of:
- Retained placenta
- Failure to progress during the second stage
- Lacerations
- Morbidly adherent placenta
- Instrumental delivery
- Large for gestational age newborn (>4000 gm)
- Hypertensive disorders
- Induction of labor
- Prolonged 1st or second stage of labor
- Measurement of cumulative blood loss (formal, as quantitative as possible)
- Weigh the pads for quantitative measurement
- Active management of the 3rd stage of labor (department-wide protocol)
Response
- Unit-standard, stage-based, obstetric hemorrhage emergency management plan with checklists
- Obstetric rapid response teams, Team Stepps.
- Support program for patients, families, and staff for all significant hemorrhages
Reporting
- Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities
- Multidisciplinary review of serious hemorrhages for systems issues
- Monitor outcomes and process metrics in perinatal quality improvement (QI) committee
The Performance Gap
Global maternal deaths have fallen 44% since 1990 but still over 303,000 women die each year from complications related to pregnancy, delivery, or within the first six weeks after delivery \cite{world44a}. A majority of deaths (64%) occur from the day of delivery through 41 days postpartum \cite{Creanga_2015}. That equates to about 830 women dying every day, 550 occurring in sub-Saharan Africa, 180 in Southern Asia, and 5 in developed countries \cite{world2016global}.
Within the United States it is estimated that approximately 600 women die each year \cite{ob15}; 14.0 per 100,000 live births \cite{world2015trends}. While that number seems to pale in comparison on the global scale the US ranks 46th in the world for maternal mortality \cite{ob17}. Of all industrialized countries, the US lags behind Kazakhstan, Libya and Qatar and is one of only 13 countries whose rates have continued to decline instead of improving over the last 25 years \cite{ob18}.
A 2015 report by the United Nations (UN) agencies and World Bank Group, Trends in Maternal Mortality: 1990 to 2015, was generated to gauge whether the UN’s Millennium Development Goals would be reached.5 The 2015 target was to reduce maternal mortality by three-quarters. Only 9 of the 100 countries participating reached the 2015 goal so the new target is to reduce global average maternal death rates below 70 per 100,000 live births by the year 2030, with no country above 140 per 100,000 live births.1
The reasons for the overall increase in maternal mortality within the US are unclear. Delaying childbearing and assisted reproductive technology (ie: in-vitro fertilization) have given rise to older mothers with an increased risk of complications than younger women \cite{Jolly_2000,Bewley_2005}. Additionally, the obesity epidemic gives rise to chronic conditions such as hypertension, diabetes, and chronic heart disease increase the risk of complications during pregnancy \cite{centers2015pregnancy,Kuklina_2009,Albrecht_2010,Kuklina_2012}.
Over a third of maternal deaths in the US are preventable, 40% could be avoided if women had access to quality care \cite{Berg_2005}. Most notably, black women have a 3 to 4-fold increased risk of death due to pregnancy compared to any other race or ethnicity \cite{creanga2014racial}. The reasons are extremely complex and not well documented. Moreover, severe maternal morbidity is much more prevalent and preventable, affecting tens of thousands of women each year \cite{Callaghan_2012,Callaghan_2008}.
Postpartum Hemorrhage (PPH)
Obstetric hemorrhage remains among the leading global causes of severe maternal morbidity and mortality \cite{Callaghan_2010,Calvert_2012,Cristina_Rossi_2012}. In some developing countries, the maternal mortality rate is as high as 1 percent of live births with nearly one-fourth of those deaths being attributable to postpartum hemorrhage (PPH)\cite{abouzahr1998antepartum}. According to the most recent mortality data reported to the CDC in 2011-2012, 11% of pregnancy-related deaths in the U.S. are caused by PP \cite{BERG_1996}. Between 1994-2006, the number of PPH cases has increased more than 25 percent, potentially driven by a 50 percent increase in uterine atony.
PPH is a "low-volume, high-risk" event for birth facilities, which has led to the down-prioritization for developing standardized intervention protocol\cite{lyndon2015improving}. Limited consideration for the implementation of coordinated approaches persists despite a consistent global recognition that the lack of communication, patient engagement, and clinical intervention strategies for managing acute hemorrhage in the postpartum period lead to an increase in maternal morbidity and mortality \cite{mander2008saving,ob36}.
