“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.
At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.
“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.
The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)
“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.
“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”
Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.
Recommendations for Managing Maternal Hemorrhage
The complete document is available at
The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.
Seven steps to reduce the risk of maternal death from hemorrhage include:
▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.
▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.
▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.
▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.
▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.
▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.
▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.
Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene