Purpose of the tool: This tool describes the key perinatal safety elements related to the management obstetric hemorrhage. The key elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) unit staff responsible for managing obstetric hemorrhage.
How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to determine how elements will be implemented on your L&D unit. Consider any existing facility policies or processes related to obstetric hemorrhage. Consider using standing orders, preprinted checklists or algorithms, and staff simulation training to support implementation. A variety of links to resources from professional organizations and other safety initiatives are indicated throughout this document.
Key Perinatal Safety Elements
|Standardize When Possible (CUSP Science of Safety)|
|Key Perinatal Safety Elements||Examples|
|Use routine and standardized hemorrhage risk assessment on admission.||
|Use standardized obstetric hemorrhage kits and carts.||
|Use standardized approach for the active management of third stage of labor for vaginal births to prevent hemorrhage.||
Consider using CUSP strategies to gain consensus on a standard approach that yields the most standardization while still allowing flexibility for patient preferences and/or where evidence is insufficient and variability in approach in unlikely to increase risk of errors. Options and examples for a standardized approach include the following:
|Create Independent Checks (CUSP Element)|
|Use cognitive aids such as checklists, flow sheets, and algorithms based on best practice guidelines to guide clinical response to obstetric hemorrhage.||
|Quantify blood loss during and after all deliveries.||
|Learn From Defects (CUSP Element)|
|Debrief and analyze obstetric hemorrhage events.||
|Have a process in place to review severe maternal hemorrhage or hemorrhage-related mortality events.||
|Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning.||Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally.|
|Simulation (SPPC Program Pillar)|
|Teamwork Training (TeamSTEPPS®)|
|Have situational awareness.||Because only 5 to 10 percent of obstetric hemorrhages occur in patients with risks for hemorrhages,1 care teams should maintain situational awareness for all patients.
Situational awareness refers to all staff caring for the patient—
|Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques.||Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of hemorrhage are particularly useful—
|Communicate during transitions of care.||
|Have high-reliability teams:
||Team members protect each other from work overload and place requests or offers for assistance in the context of patient safety. It is expected that assistance will be actively sought and offered.
|Patient and Family Engagement (CUSP Module)|
|Communicate with patient and family during a hemorrhage episode.||
|Disclose any unintended outcomes.||Use unit-established process for disclosing unintended outcomes. This may include the following:
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- Lyndon A, Lagrew D, Shields L, et al., eds. Improving Health Care Response to Obstetric Hemorrhage (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care). Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division. Stanford, CA: California Maternal Quality Care Collaborative; 2010.
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- ACOG Patient Safety and Quality Improvement Committee. ACOG Committee Opinion No. 526: Standardization of practice to improve outcomes. Obstet Gynecol 2012 May;119(5):1081-2. PMID: 22525933.
- Rizvi F, Mackey R, Barrett T, et al. Successful reduction of massive postpartum haemorrhage by use of guidelines and staff education. BJOG 2004 May;111(5):495-8. PMID: 15104617.
- American Congress of Obstetricians and Gynecologists. Patient Safety Checklist No. 10: postpartum hemorrhage from vaginal delivery. Obstet Gynecol 2013;121(5):1151-2.
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- Association of Women’s Health, Obstetric and Neonatal Nurses. Practice Brief: Clinical Management Guidelines for Women's Health and Perinatal Nurses: Quantification of Blood Loss. 2014 May. http://www.pphproject.org/downloads/awhonn_qbl.pdf. Accessed May 2, 2016.
- California Maternal Quality Care Collaborative. OB Hemorrhage Toolkit V 2.0. Improving Health Care Response to Obstetric Hemorrhage, Version 2.0: A California Toolkit to Transform Maternity Care. Released March 2015. http://www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit. Accessed May 3, 2016.
- Wisconsin Association for Perinatal Care. Postpartum Hemorrhage: Resources. 2014. http://www.perinatalweb.org/major-initiatives/postpartum-hemorrhage/resources. Accessed May 2, 2016.
- American Congress of Obstetrics and Gynecology. ACOG Simulations Consortium Learning Objectives: Postpartum Hemorrhage Caused by Uterine Atony. n.d. http://www.acog.org/~/media/Departments/Simulations%20Consortium/Learning%20Objectives/Postpartum_Hemorrhage.pdf. Accessed May 2, 2016.