Postpartum Hemorrhage Case Study

Providence Clinical Academy: Obstetrics Curriculum

What risk factors for PPH do you see in this case? Choose all
that apply.
Knowledge Check
a) Low platelets JoAnn,
The labor a 25-year-old G1P0,
epidural is placed at is
5
cm induced
of dilation.with
The prolonged
physician uses
lowoxytocin at aterm
forceps for for mild
prolonged (5 hr)
b) Prolonged second stage of labor preeclampsia. Her admission
second stage and delivers a 9 lb
hematocrit
baby. is 39% and
After an uneventful her
delivery
platelet count isheavy
190,000/µL.
c) Use of prolonged oxytocin during the induction of the placenta,
Systolic
vaginal
bleeding blood
ensues.pressure
Inspectionranged
of the
from 154 reveals
placenta to 142 no mmHg and
missing
d) Epidural anesthesia diastolic
cotyledons blood pressureoffrom
and inspection the
98 to 88 mmHg prior
lower genital tract reveals noto
lacerations orand
admission during
source labor.
of bleeding.
e) History of preeclampsia Palpation of the uterus reveals
severe atony.

f) Operative vaginal delivery

2 Providence Clinical Academy: Obstetrics 2016.07

What medication should be ordered by physician at this point?
Knowledge Check
a) Oxytocin IV push Bimanual massage is initiated
by the physician and IV
oxytocin is infusing at a rapid
b) Methergine 2 mg IM rate. There is no immediate
improvement in uterine tone.
c) Hemabate (carboprost) 0.25 mg IV Current vital signs are: BP
130/75 mmHg
P 96 bpm.
d) Cytotec (misoprostol) 800

3 Providence Clinical Academy: Obstetrics 2016.07

Which of the following interventions would not be appropriate
for JoAnn at this time? Choose all that apply.
Knowledge Check
a) Vital signs and uterine assessment to q 5 minutes
Cytotec is administered and
uterus remains atonic. The EBL
b) Weighing pads to accurately assess blood loss is 800 mL during the delivery
and another 700 mL.
Hemabate is ordered and
c) Bimanual fundal massage administered.
Current vital signs:
d) STAT laboratory testing such as CBC, PT, PTT,
fibrinogen BP 119/69 mmHg
P 108 bpm
e) Order OB Hemorrhage Pack

f) Continue to monitor patient status in the room

4 Providence Clinical Academy: Obstetrics 2016.07

Intervention & Management: Algorithm

STAGE 1 STAGE 2 STAGE 3

Cumulative Blood Loss Cumulative blood loss Cumulative blood loss

>500ml vag birth or 1500 ml >1500 ml
>1000ml C/S Continued bleeding
Pulse >120 OR
OR Decreased BP
Suspicion of DIC
Increased bleeding during Pulse >140
recovery or postpartum Decreased BP

5 Providence Clinical Academy: Obstetrics 2016.07

Stage 1
Cumulative Blood Loss >500ml vag birth>1000ml C/S OR
Increased bleeding during recovery or postpartum
 Nursing Care:
 Establish IV access if not present, at
least 18 gauge
 Increase Oxytocin and titrate to
uterine tone
 Continue vigorous fundal massage
 Assess and empty bladder
 Notify LIP/Charge Nurse
 Administer uterotonics as ordered
 Vital Signs q 5-10 minutes including O2
sat & level of consciousness
 Weigh, calculate and record cumulative
blood loss
 Administer oxygen to maintain O2 sats
at >95%
 Type and Screen (if not already done)
 Keep patient warm
 Document
6 Providence Clinical Academy: Obstetrics
 LIP:
 Methergine 0.2mg IM if not
hypertensive
 If hypertensive give *Hemabate 250mcg
IM or *Misoprostol 800mcg rectally
 Deferential Diagnosis - rule out
retained products of conception,
laceration, hematoma
 Surgeon: (if cesarean birth and still
open)
 Inspect for uncontrolled bleeding at all
levels, especially, broad ligament,
posterior uterus, and retained placenta
2016.07
Stage 2
1500 mL cumulative blood loss and continued bleeding
Pulse >120, Decreased BP
 Nursing Care:
 Start a 2nd IV and administer IV fluids
(LR is preferred)
 Place Foley with urimeter
 Continue assessing frequent vital signs
and blood loss
 I&O
 Maintain communication with charge
nurse
 Assists anesthesia provider
 Apply Bair Hugger and SCDs
 Administer medications as ordered
 Assist Anesthesia as needed
 Document
7 Providence Clinical Academy: Obstetrics
 LIP:
 Continue uterotonic medications
 Move to the OR- D/C, tamponade
balloon, uterine packing
 Order OB Hemorrhage Panel
 Type & Cross for 2 units PRBCs or OB
Hemorrhage Pack (if patient bleeding is
not responding to treatment and
interventions
 Interventions follow underlying cause for
bleeding
 Laborist
 Anesthesia:
 Monitor patient vital signs
 Provide pain relief
 Begin blood replacement as indicated
2016.07
Stage 3
Cumulative blood loss >1500 OR Pulse >140, Decreased BP Suspicion of DIC
 Nursing Care:  LIP:
 Maintains communication with team  Order OB Hemorrhage Pack
members  Uterotonics
 Administer medications as ordered  Call for GYN/ONC and/or Adult
 Set up cell saver Intensivist
 Assists anesthesia as needed  Consider uterine artery ligation,
 Monitor cumulative blood loss and interventional radiology, or
update team hysterectomy
 Document
 Draw labs
 Anesthesia:
 Monitor frequent vital signs and
communicate to team
 Arterial blood gases and repeat OB
Hemorrhage Panel
 Place central line as needed
 Continue to administer meds and blood
products

8 Providence Clinical Academy: Obstetrics 2016.07

 APPLY WHAT YOU LEARNED
Postpartum Hemorrhage Case Study

9 Providence Clinical Academy: Obstetrics 2016.07

Case Study: Background Information
 34 y.o. G2 P1001, 39 1/7 weeks
 Planned, repeat C/S
 A Neg/ Rubella Pos/ Hepatitis B Neg/ RPR non-
reactive
 Uneventful prenatal course
 No pertinent medical history
 16 g IV placed in left wrist
 Cefazolin 2 gms IV pre-op

10 Providence Clinical Academy: Obstetrics 2016.07

Case Study: Background Information

 What would this patient’s

risk factors be for PPH? Prior C/S (Trauma)

 What labs should be CBC

drawn pre-op? Type & Screen

Admission Hct 36.9

TySc sent

11 Providence Clinical Academy: Obstetrics 2016.07

 Case Study 1533
C/S delivery
150

140

130
1536
BP 116/68 Oxytocin 20
120
units in 1 L LR
110

100
BP 105/52

90

HR 90
80

70

HR 70
60

1500 1600 1700 1800 1900 2000 2100 2200

12 0 mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
150
1545- Persistent bleeding
noted on uterine layer,
140 fundus firm, figure 8 stitch
placed
130

120 1600 – Admit to

recovery room
110

100 BP 107/50
EBL 1200 ml per
anesthesia, < 1000 ml
90 per surgeon
80

70 HR 76

60

1500 1600 1700 1800 1900 2000 2100 2200

13 1000+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
1615- Nursing note
“large clot expressed
oozing , fundus boggy
150 firmed with massage “
1630 – Nursing Note
140 “large clots expressed MD
called to bedside”
130 1615-1620
Methergine 200 mcg IM
120
Misoprostol 800 mcg PR
110 HR 105

100 BP 100/48

90

80

70 1645 Return to the OR

60

1500 1600 1700 1800 1900 2000 2100 2200

14 1000+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
1700 D&C, EBL
noted at 500 ml
150 1715
Hemabate 250 mcg
140 IM
1715
130 Bakri balloon placed
1730
Active bleeding stopped
120 T&C for 4 units
CBC, Coags drawn
110 HR 115

