14 Postpartum Hemorrhage on Labor and Delivery.pdf - Vtr

<strong>Postpartum</strong> <strong>Hemorrhage</strong> on Labor and Delivery
Table 2. Stages of <strong>Postpartum</strong> <strong>Hemorrhage</strong>
Antepartum Up to Time of Delivery
Stage 0 All births postpartum
Stage 1 4 500 mL vaginal delivery or >1,000 mL cesarean
delivery
Brisk bleeding, large gush, large or multiple clots
Boggy uterus
Vital sign triggers
AND
o 1,500 mL cumulative blood loss
Stage 2 Continued bleeding despite stage 1 maneuvers
Continued vital sign instability
Symptomatic
AND
o 1,500 mL cumulative blood loss
Stage 3 Cumulative blood loss >1,500 mL
Z2 U PRBCs given
Coagulopathy suspected
Insufficient response to prior actions
Adapted from California Maternal Quality Care Collaborative. 5
PRBCs ¼ packed red blood cells.
One of the cardinal recommendations from the
CMQCC is to establish the standard of structured assessments
of blood loss, vital signs, fundal height, and uterine
tone after all deliveries, and to define specific triggers for
action to limit the risk for denial and delay. Accurate blood
loss estimation is improved by the use of calibrated drapes
and formal staff training. 5,63–66 Blood contained in absorbing
materials (e.g., pads, sponges) can be quantified by
weighing all items, subtracting the dry weight of each, and
assuming 1 g weight ¼ 1 mL blood. 5 Immediately after
delivery, the team should routinely tabulate fluid volume in
suction canisters, calibrated drapes, and absorbing materials;
any subsequent volume is assumed to be blood, not
amniotic fluid.
Because hemorrhage is so often concealed or underestimated,
monitoring protocols with clear triggers for escalating
care are essential. 5,23 A Modified Obstetric
Early Warning Scoring (MEOWS) system adapted from
the Saving Mothers’ Lives report is presented
in Table 3. 5,23,67,68 A recent prospective evaluation in a
delivery center in the United Kingdom suggests that
Modified Obstetric Early Warning Scoring triggers are
89% sensitive (95% confidence interval: 81 to 95%), 79%
specific (95% confidence interval: 76 to 82%), with a
positive predictive value of 39% (95% confidence interval:
32 to 46%) and a negative predictive value of 98% (95%
confidence interval: 96 to 99%) to predict severe obstetric
morbidity. 69 Thirteen percent of women in this sample
developed some morbidity, including 5.5% with hemorrhage,
4% with preeclampsia, and 2.5% with infection.
The study found that hypotension was the least specific
criterion in predicting severe morbidity. But this was based
on a threshold of 90 to 100 mmHg to define mild hypotension
and