There are many potential causes for PPH, but chief among them is uterine atony or the inability of the uterus to contract and retract following childbirth. PPH in a previous pregnancy also can increase the risk of hemorrhage during a subsequent delivery. A contributing factor to the lack of standard coordinated approaches to PPH is the issue that there is no precise definition for the condition. Literature defines PPH as blood loss of more than 500 mL following a vaginal delivery or more than 1000 mL following a cesarean section delivery.28,\cite{ob37} PPH is also classified by time frame with Primary PPH occurring in the first twenty-four hours and secondary or late-term PPH occurring in the subsequent period.
Further, blood loss during delivery can be difficult to measure, which is attributable to lack of standardization on how to manage blood collected during childbirth as well as improvements in medical products that can absorb a deceivingly high amount of fluid. The lack of clear guidelines for measuring blood loss during childbirth often leads to underestimation and a clinician may not diagnose Primary PPH.
Population-based studies have identified some significant risk factors that may result in PPH:
- Retained Placenta
- Failure to Progress During the Second Stage Of Labor
- Placenta Accreta, Increta, and Percreta
- Lacerations
- Instrumental Delivery
- Large Gestational Age (LGA) Newborns
- Hypertensive Disorders
- Induced Labor
- Augmentation of Labor With Oxytocin \cite{16272036}
Another issue that leads to the missed diagnosis of PPH is the physiological difference between expectant mothers. On average, mothers of single pregnancies have between 30-50 percent higher blood volume than a non-pregnant woman. Within the pregnant population, other blood-related physiological traits such as anemia, underlying cardiac conditions, or preeclampsia will also impact a mother's ability to tolerate blood loss.
Lack of timely and medically appropriate response to PPH is what results in poor outcomes. Early recognition of PPH and a timely, coordinated intervention are essential to reducing associated morbidity and mortality.
Leadership Plan
- Individual practices, hospitals, and hospital systems should develop systems of care that deliver risk-appropriate care to women pre- and post-delivery.
- Managing PPH requires a comprehensive and interdisciplinary commitment from administrative and medical leaders.
- While there are prescriptive clinical interventions, highlighted in the practice plan, engaging expectant mothers and those supporting them is critical to the holistic improvement of an institution's obstetric safety including PPH.
- Women with risk factors for PPH should be identified and counseled as appropriate for their level of risk and gestational age.
- It is important that leaders ensure availability of resources such as personnel, equipment, blood products and trained personnel.
- Establishing PPH protocols, creation of PPH kits, and appropriate training and simulation drills reduces the risk of PPH.
Practice Plan
The Council on Patient Safety in Women's Health Care developed comprehensive bundles and list of resources that apply to the prevention of harm from PPH and other maternal safety issues. The bundles are a roadmap for hospitals to use in the prevention of harm for these two pregnancy-related conditions.
It is important to remember that approach to management of PPH depends on the etiology in a patient who has had a vaginal delivery or a cesarean section. Treatment of atony depends on the route of delivery. Coagulopathies are managed medically whilst trauma-related PPH is managed surgically.
Technology Plan
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org. - Electronic Health Record (EHR)
- Web-based/EHR predictive algorithms that elicit specific data as but not limited to vital signs (BP, temp, HR, RR and SpO2), lab values, nurses notes and event reports.
- Close monitoring of hemodynamics such as heart rate and blood pressure.
- Ultrasound technology for assessment of retained products, retained placenta or abruption.
Metrics
Severe Maternal Morbidity among Hemorrhage Cases
Outcome Measure Formula
Numerator: Among the denominator, all cases with any SMM code
Denominator: All mothers during their birth admission, excluding extopics and miscarriages, meeting one of the following criteria:
- Presence of an abruption, previa or antepartum hemorrhage diagnosis code
- Presence of transfusion procedure code without a sick cell crisis diagnosis code
- Presence of a postpartum hemorrhage diagnosis code
Rate is typically displayed as: All cases w/ any SMM Code/All mothers meeting denominator criteria
Metric Recommendations
Direct Impact: All Pregnant Patients
Lives Spared Harm: