Postpartum Hemorrhage Case Study

Postpartum Hemorrhage Case Study
Providence Clinical Academy: Obstetrics Curriculum

Knowledge Check Low platelets Prolonged second stage of labor
What risk factors for PPH do you see in this case? Choose all that apply. Low platelets Prolonged second stage of labor Use of prolonged oxytocin during the induction Epidural anesthesia History of preeclampsia Operative vaginal delivery Knowledge Check The labor epidural is placed at 5 cm of dilation. The physician uses low forceps for a prolonged (5 hr) second stage and delivers a 9 lb baby. After an uneventful delivery of the placenta, heavy vaginal bleeding ensues. Inspection of the placenta reveals no missing cotyledons and inspection of the lower genital tract reveals no lacerations or source of bleeding. Palpation of the uterus reveals severe atony. JoAnn, a 25-year-old G1P0, is induced with prolonged oxytocin at term for mild preeclampsia. Her admission hematocrit is 39% and her platelet count is 190,000/µL. Systolic blood pressure ranged from 154 to 142 mmHg and diastolic blood pressure from 98 to 88 mmHg prior to admission and during labor. A second stage of more than 4 hours is a risk, as is operative vaginal delivery because the use of instruments can lead to vaginal and perineal lacerations. The use of oxytocin during labor, especially for long periods of time, does increase the risk of uterine atony. With a platelet count of 190,000/µL, this patient is in the normal range. Epidural anesthesia and not linked with an increased risk of hemorrhage. Providence Clinical Academy: Obstetrics

Current vital signs are: BP 130/75 mmHg
What medication should be ordered by physician at this point? Oxytocin IV push Methergine 2 mg IM Hemabate (carboprost) 0.25 mg IV Cytotec (misoprostol) 800 Knowledge Check Bimanual massage is initiated by the physician and IV oxytocin is infusing at a rapid rate. There is no immediate improvement in uterine tone. Current vital signs are: BP 130/75 mmHg P 96 bpm. Oxytocin should not be given IV push. The correct dose of Methergine is 0.2 mg and it is contraindicated in women with hypertension hemabate is given IM (not IV) Providence Clinical Academy: Obstetrics

Vital signs and uterine assessment to q 5 minutes
Which of the following interventions would not be appropriate for JoAnn at this time? Choose all that apply. Vital signs and uterine assessment to q 5 minutes Weighing pads to accurately assess blood loss Bimanual fundal massage STAT laboratory testing such as CBC, PT, PTT, fibrinogen Order OB Hemorrhage Pack Continue to monitor patient status in the room Knowledge Check Cytotec is administered and uterus remains atonic. The EBL is 800 mL during the delivery and another 700 mL. Hemabate is ordered and administered. Current vital signs: BP 119/69 mmHg P 108 bpm Fundal massage encourages uterine contraction. This patient has lost more than 1500 mL, accurate measurement of ongoing blood loss and increasing frequency of assessment is key to the optimizing management. Blood products should be ordered but at this point she may not need all components of the OB Hemorrhage Pack. It is important to obtain lab results. Pulse oximetry is a noninvasive method of monitoring oxygen saturation and pulse rate. Oxygen saturation levels can provide clues concerning whether the patient is shunting blood away from the periphery (as a result of hypovolemia) or is developing hypoxia as a result of anemia or inadequate ventilation. In any situation involving shock, the goal is to maximize the oxygen delivery to the tissues. Oxygen should be given to keep her SpO2 above 90%. Patient should be moved to the OR to rule out lacerations and potential D and C. Providence Clinical Academy: Obstetrics

Intervention & Management: Algorithm
STAGE 1 Cumulative Blood Loss >500ml vag birth or >1000ml C/S OR Increased bleeding during recovery or postpartum STAGE 2 Cumulative blood loss 1500 ml Continued bleeding Pulse >120 Decreased BP STAGE 3 >1500 ml Suspicion of DIC Pulse >140 Based on CMQCC algorithms Providence Clinical Academy: Obstetrics

Stage 1 Cumulative Blood Loss >500ml vag birth>1000ml C/S OR Increased bleeding during recovery or postpartum Nursing Care: Establish IV access if not present, at least 18 gauge Increase Oxytocin and titrate to uterine tone Continue vigorous fundal massage Assess and empty bladder Notify LIP/Charge Nurse Administer uterotonics as ordered Vital Signs q 5-10 minutes including O2 sat & level of consciousness Weigh, calculate and record cumulative blood loss Administer oxygen to maintain O2 sats at >95% Type and Screen (if not already done) Keep patient warm Document LIP: Methergine 0.2mg IM if not hypertensive If hypertensive give *Hemabate 250mcg IM or *Misoprostol 800mcg rectally Deferential Diagnosis - rule out retained products of conception, laceration, hematoma Surgeon: (if cesarean birth and still open) Inspect for uncontrolled bleeding at all levels, especially, broad ligament, posterior uterus, and retained placenta Providence Clinical Academy: Obstetrics

Stage 2 1500 mL cumulative blood loss and continued bleeding Pulse >120, Decreased BP
Nursing Care: Start a 2nd IV and administer IV fluids (LR is preferred) Place Foley with urimeter Continue assessing frequent vital signs and blood loss I & O Maintain communication with charge nurse Assists anesthesia provider Apply Bair Hugger and SCDs Administer medications as ordered ⁯Assist Anesthesia as needed Document LIP: Continue uterotonic medications Move to the OR- D/C, tamponade balloon, uterine packing Order OB Hemorrhage Panel Type & Cross for 2 units PRBCs or OB Hemorrhage Pack (if patient bleeding is not responding to treatment and interventions Interventions follow underlying cause for bleeding Laborist Anesthesia: Monitor patient vital signs Provide pain relief Begin blood replacement as indicated Providence Clinical Academy: Obstetrics

Stage 3 Cumulative blood loss >1500 OR Pulse >140, Decreased BP Suspicion of DIC
Nursing Care: Maintains communication with team members Administer medications as ordered Set up cell saver Assists anesthesia as needed Monitor cumulative blood loss and update team Document Draw labs LIP: Order OB Hemorrhage Pack Uterotonics Call for GYN/ONC and/or Adult Intensivist Consider uterine artery ligation, interventional radiology, or hysterectomy Anesthesia: Monitor frequent vital signs and communicate to team Arterial blood gases and repeat OB Hemorrhage Panel Place central line as needed Continue to administer meds and blood products Providence Clinical Academy: Obstetrics

APPLY WHAT YOU LEARNED Postpartum Hemorrhage Case Study
Providence Clinical Academy: Obstetrics

Case Study: Background Information
34 y.o. G2 P1001, 39 1/7 weeks Planned, repeat C/S A Neg/ Rubella Pos/ Hepatitis B Neg/ RPR non- reactive Uneventful prenatal course No pertinent medical history 16 g IV placed in left wrist Cefazolin 2 gms IV pre-op Providence Clinical Academy: Obstetrics

Case Study: Background Information
What would this patient’s risk factors be for PPH? What labs should be drawn pre-op? Prior C/S (Trauma) CBC Type & Screen Admission Hct 36.9 TySc sent Providence Clinical Academy: Obstetrics

Case Study 0 mL Cumulative Blood Loss 1533 C/S delivery 1536
140 130 120 110 100 90 80 70 60 150 1536 Oxytocin 20 units in 1 L LR BP 116/68 BP 105/52 HR 90 HR 70 1500 1600 1700 1800 1900 2000 2100 2200 0 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 12

EBL 1200 ml per anesthesia, < 1000 ml per surgeon
Case Study 1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed 140 130 120 110 100 90 80 70 60 150 1600 – Admit to recovery room EBL 1200 ml per anesthesia, < 1000 ml per surgeon BP 107/50 HR 76 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 13

Case Study 1000+ mL Cumulative Blood Loss 1615- Nursing note
“large clot expressed oozing , fundus boggy firmed with massage “ 140 130 120 110 100 90 80 70 60 150 1630 – Nursing Note “large clots expressed MD called to bedside” Methergine 200 mcg IM Misoprostol 800 mcg PR HR 105 BP 100/48 1645 Return to the OR 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 14

Case Study 1500+ mL Cumulative Blood Loss
1700 D&C, EBL noted at 500 ml 140 130 120 110 100 90 80 70 60 150 1715 Hemabate 250 mcg IM 1715 Bakri balloon placed Active bleeding stopped 1730 T&C for 4 units CBC, Coags drawn HR 115 BP 98/50 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 15

Case Study 1500+ mL Cumulative Blood Loss 1745
Bleeding slowed to minimal 140 130 120 110 100 90 80 70 60 150 HR 140 Oxytocin 30 units in 500 mL BP 95/60 1840 Hct 32.5 Platelets 129 Fibrinogen 205 Cefazolin 2 gm IV 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 16

Case Study 1700+ mL Cumulative Blood Loss HR 150 1945
140 130 120 110 100 90 80 70 60 150 1945 200 mL noted in Bakri Balloon Fundus 3-5 cm above umbilicus Abdomen tender 1955 OB at bedside U/S done – shows large clot 2000 Hct 26.9 Platelets 131 Fibrinogen 151 BP 89/45 2015 Hct 21 per I-Stat 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 17

Case Study 2200+ mL Cumulative Blood Loss 2015 1 unit PRBCs 2030
140 130 120 110 100 90 80 70 60 150 2030 Pt transferred to interventional radiology “moderate amount of bleeding continues” HR 140 2045 Midazolam and Fentanyl for sedation 2055 Hemorrhage pack ordered unit PRBCs BP 80/39 unit PRBCs 2140 Bilateral uterine artery embolization. Hemostatsis achieved ml blood loss into Bakri Balloon 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 18

Case Study 2200+ mL Cumulative Blood Loss 2200 Transferred to recovery
140 130 120 110 100 90 80 70 60 150 HR 125 2200 4-pack FFP 2225 4-pack FFP BP 92/64 2245 4-pack FFP 2250 Cryoprecipitate 2300 Cryoprecipitate, and 1 unit PRBCs 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 19

Case Study: Conclusion
The patient remained stable in recovery after the uterine artery embolization with scant lochia rubra then transferred to ICU after recovery Labs were the following: 0000 Hct 30.6, WBC 24.9, Platelets 88, Fibrinogen Hct 29.1, WBC 19.1, Platelets 75, Fibrinogen Hct 28.6, WBC 15.9, Platelets 67, Fibrinogen 226 Bakri Balloon removed at noon post-op day #1 with 200 mL blood loss in bag Total EBL = ??? Pt transferred in stable condition to postpartum at 1500 Discharged to home on post-op day #5 Providence Clinical Academy: Obstetrics

Which of these common mistakes occurred in this case?
Treating postpartum hemorrhage as a diagnosis and not identifying the cause Underestimation of blood loss Inattention to vital sign trends Delay in intervening surgically if needed Delay in laboratory assessment Delay in instituting blood replacement therapy Delay in moving from “normal delivery” to “life threatening emergency” Poor communication between nurse and OB providers on amount of blood loss, vital signs and other clinical indicators Lack of communication between OB provider and anesthesia who is managing blood loss and replacement therapy Insufficient preoperative preparation for massive hemorrhage (placenta previa, known or suspected accreta) Providence Clinical Academy: Obstetrics

Case Study Reflection Underestimation of blood loss- it was difficult to determine cumulative blood loss during this case. The RN should of weighed blood loss and a cumulative total should have been noted. Inattention to vital signs and delay in instituting blood replacement therapy - the patient was tachycardic an hypotensive, blood replaced was delayed until laboratory values reflected the need for blood replacement. Providence Clinical Academy: Obstetrics

Case Study: Stage 0 0 mL Cumulative Blood Loss 1533 C/S delivery 1536
140 130 120 110 100 90 80 70 60 150 1536 Oxytocin 20 units in 1 L LR BP 116/68 BP 105/52 HR 90 HR 70 1500 1600 1700 1800 1900 2000 2100 2200 0 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 23

EBL 1200 ml per anesthesia, < 1000 ml per surgeon
Case Study: Stage 1 1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed 140 130 120 110 100 90 80 70 60 150 1600 – Admit to recovery room EBL 1200 ml per anesthesia, < 1000 ml per surgeon BP 107/50 Stage 1: Greater than 1000 mL blood loss with stable vital signs Exact blood loss unknown as laps have not been weighed Oxytocin should be increased HR 76 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 24

Case Study: Stage 2 Stage 2:
1615- Nursing note “large clot expressed oozing , fundus boggy firmed with massage “ 140 130 120 110 100 90 80 70 60 150 1630 – Nursing Note “large clots expressed MD called to bedside” Methergine 200 mcg IM Misoprostol 800 mcg PR Stage 2: Less than 1500 mL blood loss & continued bleeding & decreased BP/elevated HR Need a 2nd IV OB Hemorrhage labs and at least 2 units of PRBCs should be ordered Increase Oxytocin rate Give Hemabate and repeat all Uterotonics per guidelines HR 105 BP 100/48 1645 Return to the OR 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 25

Case Study: Stage 3 Stage 3: Greater than 1500 mL blood loss
1700 D&C, EBL noted at 500 ml 140 130 120 110 100 90 80 70 60 150 1715 Hemabate 250 mcg IM 1715 Bakri balloon placed Active bleeding stopped 1730 T&C for 4 units CBC, Coags drawn HR 115 Stage 3: Greater than 1500 mL blood loss 2nd IV, labs, and PRBCs should have already been ordered Hemabate may be repeated q mins x 8 BP 98/50 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 26

Methergine may be repeated q 2-4 hours x 5 (only given 1x at this point) Hemabate may be repeated q mins x 8 (only given x1 at this point) OB Hemorrhage blood products should be ordered 1745 Bleeding slowed to minimal 140 130 120 110 100 90 80 70 60 150 HR 140 Oxytocin 30 units in 500 mL BP 95/60 1840 Hct 32.5 Platelets 129 Fibrinogen 205 Cefazolin 2 gm IV 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 27

HR 150 140 130 120 110 100 90 80 70 60 150 1945 200 mL noted in Bakri Balloon Fundus 3-5 cm above umbilicus Abdomen tender 1955 OB at bedside U/S done – shows large clot Stage 3: Greater than 1500 mL blood loss Methergine may be repeated q 2-4 hours x 5 (only given 1x at this point) Hemabate may be repeated q mins x 8 (only given x1 at this point) OB Panel to be repeated q 30 mins (this was done 1 hour ago at this point) No blood has yet been transfused at this time (Type & Cross for 4 units ordered at 1730) 2000 Hct 26.9 Platelets 131 Fibrinogen 151 BP 89/45 2015 Hct 21 per I-Stat 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 28

Case Study: Stage 3 Stage 3:
unit PRBCs 140 130 120 110 100 90 80 70 60 150 2030 Pt transferred to interventional radiology “moderate amount of bleeding continues” HR 140 2045 Midazolam and Fentanyl for sedation Stage 3: 1st unit of PRBCs given 3 hours after it was ordered Still only 1 dose of Hemabate and Methergine given at this time OB Hem blood products ordered 5 hours after start of Stage 3 2055 Hemorrhage pack ordered unit PRBCs BP 80/39 unit PRBCs 2140 Bilateral uterine artery embolization. Hemostatsis achieved ml blood loss into Bakri Balloon 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 29

Case Study: Stage 3 Stage 3: Still no other uterotonics administered
2200 Transferred to recovery Stage 3: Still no other uterotonics administered No labs since 2015 OB Hem Panel to be done q 30 mins in PPH 140 130 120 110 100 90 80 70 60 150 HR 125 2200 4-pack FFP 2225 4-pack FFP BP 92/64 2245 4-pack FFP 2250 Cryoprecipitate 2300 Cryoprecipitate, and 1 unit PRBCs 1500 1600 1700 1800 1900 2000 2100 2200 mL Providence Clinical Academy: Obstetrics Cumulative Blood Loss 30

Possible internal bleeding Knowledge Check
What are the possible physiologic reasons for Sarah’s current condition? (choose all that apply) Nausea due to ice chips Tachycardia related to pain, repositioning, and movement during transfer from OB/PACU to postpartum Possible internal bleeding Knowledge Check After C/S delivery Sarah is transferred to the OB/PACU. The 2nd PP check reveals: BP 99/50 Pulse 126 RR 20 Temp 98.2° F (oral) The abdominal dressing is C, D, & I 2 cm below Abdomen palpates slightly distended Patient complains of slight nausea. Ice chips or sips of liquid following a surgical procedure can produce nausea. Pain, anxiety, and activity can increase a patient’s heart rate. Mild hypotension is not unusual following a dose of pain medicine. All of these are potential explanations for Sarah's physiologic state. Close evaluation and increasing the frequency of her vital signs and uterine assessment will help the clinical team understand her condition. Providence Clinical Academy: Obstetrics

