Labor and Delivery Unit Safety: Obstetric Hemorrhage

• Individual risk factors predict some occurrences of obstetric hemorrhage.¹ A unit process for routinely assessing risk of hemorrhage upon admission to antepartum or L&D units can identify individuals at risk to ensure a prepared health care team.
• Risk assessment may include presence of clinical conditions that increase risk of hemorrhage, or patient preferences that may limit the use of blood and blood products in the event of a hemorrhage.
• A unit process for risk assessment can include assessing for conditions that are associated with obstetric hemorrhage, and may describe the unit process for different levels of risk. For example—
  • Criteria for type and hold, type and screen, and type and cross on admission and as intrapartum status changes.
  • Criteria for intravenous access on admission and as intrapartum status changes.
  • Criteria for having specialized equipment (e.g., rapid volume infusers, cell saver technology) readily accessible.
• Several professional organizations and initiatives offer examples of conditions that increase risk of hemorrhage and sample risk assessment tools.^2-4

• Rapid access to pharmacologic therapy and surgical equipment necessary to respond quickly to a hemorrhage is facilitated by the use of prepackaged carts, kits, and trays.
• These carts, kits, and trays can be stocked and stored on postpartum unit and L&D units. Such carts and kits may include commonly administered uterotonic agents, intravenous-access materials and fluids, equipment for bedside vaginal examination and manual evacuation, task lighting, and equipment for surgical management.
• Several professional organizations and initiatives^2,3 offer suggestions for medications and supplies to stock in hemorrhage kits, carts, or trays.

• The routine use of a unitwide approach for the active management of the third stage of labor can reduce variability among providers and nursing staff, potentially minimizing the risk of error. However, achieving unitwide agreement on the specifics of an approach may be challenging because of the available evidence about active management, differing values and opinions about the use of active versus expectant management, and patient preferences.

Consider using CUSP strategies to gain consensus on a standard approach that yields the most standardization while still allowing flexibility for patient preferences and/or where evidence is insufficient and variability in approach in unlikely to increase risk of errors. Options and examples for a standardized approach include the following:

• Evidence of benefit and harms: Studies show that the active management of the third stage reduces maternal blood loss and rates of postpartum hemorrhage. However, this approach is also associated with increased maternal diastolic blood pressure, pain, use of analgesia, and number of women returning to hospital due to bleeding, and nausea (specific to ergot-derived uterotonics).⁵
• Components of active management of third stage: The components typically include^6-10—
  • Use of a uterotonic drug soon after birth (oxytocin or ergot-derived agents).
  • Controlled cord traction.
  • Performance of uterine massage after the delivery of the placenta.
  Some consider early cord clamping to also be part of active management, but available evidence does not suggest it reduces rates of hemorrhage, and delayed cord clamping may provide health benefits to the neonate.^9-11
• Evidence about the individual components of active management:
  • Evidence suggests that the uterotonic agent is the most important component of active management; oxytocin is typically recommended as it has the most favorable risk/benefit profile.^10,12,13
• Options for timing of uterotonic administration vary; it can be given upon delivery of the anterior shoulder, upon delivery of the entire baby, at the first sign of placental separation, or upon expulsion of the placenta. Evidence of timing is limited to studies using intravenous oxytocin; these studies suggest no differences between administration before or after placental expulsion.¹⁴
• Evidence suggests that controlled cord traction in vaginal deliveries slightly reduces postpartum hemorrhage, shortens the duration of the third stage, and reduces risk of manual placental removal but has no effect on severe hemorrhage, need for transfusion, or therapeutic uterotonics. Thus, providers and women may consider using if these outcomes are considered important.¹²
• The evidence is insufficient regarding the effectiveness of uterine massage alone or in addition to uterotonics. Some recent guidelines have recommended against the prophylactic use of massage for women who have received prophylactic uterotonics because it may cause maternal discomfort, with little added benefit.^10,13

• The evidence suggests that cognitive aids such as checklists, flow sheets, protocols, and algorithms based on best practices may improve team response and management of hemorrhage.^15-17
• These aids provide logic and focus to guide responses in what can sometimes be a chaotic environment. These aids ensure that available treatment options are considered and can help the team maintain situational awareness about what has been done, what the current status is, and what steps may come next. Lastly, these aids can help with documentation of the hemorrhage episode.
• Examples of checklists, flow sheets, protocols, and algorithms for clinical response to obstetric hemorrhage are available in the published literature, through perinatal safety and quality collaboratives and professional
  organizations.^1-3,9,18

