In October 2017, the American College of Obstetricians and Gynecologists (ACOG) updated their recommendations on evaluation, prevention, and management of postpartum hemorrhage (PPH). Risk factors are discussed in detail and include the most common, uterine atony, along with retained placenta, lacerations of the birth canal, uterine rupture, placenta accreta, various types of coagulopathies, uterine inversion, and infection. Use of a risk assessment tool for PPH such as one discussed in the toolkit for PPH published by the California Maternal Quality Care Collaborative (Lyndon, Lagrew, Shields, Main, & Cape, 2015) is recommended. Women can be identified on admission as low, medium, or high risk based on clinical factors. These factors can change over the course of labor and birth. Prevention is focused on active management of the third stage of labor including intravenous or intramuscular oxytocin, uterine massage, and umbilical cord traction (ACOG).
A number of management strategies are discussed including various medications to treat uterine atony, transfusion of blood products, tamponade techniques, uterine artery embolization, and surgical management (ACOG, 2017). A major recommendation is use of a standard, step-by-step assessment and response protocol in all perinatal units. All care providers should know what to expect and how to respond when PPH occurs and as the clinical situation evolves. The PPH response system from the Council on Patient Safety in Women's Healthcare (2015) that includes content based on the concepts of readiness, recognition and prevention, multidisciplinary response, and reporting and system learning is recommended, as are hemorrhage drills and team-based learning. Additional resources for PPH are offered by ACOG at https://www.acog.org/Womens-Health/Postpartum-Hemorrhage#Providers. Nurses and other members of the obstetric clinical team should be aware of the updated recommendations. If perinatal nurses are working on a unit that does not have a PPH protocol or obstetric hemorrhage drills, review and sharing of the ACOG practice bulletin with other members of the multidisciplinary team may help to encourage adoption to promote patient safety.
Key Recommendations for Postpartum Hemorrhage (ACOG, 2017)
* Standard PPH response system (e.g., recommended by the Council on Patient Safety in Women's Healthcare [2015] that includes a functioning massive transfusion protocol with fixed ratios of packed red blood cells, fresh frozen plasma, and platelets)
* Multidisciplinary response team
* Uterotonics as first-line treatment for PPH
* Timely escalation of treatment plan if uterotonics are not successful, including tamponade techniques or surgical management
* Consideration for use of tranexamic acid if first-line treatments are unsuccessful
* Plans for maintaining hemodynamic stability
* Plans for identifying the PPH cause
* PPH drills
References