Postpartum Hemorrhage (PPH) is the leading cause of maternal mortality worldwide, and cases are currently on the rise across the globe. However, up to 70% of hemorrhage-related obstetric deaths may be prevented with prompt recognition of excessive blood loss and standardized emergency plans (1,2,3). This blog will explore how OB educators and clinicians can help improve care for mothers who develop postpartum hemorrhage. 

Estimating postpartum blood loss

Early recognition of abnormal postpartum blood loss is critical for clinicians to intervene promptly and prevent maternal death. Clinicians often use visual estimates to initially determine that a mother’s postpartum bleeding is excessive and worrisome. However, this assessment method can significantly underestimate large volume blood loss by 35%-50%. Evidence now shows that measuring blood loss with calibrated drapes or graduated fluid basins is much more accurate. Ultimately, quantitative blood loss measurement should be used as part of an early warning system for PPH (4,5,6). 

Care bundles for PPH management

Once PPH has been identified, standardized care bundles can be used to promote compliance with evidence-based best practices to improve maternal outcomes. Care bundles for PPH typically include uterine massage, isotonic crystalloids, uterotonic drugs and tranexamic acid (TXA). Acronyms may also be included to improve memorability of interventions, such as “MOTIVate,” meaning massage, oxytocics, TXA, and IV fluids. Of course, establishing a culture of safety is essential for successful implementation of PPH care bundles. Additionally, multidisciplinary reviews can be used to identify opportunities to improve teamwork, skills and outcomes (7,8). 

Creating a PPH emergency cart

To prevent delays in treatment of PPH, all needed supplies and medications should be kept in close proximity to the patient. As it can take considerable time to collect everything from various storage areas, a designated PPH emergency cart is recommended. It should be designed with input from pharmacy, obstetric, and nursing providers to have everything needed to manage refractory hemorrhage. The facility’s hemorrhage protocols should be affixed to the top of the cart, along with the names, doses, and routes of administration for uterotonic medications and TXA. The PPH cart can be placed outside the room at delivery for mothers who are known to be at high risk for hemorrhage. Large facilities may require multiple carts for labor and delivery, surgical, and postpartum units (8,9,10). 

Simulation training

Simulation training scenarios can be used to prepare OB students and clinicians to effectively manage low-volume, high-stakes events such as PPH. In fact, the American College of Obstetricians and Gynecologists states that establishing protocols with standardized interventions and onsite drills improves patient care in OB emergencies. Healthcare facilities should schedule PPH simulations at least annually, with more frequent sessions for units with low volume of deliveries. Optimally, these scenarios should include participants from medicine, nursing, blood bank, and pharmacy to improve interdisciplinary communication and coordination. PPH simulation training should also be included as part of pre-licensure nursing curricula to increase student knowledge and confidence. All simulations should be followed with debriefing sessions to identify strengths, weaknesses, and opportunities for improvement (5,11,12,13). 

Final thoughts

A stocked emergency cart is an essential component of effective PPH management. However, it can be difficult for nursing programs to create their own PPH carts. To meet this need, DiaMedical USA and SimLabSolutions created a Loaded Postpartum Hemorrhage Cart to train nursing students about this maternal emergency. Below you can find one of our most recent Tuesday Teaching's episodes, which covers the SimLabSolutions Loaded Postpartum Hemorrhage Cart. Designed specifically for instructional use, the drawers are stocked with all of the supplies and simulated medications that are needed to manage PPH. Educators can even create customized emergency carts for their programs. For more information, reach out to a DiaMedical USA expert at 877-593-6011 or info@diamedicalusa.com.

References

1. Ahmadzia, H., Grotegut, C., & James, A. (2020). A national update on rates of postpartum haemorrhage and related interventions. Blood Transfusion, 18(4), 247-253. 
2. National Institute for Children’s Health Quality. (2022). Taking on a leading cause of maternal death: Improving postpartum hemorrhage care. Retrieved from https://www.nichq.org/insight/taking-leading-cause-maternal-death-improving-postpartum-hemorrhage-care 
3. Zaharatos, J., St. Pierre, A., Cornell, A., Pasalic, E. & Goodman, D. (2018). Building U.S. capacity to review and prevent maternal deaths. Journal of Women’s Health, 27(1), 1-5. 
4. Lertbunnaphong, T., Lapthanapat, N., Leetheeragul, J., Hakulbabrb, P., & Ownon, A. (2016). Postpartum blood loss: visual estimation versus objective quantification with a novel birthing drape. Singapore Medical Journal, 57(6), 325-328. 
5. Indiana Perinatal Quality Improvement Collaborative. (2019). Maternal hemorrhage toolkit. Retrieved from https://www.in.gov/health/laboroflove/files/maternal-hemorrhage-tool-kit-august-2019.pdf 
6. Hancock, A., Weeks, A., & Lavender, D. (2015). Is accurate and reliable blood loss estimation the 'crucial step' in early detection of postpartum haemorrhage: An integrative review of the literature. BMC Pregnancy and Childbirth,15, 230. 
7. Althabe, F., Therrien, M., Pingray, V., Hermida, J., … Miller, S. (2020). Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation. International Journal of Gynecology & Obstetrics, 148(3), 290–299.
8. Joseph, N., Worrell, N., Collins, J., Schmidt, M., … Lindsay, M. (2020). Implementation of a postpartum hemorrhage safety bundle at an urban safety-net hospital. AJP Reports, 10(3), e255–e261. 
9. Kogutt, B., Kim, J., Will, S., & Sheffield, J. (2022). Development of an obstetric hemorrhage response intervention: The postpartum hemorrhage cart and medication kit. Joint Commission Journal on Quality and Patient Safety, 48(2),120-128. 
10. Dellapiana, G. & Gregory, K. (2022). Postpartum hemorrhage carts: Saving time can save lives. Joint Commission Journal on Quality and Patient Safety, 48(2),167-68.
11. Lutgendorf, M., Spalding, C., Drake, E., Spence, D., … Morocco, K. (2017). Multidisciplinary in situ simulation-based training as a postpartum hemorrhage quality improvement project. Military Medicine,182(3), e1762-e1766.  
12. Riley, E., Ward, N., Capps, N., McCormack, L., & deGravelles, P. (2021). Piloting a high-fidelity postpartum hemorrhage simulation with prelicensure nursing students: Evaluating knowledge, confidence, and satisfaction. Teaching and Learning in Nursing, 16(4), 296-300. 
13. Karadas, M. & Terzioglu, F. (2019). The impact of the using high-fidelity simulation and standardized patients to management of postpartum hemorrhage in undergraduate nursing students: A randomized controlled study in Turkey. Health Care for Women International, 40(5), 597-612.