• Nonstandardized, informal, visual estimation methods typically underestimate blood loss, resulting in delayed recognition and management of obstetric hemorrhage.^19,20
• The routine use of quantitative methods for measuring blood loss by the health care team may facilitate earlier recognition and intervention, though few studies have formally evaluated whether this approach improves outcomes.^10,21-23
• Methods for quantification of blood loss may vary by type of delivery (vaginal or cesarean), but typically involve quantifying blood loss beginning immediately after birth of the infant, using calibrated under-buttocks drapes, weighing blood-soaked objects to estimate volume, and directly measuring blood in collection containers. Standardized visual estimation of blood-soaked materials using visual aids is also an option for quantification of blood loss.²⁴
• Staff training may be required to effectively implement routine and efficient quantification of blood loss. Several professional organizations and initiatives offer of training materials and cognitive aids for quantification of blood loss.^2,25

• A unit can decide its approach to debriefing events based on seriousness of event, expertise available, and data monitoring and tracking capabilities.
  • Informal debriefings by clinical team immediately following event using an approach that does not shame or blame individuals. This allows for understanding of what went well, what could have gone better, and what could be done differently next time.
  • Regular forum with a multidisciplinary team to learn from defects and sensemaking using the following tools:
    • Discovery form.
    • Root cause analysis.
    • Eindhoven model.
    • Failure mode and effects analysis.
    • Probabilistic risk assessment.
    • Causal tree worksheet.
    • Interdisciplinary case reviews.

• Unit can decide its approach to reviewing cases of severe obstetric hemorrhage. This might include an existing medical peer review process or review by a perinatal safety or quality committee.
• A sample process and forms for a committee review are available at the Council on Patient Safety in Women’s Health Care, www.safehealthcareforeverywoman.org
  Select: "Get SMM Form" menu.

• Antepartum hemorrhage.
• Postpartum hemorrhage.

• Two sample scenarios available through the AHRQ Safety Program for Perinatal Care can be used to train teams on key perinatal safety elements related to obstetric hemorrhage. One scenario is an antepartum hemorrhage, and the other is a postpartum hemorrhage. These scenarios reinforce teamwork and communication related to—
  • Situational awareness.
  • Early identification of hemorrhage through quantification of blood loss.
  • Use of cognitive aids, checklists, and protocols to focus clinical management.
  • Communication with rapid responders and other units of the hospital (e.g., lab, blood bank, OR).
  • Communication with patient/family.
  • Use of briefings, huddles, and debriefings.
• Several professional organizations and initiatives also offer sample simulation scenarios and "drills" related to obstetric hemorrhage.^26-28

• Knowing what the patient’s plan is through briefings and team management.
• Being aware of what is going on and what is likely to happen next.
• Verifying and checking back on information.
• Providing ongoing updates.

• For communicating a sense of urgency when requesting other unit personnel and provider for help responding to a hemorrhage.
• For communicating changes in maternal or fetal status.
• When giving and receiving new orders to manage the hemorrhage.
• When briefing new care team members who arrive to support a rapid response.
• When regrouping to discuss plan of care if primary maneuvers fail to relieve the dystocia.

• Use of transition communication techniques assures a shared mental model of plan of care and patient risks for hemorrhage between shifts or between units.

• Anyone can sound an alarm, request help, or challenge the status quo.
• Hierarchy is minimized.
• Communication is continuous, valued, and expected.

• Team members will advocate for the patient when one person's viewpoint does not coincide with another's.
  • Assert a corrective action in a firm and respectful manner.
  • Use CUS language: "I am concerned. I am uncomfortable. This is a safety issue."
  • Use the "two challenge" rule, repeating the concern, and asking whether you have been heard.
  • Use a predetermined "stop the line" phrase.
• Team members manage conflict using a constructive positive approach to emphasize "what is right, not who is right":
  • D: Describe the specific behavior or situation.
  • E: Express how the situation makes you feel or concerns you.
  • S: Suggest other alternatives.
  • C: Consequences stated in terms of team goals, not punishment.

• The patient and family are part of the team.
  • Ensure a shared mental model with patient and family as well as the clinical team.
  • Have training and policies for L&D staff to provide timely, clear information to patient and family to explain what is happening, what needs to happen next, risks, benefits, and processes for obtaining consent.
  • Provide reassurance continuously.

• Prompt, compassionate, and honest communication with the patient and family.
• Investigation.
• Ongoing communication with the patient and family.
• Apology and remediation.
• System and process improvement.
• Measurement and evaluation.
• Education and training.