100

90
BP 98/50
80

70

60

1500 1600 1700 1800 1900 2000 2100 2200

15 1500+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
1745
150 Bleeding slowed to minimal
HR 140
140 Oxytocin 30 units in 500 mL

130

120

110
BP 95/60
100

90

1840
80
Hct 32.5
Platelets 129
70
Fibrinogen 205

60
Cefazolin 2 gm IV

1500 1600 1700 1800 1900 2000 2100 2200

16 1500+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
HR 150
150 1945
200 mL noted in Bakri Balloon
1955
140 Fundus 3-5 cm above umbilicus
OB at bedside
Abdomen tender
U/S done – shows large clot
130

120

110 2000
Hct 26.9
100 Platelets 131
Fibrinogen 151
90

BP 89/45
80

70
2015
Hct 21 per I-Stat
60

1500 1600 1700 1800 1900 2000 2100 2200

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Cumulative Blood Loss
 Case Study
2015 1 unit PRBCs
150

2030 HR 140
140 Pt transferred to interventional radiology
“moderate amount of bleeding continues”
130
2045
Midazolam and
Fentanyl for sedation
120

110

100
2055
90
Hemorrhage pack ordered
2100 1 unit
80 PRBCs BP 80/39
2130 1 unit
70 PRBCs

60
2140 Bilateral uterine artery embolization.
Hemostatsis achieved. 500 ml blood loss into Bakri Balloon

1500 1600 1700 1800 1900 2000 2100 2200

18 2200+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study
2200
150 Transferred to recovery

140 HR 125
2200
130 4-pack FFP

120
2225
4-pack FFP
110

100 BP 92/64

90

2245
80 4-pack FFP
2250
70
Cryoprecipitate
60 2300
Cryoprecipitate, and 1 unit PRBCs

1500 1600 1700 1800 1900 2000 2100 2200

19 2200+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
Case Study: Conclusion
The patient remained stable in recovery after the uterine artery embolization
with scant lochia rubra then transferred to ICU after recovery
Labs were the following:
0000
Hct 30.6, WBC 24.9, Platelets 88, Fibrinogen 164
0400
Hct 29.1, WBC 19.1, Platelets 75, Fibrinogen 199
0730
Hct 28.6, WBC 15.9, Platelets 67, Fibrinogen 226

Bakri Balloon removed at noon post-op day #1 with 200 mL blood loss in bag
Total EBL = ???
Pt transferred in stable condition to postpartum at 1500
Discharged to home on post-op day #5
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Which of these common mistakes occurred in
this case?
1. Treating postpartum hemorrhage as a diagnosis and not
identifying the cause
2. Underestimation of blood loss
3. Inattention to vital sign trends
4. Delay in intervening surgically if needed
5. Delay in laboratory assessment
6. Delay in instituting blood replacement therapy
7. Delay in moving from “normal delivery” to “life threatening
emergency”
8. Poor communication between nurse and OB providers on
amount of blood loss, vital signs and other clinical indicators
9. Lack of communication between OB provider and anesthesia
who is managing blood loss and replacement therapy
10. Insufficient preoperative preparation for massive hemorrhage
(placenta previa, known or suspected accreta)

21 Providence Clinical Academy: Obstetrics 2016.07

Case Study Reflection
 Underestimation of blood loss- it was difficult to
determine cumulative blood loss during this case. The
RN should of weighed blood loss and a cumulative total
should have been noted.

 Inattention to vital signs and delay in instituting blood

replacement therapy - the patient was tachycardic an
hypotensive, blood replaced was delayed until laboratory
values reflected the need for blood replacement.

