Delays in Response and Recognition

• Obstetric (OB) clinicians and nursing staff should be vigilant for signs of maternal hemorrhage by monitoring quantitative blood loss (QBL), hemodynamic vital signs, labs, and patient complaints of abdominal pain throughout birth hospitalization.
• OB clinicians, Certified Nurse Midwives and care teams should have a greater understanding of Amniotic Fluid Embolism (AFE) pathophysiology and diagnostic criteria to distinguish between AFE and hemorrhage.
• OB Nursing staff should receive education and training regarding responsibility to escalate care for pregnant and postpartum patients using Maternal Early Warning Signs in all locations of care (Emergency Department, Operating Room, Post-Anesthesia Care Unit, Postpartum, Labor and Delivery, and Emergency Medical Systems).
  
• Prepare all birth facilities, particularly small-volume or low-resource hospitals, to manage severe hemorrhage using standardized tools (see CMQCC OB Hemorrhage Toolkit, V. 3.0), including the following:
  • a plan to transfer each patient at high risk of hemorrhage to a higher-level facility prior to giving birth, whenever possible;
  • physician availability to evaluate patient in timely manner;
  • trained staff to assist in emergency cesarean or unplanned hysterectomy with necessary equipment;
  • consultation policies with back-up surgeons and medical specialties- i.e., interventional radiology, gynecologic oncology, general surgery, and Blood Bank;
  • blood products on hand or in storage at facility, especially fresh frozen plasma (FFP), platelets, cryoprecipitate, O negative blood; and
  • regular staff training including low-fidelity simulation or drills, with annual Continuing Medical Education on the acute management of obstetric hemorrhage.
• Train multidisciplinary clinicians to be proactive and aggressively manage severe hemorrhage. Key considerations include the following:
  • Establishing early wide bore IV access.
    
  • Moving along the stage-based pathway in a standardized hemorrhage protocol rather than repeat procedures.
  • Requesting emergency-release blood products early.
  • For an evolving hemorrhage, do not delay transfusion by ordering type and crossmatched red blood cells. Instead, use of un-crossmatched O type blood is recommended.
  • Consider early transfusion for patients with a severe hemorrhage that is not responsive to first- and second-line treatment measures.
  • Consider point-of-care monitoring for close assessment of hemoglobin (Hb)/hematocrit (Hct) and coagulation indices.
  • Providing continuous heart rate and pulse oximetry monitoring and every 1-2 minute blood pressure assessments.
  • Including tranexamic acid (TXA) among medication treatments when appropriate.
  • Considering early placement of an intrauterine device (e.g., intrauterine balloon tamponade; vacuum device) for patients with refractory uterine atony that is not responsive to first- and second-line uterotonics or severe placental bed bleeding.
  • Mobilizing OB Rapid Response Team.
  • Consider early requests for help from allied specialties (General Surgery, Emergency Department, Hospital Medicine, Intensive Care, Anesthesiology).
  • If atony treatment with an intrauterine device is not successful, proceeding to hysterectomy or interventional radiology (based on the acuity or severity of hemorrhage, patient’s hemodynamic status, and ability to mobilize surgical/radiological support).
  • If AFE is suspected, considering specialist input (from anesthesiology, intensive care, cardiology, and other surgical disciplines) as massive transfusion and hemostatic and cardiovascular support are often required.
  • Not transferring patients from the operating room or the labor and delivery unit to the postpartum unit or intensive care unit until bleeding has resolved and patients are hemodynamically stable.
  • Training all staff to recognize that patients with hemodynamic instability after delivery in the absence of external bleeding should undergo emergent clinical evaluation for intra-abdominal hemorrhage, with a high likelihood for needing surgical exploration.

Lack of Adherence to Protocols

• Attention should be paid to family concerns about a plan of care during intrapartum and postpartum and responses to these concerns should be documented.
• All birth facilities need to standardize hemorrhage protocols, engage in simulation drills with an emphasis on roles and teamwork, and develop consistent methodology for quantification of blood loss.
• The Transfusion Service (or Blood Bank), in coordination with the OB Department, needs to create hemorrhage protocols for a) emergent release of blood products and b) massive transfusions.

Inadequate Assessment

• In the prenatal setting, for patients with diagnosed placenta accreta spectrum or with other high risks for hemorrhage, a patient centered care plan should be developed with a MFM consult that includes counselling patients/family about pregnancy options and risks involved and scheduling delivery in a well-resourced facility with a comprehensive surgical team.
  
• All pregnant patients should be screened for iron deficiency anemia and treated appropriately. Automated systems will facilitate implementation and sustainability.
• All patients should be assessed for hemorrhage risk during labor admission and again prior to delivery. Planning should occur for those at elevated risk.
• For patients who refuse blood products, OB clinicians need to have a patient centered plan for optimizing hemoglobin prior to delivery and for managing hemorrhage should it occur at birth.

Coordination of Care

• Facility should ensure that OB clinicians and Anesthesia teams coordinate with lab and blood banks to facilitate ample response to rapidly identify and manage blood loss over 1500 ml (a key concern in abruption, uterine rupture, infection, and other conditions), including the following:
  • ensuring timely turnaround of lab values to identify Disseminated Intravascular Coagulation (DIC) (including coagulant values and fibrinogen);
  • reaching team agreement to treat low fibrinogen values; and
  • establishing time frames of availability for FFP, cryoprecipitate, or fibrinogen concentrate.
• Teamwork is critical in complex hemorrhage cases; birth facilities need to use standardized communication to ensure clear roles and actions.
  • Create safe places for people to speak up and be heard.

Emergency Medicine

• Emergency medicine clinical staff need to be aware of the highlights of the maternal quality toolkits to assess all patients for pregnancy and postpartum status and to know when to consult with an OB clinician.
• Provide training and standardized protocols for Emergency Department clinicians for evaluation of abdominal pain, ectopic pregnancy, and antepartum bleeding at all gestations.

Discrimination

• For ALL patients, OB clinicians and facilities need to provide culturally sensitive, responsive, and non-judgmental care.
• Call social work to assist with communication and education. Patients who experience disrespectful and judgmental care are more likely to delay or not seek early care.
• For patients with non-English language preferences, OB clinicians and birth facilities are legally obligated to have qualified interpreters available in person or virtually for all decision making and have key educational materials translated in patients’ preferred languages.
  • If the clinician speaks the patient's language, document that in the patient's record. 
  • Use family members only as a last resort for interpretation.
• Hospitals and health care systems need to examine how implicit bias, structural discrimination, and systemic racism impact patient access to high-quality, risk-appropriate maternity care and enact anti-racist policies and practices to ensure respectful, patient-centered care delivery and eliminate inequities.