Request a bedside assessment by the charge nurse
Nursing interventions should include all of the following EXCEPT? Request a bedside assessment by the charge nurse Request a bedside assessment by the physician Request an order to type and crossmatch the patient Administer additional antiemetics Bolus with IV fluids Prepare to start second IV line for access Knowledge Check At the next assessment: Sarah’s fundus is difficult to palpate. Abd dressing C, D, & I Lochia is scant. BP 88/50 mmHg Pulse is 130 bpm. After administration of an antiemetic, Sarah starts vomiting and her skin is clammy to touch. She says she feels weak and cold. All are correct except administering additional antiemetics. Uterine atony is the most common, but not the only, cause of PPH. Sarah’s nausea and vomiting are most likely symptoms of her changing vital signs. Additional antiemetics are a waste of time. The underlying reason behind the symptom of PPH needs to be addressed. In any patient with a potential PPH, starting a secondary IV provides access for life-saving medication, fluid, or blood administration. Providence Clinical Academy: Obstetrics

Notify anesthesia and immediately transfer to OR
What should be the next management plan? (choose all that apply) Notify anesthesia and immediately transfer to OR Continue to monitor, blood pressure, and pulse oximetry monitors Run IV of LR wide open to increase her fluid volume Administer 2 units of blood emergently without verification Order OB Hemorrhage labs Apply oxygen via non-rebreather face mask Knowledge Check Sarah's physician is at the bedside. BP 85/30 mmHg P 140 bpm There is no new urine output Lochia is scant. ABD dressing is C,D, & I. The abdomen is distended and the uterus cannot be palpated. Sarah now rates her pain at 7. Blood products are always verified before administration regardless of urgency. Not doing so could result in drastic consequences for the patient. Swedish protocol allows nurses to act in emergency situations. In an emergent situation, a nurse should move a patient directly to the OR rather than wait for an order. A patient can be moved to the OR table and monitors can be applied without a physician order. Sarah's IV should run wide open in an effort to stabilize her hemodynamic status. Oxygen might be beneficial. Anticipating the likely lab work would help ensure that specimens are obtained quickly. Providence Clinical Academy: Obstetrics

Transfuse 1 unit of PRBC pending lab results
What transfusion orders should be given at this time? (choose all that apply) Transfuse 4 units of PRBC now and anticipate an order for 2 additional units Transfuse 1 unit of PRBC pending lab results Thaw fresh frozen plasma and give as soon as available Give 1 unit of pooled platelets Give recombinant factor VIIa Knowledge Check When the surgery starts, the obstetrician finds Sarah’s abdomen full of blood. The LIP found the left uterine artery is lacerated. The bleeding is controlled with additional suturing. After suctioning, the canister contains 1500 mL of blood. Capillary oozing is visible. The lab results will be available in 5 minutes. BP 80/42 mmHg Pulse is 140 bpm. While Sarah's hematocrit was initially within normal limits, no accurate estimate is available of the blood lost she lost 1000ml during the first surgery. Given there is 1500 mL of blood in the suction canister and blood on the lap pads, we can conclude that Sarah's blood loss has been substantial. The capillary is suggestive of DIC. Thus, blood replacement should begin transfusing PRBC as soon as possible and anticipate the need for additional units. Fresh frozen plasma should be administered as well. Transfusing 1 unit of PRBC is incorrect because she needs more than 1 unit and there is no time to wait for lab results. Platelets are always administered in units of 6 or 10 and recombinant factor VIIa is given for a specific thrombophelia. Providence Clinical Academy: Obstetrics

Strict input and output records Follow PACU protocol Knowledge Check
Further management of this patient should include? (choose all that apply) Anticipate that more blood and blood products will be ordered and administered Apply warming unit to the patient (warming blankets such as Bear Hugger®) Strict input and output records Follow PACU protocol Knowledge Check Sarah’s active bleeding has subsided and there is only slight capillary oozing after the laparotomy. Initial PACU lab values include: Hct 20% Fibrinogen 60 mg/dL Platelets 55,000/µL Core temp 96.2°F BP 104/58 mmHg Pulse 112 bpm. Coagulations show persistent coagulopathy (fibrinogen 60 mg/dL), and thrombocytopenia (platelets 55,000/µL). Sarah’s DIC is improving but will probably require additional blood and blood products. Strict I&O will provide critical information for the physician to make decisions regarding the type and amount of fluid, blood, and blood products Sarah will require. Increasing Sarah’s core temperature will promote tissue perfusion and oxygenation as well as make Sarah more comfortable. The sequential compression stockings to avoid deep vein thrombosis should be continued as well as other PACU protocols. Providence Clinical Academy: Obstetrics

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