1. A Journey to Improve Outcomes for Women with Post Partum Hemorrhage
It Takes a Village
A Journey to Improve Outcomes for Women with Post Partum Hemorrhage
Danette Schloeder, PMC-CNS, RNC-OB, C-EFM
Providence Alaska Medical Center
Introduce self
I would like to share my journey towards improving the outcomes for women experiencing post partum hemorrhage and how it really did take a village.

2. Our Problem June 2015-December 2015 5 Mass Transfusions
Approximate EBL’s over 10,000mL
1 patient received 128 units blood products
All had ICU stays for hemorrhagic shock
All had resulting hysterectomies
Extended length of stay
Separation from infant
So lets talk about my problem.
Between June 2015 and December 2015, we experienced an abnormal phenomenon. We had 5 patients who required mass transfusions. Our previous mass transfusion had been in years prior.
There patient’s had blood losses around mL
One patient received over 128 units of blood products and coded on 2 separate occasions
All the patients ended up with hysterectomies, ICU stays for hemorrhagic shock, extended length of stays, and endured a long separation from their newborn.

3. Our Plan
Create tools to improve our identification of postpartum hemorrhage
Identify methods to improve our response to postpartum hemorrhage
Collaborate with other departments to improve the outcomes of our patients at highest risk for mass transfusion
Read Slide

4. Tools to Improve Identification
System PPH Protocol
Blood visualization guides
Everything Blood
Simulations
System Work.
Built into EPIC
Visualization Guides
Everything Blood
Simulations

5. Everything Blood

6. Protocol

7. Methods to Improve Management
Code Stork
Carts/equipment
Percreta Protocol
My first group was the Blood Bank. I took time to understand their processes and challenges and built that into my education.
We created visual guides
We use real blood
We built patients into EPIC that we can bar code scan and administer blood
We created MTP coolers and practices unpacking them, monitoring temperatures, and repacking them.
Emphasis on blood being a precious gift and not to waste it.

8. Placenta Percreta Life threatening condition
Increase seems to parallel the c-section rate
Associated with myometrial damage
Invasion of the placenta through the myometrium and serosa
Attaches to adjacent organs
Practitioner/Consultant/Leader
Placenta accreta is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. It turned out to be the bulk of our mass transfusions
Placenta accreta is a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine
Placenta percreta describes invasion through the myometrium and serosa, and occasionally into adjacent organs, such as the bladder. Clinically, placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by massive obstetric hemorrhage, leading to disseminated intravascular coagulopathy; the need for hysterectomy; surgical injury to the ureters, bladder, bowel, or neurovascular structures; adult respiratory distress syndrome; acute transfusion reaction; electrolyte imbalance; and renal failure.
The average blood loss at delivery in women with placenta accreta is 3,000–5,000 mL (2). As many as 90% of patients with placenta accreta require blood transfusion, and 40% require more than 10 units of packed red blood cells. Maternal mortality with placenta accreta has been reported to be as high as 7% (3). Maternal death may occur despite optimal planning, transfusion management, and surgical care. From a cohort of 39,244 women who underwent cesarean delivery, researchers identified 186 that had a cesarean hysterectomy performed had an accrete
The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate.
Women at greatest risk of placenta accreta are those who have myometrial damage caused by a previous cesarean delivery with either an anterior or posterior placenta previa overlying the uterine scar.
Diagnosis of placenta accreta before delivery allows multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.
Grayscale ultrasonography is sensitive enough and specific enough for the diagnosis of placenta accreta; magnetic resonance imaging may be helpful in ambiguous cases.
Although recognized obstetric risk factors allow the identification of most cases during the antepartum period, the diagnosis is occasionally discovered at the time of delivery.
In general, the recommended management of suspected placenta accreta is planned preterm cesarean hysterectomy with the placenta left in situ because attempts at removal of the placenta are associated with significant hemorrhagic morbidity. However, surgical management of placenta accreta may be individualized.
Although a planned delivery is the goal, a contingency plan for an emergency delivery should be developed for each patient, which may include following an institutional protocol for maternal hemorrhage management.

9. Customary Management
Planned preterm c-section and hysterectomy with mass transfusion
C-section with placenta left in situ
Unplanned c-section upon presenting with bleeding resulting in mass transfusion and hemorrhagic shock

10. Improved Collaboration
Main OR
GYN Oncologists/ Urology
Interventional Radiology
Perinatology
Anesthesia
Perfusionists
Blood Bank
Imaging
I put on my Leader hat and started having conversations. My primary support was our Perinatologist. She was often called during the mass transfusion to try and assist with the bleeding. She believed there was a better way to delivery these at risk women in controlled situations.
Her super power was clinical care.
My super power was collaboration with departments that would rather take care of a patient with a sword in their chest. They believed pregnant patients should never leave the maternity center.

11. Accreta Protocol Perinatal Planning Diagnostic Mapping
Uterine Artery Embolization
Stents
C/Hyst
Cell Saver
So was born the Accreta Protocol. The goal is to deliver the patient at 34 weeks gestation in a controlled circumstance.
Includes a preoperative visit and education with the patient the day before the scheduled case. The patient gets an MRI and the location of the placenta is mapped and literaly drawn on the uterus so everyone knows what area to avoid.
The patient arrives in Labor and Delivery that morning and an epidural catheter is placed but not dosed.
The team then moves with the patient to the Cath Lab where uterine artery balloons are placed but not inflated.
The Labor and Delivery nurse monitors the status of the baby with electronic fetal monitoring.
The enlarging team then moves to the Operating Room where an Urologist places urinary stents to mark the ureters.
The anesthesiologist then doses the epidural and the case begins.
NICU is there to receive the baby.
Implementing the protocol required advanced planning and care coordination by Me.
The protocol identifies that one of the first steps when any provider suspects a placenta percreta is to call me.
I then coordinates with anesthesia, cath lab, blood bank, Neonatal Intensive Care Unit and the Operating Room to make sure all care coordination is complete. I also communicates with all the charge nurses and day of surgery nurses so they understand the protocol.

12. Outcomes 5 cases performed in last 12 months EBL < 600mL
No blood products other than cell saver
No ICU admissions
Average length of stay
Early initiation of breastfeeding
High patient/staff satisfaction
Between December 2015 and March 2016, 5 cases were performed using this innovative protocol.
All cases had less than 600ml blood loss and the patient did not receive any blood other than her own.
None of the patients required a stay in the Intensive Care Unit

13. Outcomes
Pre-implementation of the Percreta protocol and the education, the blood transfusion rate for Labor and Delivery was 11.1%.
This dropped in the first month to 6.7% and then to 0%.
During this period, there was one mass transfusion requiring 17 units of blood.