OB Hemorrhage Initiative
2009-2010
In collaboration with
California Maternal Quality
Care Collaborative
Education
• Multiple educational sessions with nursing
and ancillary support staff
• Didactic component
• Hands on
– QBL pretest and posttest
– Management of Bakri balloon
• Similar presentation to MDs
– Sponsored by Perinatologist
Staff Education
Nursing staff attended a 45
minute in-service on CMQCC
hemorrhage to include the
introduction of Quantitative
Blood Loss. Several stations of
simulated blood loss were
included for nurse evaluation
with pre and post test. Also,
introduction to the use and
care of the patient with a Bakri
Balloon was provided.
In-situ Hemorrhage Drills
Multidisciplinary drills were instituted in a new
format utilizing adult learning principles –
Pre-brief
In-situ scenario
Debriefing
Survey Monkey to MDs
A survey link was emailed to each physician with
obstetric care privileges regarding visual estimation
of blood loss. Results were varied – supported other
research which states underestimation with larger
amounts; as well as overestimation with smaller
amounts.
Staff and MD education
Evening education and dinner
provided to medical
caregivers with didactic and
hands on instruction related
to CMQCC OB Hemorrhage
initiative as well as
Quantitative Blood Loss inservice. Results of “Survey
Monkey” were discussed.
Collaborative effort between
Perinatal medicine and
nursing.
Quantification of Blood Loss
• Ongoing assessment through
recovery period
• Better assessment methods
– Visual cues (posters)
– Multidisciplinary blood loss
education
Postpartum blood loss is categorized with each patient and
this information is a component of the nurse handover
report through all transfers of care.
25 ml peripad
50 ml peripad
100 ml peripad
A saturated 4x4 12-ply sponge =
5 ml
Other methods of
quantification:
•Weight
•Direct
Measurement
100 ml chux
250 ml chux
350 ml chux
25 ml
50 ml
500 ml chux
75 ml
100 ml
Visual Cue Chart – present in
each delivery room in a discrete
location
18x18 laps: 25 ml approx 50%; 50 ml approx 75%;
75 ml entire surface; 100 ml saturated and dripping
Three Methods of
Quanitification
Visual Estimation –
with visual cues
Weight - Scale
Direct Measurement
Hemorrhage Debriefing
Debriefing tool is used to
report hemorrhage and
comment on events. Issues
such as communication,
equipment availability, ease
of access to meds etc are
addressed. Process
improvement is a key
component of findings from
the debriefing tool.
Documentation
The OB Hemorrhage
report form is used as a
recording tool during a
hemorrhage situation
that serves to record
events, meds, and
procedures. It is similar
to a “code sheet” –
when signed by the
physician it serves as an
order sheet for events
and interventions.
Documentation
Introduced “QBL” into postpartum recovery documentation. A
quantitative amount is entered at each pad or chux change to
decrease the incidence of denial or delay.
Risk Assessment
High
Medium
Low
Risk
Assessment
on
Admission
Results of risk assessment
will affect patient care
planning
Women are assessed and assigned a Hemorrhage risk status on
admission and is an ongoing assessment during labor. The level of risk
identified correlates with level of lab tests needed.
OB Hemorrhage Cart
We created a central location for identified equipment and
supplies needed for the management of an OB
hemorrhage. We have used drills and real events to
improve content and function of this cart.
OB Hemorrhage Kit
Oxytocin – Methergine – Hemabate - Misoprostol
Medications commonly needed for
treatment of OB hemorrhage are
contained in a “Hemorrhage Kit” in the
Pyxis. This has been an improvement
process in itself. Through drills and real
events, this has evolved and is still
evolving to provide convenient and
timely distribution of these medications.