22 Providence Clinical Academy: Obstetrics 2016.07

 Case Study: Stage 0 1533
C/S delivery
150

140

130
1536
BP 116/68 Oxytocin 20
120
units in 1 L LR
110

100
BP 105/52

90

HR 90
80

70

HR 70
60

1500 1600 1700 1800 1900 2000 2100 2200

23 0 mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 1
150
1545- Persistent bleeding
noted on uterine layer,
140 fundus firm, figure 8 stitch
placed
130

120 1600 – Admit to

recovery room
110

100 BP 107/50
EBL 1200 ml per
anesthesia, < 1000 ml
90 per surgeon
80
Stage 1:
70 HR 76 Greater than 1000 mL blood
loss with stable vital signs
60
•Exact blood loss unknown as
laps have not been weighed
1500 1600 1700 1800 •Oxytocin
1900 should
2000 be increased
2100 2200

24 1000+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 2
1615- Nursing note
“large clot expressed
oozing , fundus boggy
150 firmed with massage “
1630 – Nursing Note
140 “large clots expressed MD
called to bedside”
130 1615-1620
Methergine 200 mcg IM Stage 2:
120
Misoprostol 800 mcg PR Less than 1500 mL blood loss
110 HR 105
& continued bleeding &
decreased BP/elevated HR
100 BP 100/48 • Need a 2nd IV
• OB Hemorrhage labs and at
90
least 2 units of PRBCs should
80
be ordered
• Increase Oxytocin rate
70 1645 Return to the OR • Give Hemabate and repeat
all Uterotonics per guidelines
60

1500 1600 1700 1800 1900 2000 2100 2200

25 1000+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 3
1700 D&C, EBL
noted at 500 ml
150 1715
Hemabate 250 mcg
140 IM
1715
130 Bakri balloon placed
1730
Active bleeding stopped
120 T&C for 4 units
CBC, Coags drawn
110 HR 115

100
Stage 3:
90 Greater than 1500 mL blood
BP 98/50
loss
80
• 2nd IV, labs, and PRBCs
70
should have already been
ordered
60 • Hemabate may be repeated
q 15-90 mins x 8
1500 1600 1700 1800 1900 2000 2100 2200

26 1500+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 3 Stage 3:
Greater than 1500 mL blood loss
1745
• Methergine may be repeated q 2-
150 Bleeding slowed to minimal 4 hours x 5 (only given 1x at this
HR 140 point)
140 Oxytocin 30 units in 500 mL • Hemabate may be repeated q 15-
130
90 mins x 8 (only given x1 at this
point)
120 • OB Hemorrhage blood products
should be ordered
110
BP 95/60
100

90

1840
80
Hct 32.5
Platelets 129
70
Fibrinogen 205

60
Cefazolin 2 gm IV

1500 1600 1700 1800 1900 2000 2100 2200

27 1500+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 3
HR 150
150 1945
200 mL noted in Bakri Balloon
1955
140 Fundus 3-5 cm above umbilicus
OB at bedside
Abdomen tender
U/S done – shows large clot
130

120

110 2000
Stage 3: Hct 26.9
100 Greater than 1500 mL blood loss Platelets 131
• Methergine may be repeated q 2-4 hours x 5 Fibrinogen 151
90
(only given 1x at this point)
• Hemabate may be repeated q 15-90 mins x 8 BP 89/45
80
(only given x1 at this point)
70 • OB Panel to be repeated q 30 mins (this was 2015
done 1 hour ago at this point) Hct 21 per I-Stat
60
• No blood has yet been transfused at this time
(Type & Cross for 4 units ordered at 1730)
1500 1600 1700 1800 1900 2000 2100 2200

28 1700+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 3
2015 1 unit PRBCs
150

2030 HR 140
140 Pt transferred to interventional radiology
“moderate amount of bleeding continues”
130
2045
Midazolam and
120
Stage 3: Fentanyl for sedation
• 1st unit of PRBCs given 3
110 hours after it was ordered
• Still only 1 dose of
100
Hemabate and Methergine 2055
90
given at this time Hemorrhage pack ordered
• OB Hem blood products 2100 1 unit
80 ordered 5 hours after start PRBCs BP 80/39
of Stage 3 2130 1 unit
70 PRBCs

60
2140 Bilateral uterine artery embolization.
Hemostatsis achieved. 500 ml blood loss into Bakri Balloon

1500 1600 1700 1800 1900 2000 2100 2200

29 2200+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
 Case Study: Stage 3
2200
150 Stage 3: Transferred to recovery
• Still no other uterotonics
140
administered HR 125
• No labs since 2015 2200
130 4-pack FFP
•OB Hem Panel to be done q
120 30 mins in PPH
2225
4-pack FFP
110

100 BP 92/64

90

2245
80 4-pack FFP
2250
70
Cryoprecipitate
60 2300
Cryoprecipitate, and 1 unit PRBCs

1500 1600 1700 1800 1900 2000 2100 2200

30 2200+ mL Providence Clinical Academy: Obstetrics 2016.07

Cumulative Blood Loss
What are the possible physiologic reasons for Sarah’s current
condition? (choose all that apply)
Knowledge Check
After C/S delivery Sarah is
a) Nausea due to ice chips transferred to the OB/PACU.
The 2nd PP check reveals: BP
b) Tachycardia related to pain, repositioning, and movement 99/50
Pulse 126
during transfer from OB/PACU to postpartum RR 20
Temp 98.2° F (oral)
The abdominal dressing is C, D, &
c) Possible internal bleeding I
FF @ 2 cm below
Abdomen palpates slightly
distended
Patient complains of slight nausea.

31 Providence Clinical Academy: Obstetrics 2016.07

Nursing interventions should include all of the following EXCEPT?

a) Request a bedside assessment by the charge nurse Knowledge Check

At the next assessment:
b) Request a bedside assessment by the physician
Sarah’s fundus is difficult to
palpate.
c) Request an order to type and crossmatch the patient
Abd dressing C, D, & I
d) Administer additional antiemetics
Lochia is scant.
BP 88/50 mmHg
e) Bolus with IV fluids
Pulse is 130 bpm.

f) Prepare to start second IV line for access After administration of an

antiemetic, Sarah starts vomiting
and her skin is clammy to touch.
She says she feels weak and cold.

32 Providence Clinical Academy: Obstetrics 2016.07

What should be the next management plan? (choose all that apply)

a) Notify anesthesia and immediately transfer to OR Knowledge Check

Sarah's physician is at the
b) Continue to monitor, blood pressure, and pulse oximetry bedside.
monitors
BP 85/30 mmHg
c) Run IV of LR wide open to increase her fluid volume P 140 bpm

d) Administer 2 units of blood emergently without There is no new urine output

verification Lochia is scant.

e) Order OB Hemorrhage labs ABD dressing is C,D, & I.

The abdomen is distended and
f) Apply oxygen via non-rebreather face mask the uterus cannot be palpated.
Sarah now rates her pain at 7.

33 Providence Clinical Academy: Obstetrics 2016.07

What transfusion orders should be given at this time? (choose all that
apply)
Knowledge Check
a) Transfuse 4 units of PRBC now and anticipate an order When the surgery starts, the
for 2 additional units obstetrician finds Sarah’s
abdomen full of blood.
b) Transfuse 1 unit of PRBC pending lab results The LIP found the left uterine
artery is lacerated. The bleeding is
controlled with additional
c) Thaw fresh frozen plasma and give as soon as available suturing.
After suctioning, the canister
contains 1500 mL of blood.
d) Give 1 unit of pooled platelets Capillary oozing is visible. The lab
results will be available in 5
minutes.
e) Give recombinant factor VIIa BP 80/42 mmHg
Pulse is 140 bpm.

34 Providence Clinical Academy: Obstetrics 2016.07

Further management of this patient should include? (choose all that
apply)
Knowledge Check
a) Anticipate that more blood and blood products will be Sarah’s active bleeding has
subsided and there is only slight
ordered and administered capillary oozing after the
laparotomy.
Initial PACU lab values include:
b) Apply warming unit to the patient (warming blankets Hct 20%
such as Bear Hugger®) Fibrinogen 60 mg/dL
Platelets 55,000/µL

c) Strict input and output records Core temp 96.2°F

BP 104/58 mmHg
Pulse 112 bpm.
d) Follow PACU protocol

35 Providence Clinical Academy: Obstetrics 2016.07