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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016

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CLINICAL GUIDELINE FOR THE MANAGEMENT OF A MAJOR OBSTETRICHAEMORRHAGE AND ESCALATION TO MASSIVE OBSTETRIC HAEMORRHAGE

AND PROFORMA

1. Aim/Purpose of this Guideline1.1. This guidance applies to obstetricians, obstetric anesthetists, midwives,nurses and maternity support workers and gives guidance on the recognition andmanagement of a major/massive obstetric haemorrhage.

2. The Guidance2.1. Definition: Major Obstetric haemorrhage is defined as blood loss>2000ml orrate of blood loss of 150mls/min, or 50% blood volume loss within 3hrs. It canalso result in a decrease in Hb>4g/dl, or acute transfusion requirement>4 units. A

majorobstetric haemorrhage that triggers the massive obstetric haemorrhageprotocol is defined as blood loss that is uncontrolled and ongoing with a rate of bloodloss of 150mls/minute.

2.2. Communication and Resuscitation must be simultaneous.Trigger Phrase: The lead anaesthetist /Obstetrician leading on management ofthe major obstetric haemorrhage must communicate to all members of the clinicalteam involved in the care of the women that the situation has now become aMassive obstetric haemorrhage(MOH).The time that this took place must benoted and documented on the proforma. Any subsequent communication between theclinical team, other clinical areas, portering personal and laboratory personal,

must include the trigger phrase of Massive obstetric haemorrhage.2.3. Communicate:

Call the senior midwife, resident anaesthetist, Obstetric registrar and SHO

Involve senior medical staff early (Consultant anaesthetist and Obstetrician)

Midwifery coordinator to nominate one person to communicate with lab staffand support services

Nominated person to call the paediatrician if the baby is alive and undelivered

Nominated person to call the blood bank (Tel: 2500) and alert lab staff thatthere is a major obstetric haemorrhage.

Allocate a maternity support worker or porter to be on stand by for urgent

blood samples/collection of blood.Commence a modified obstetric early warning system (MOEWS) chartincluding fluid balance monitoring, if the woman is already in theatre themonitoring will be done by the anaesthetist using the appropriate anaestheticchart and the MEOWS chart will not be started until the woman is in recovery.

2.4. Resuscitate:

Airway, Breathing, Circulation, Drugs/Disability, and Emergency Surgery.

Oxygen 100% via face mask

Full left lateral tilt for APH- Head down, legs up.

2 large bore IV cannuale. Take blood at the same time for cross match (4units), FBC and Coagulation screen. Label cross-match tube at patients sidefrom wrist band.


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2.7. References:1. BJA-CEACCP: Massive haemorrhage in pregnancy volume 5 number 6 20052. The Scottish obstetric guidelines and audit project; The Management of PPH

(Updated March2002)3. Frca.co.uk (Emergency treatment of obstetric haemorrhage) Blood transfusion

and the anaesthetist: management of massive haemorrhage. AAGBI Oct 2010

3. Monitoring compliance and effectiveness

Element to bemonitored

The audit will take into account record keeping by obstetric,anaesthetic and paediatric doctors, midwives, nurse, studentsand maternity support workers.

The results will be inputted onto an excel spreadsheetThe audit will be registered with the Trusts audit department

Lead Labour ward and risk management lead consultant Obstetrician

Tool 1. Diagnosis

Was a PPH proforma completed

Was there an opinion given for the cause of bleeding2. Communication

Was it documented that the trigger phrase Massive obstetric

haemorrhage was usedWas it documented that the delivery suite coordinator attended

Was it documented that the resident anaesthetist attended

Was it documented that the attended Obstetric registrarattended

Was it documented that the consultant Obstetrician attended

Was it documented that a senior anaesthetist attended

Was it documented that blood bank were informed

Was it documented that a MSW/porter were available

for urgent samples

3. TreatmentWas initial management as per the MOH proforma

Were appropriate uterotonics used

Was appropriate fluid/blood replacement documented

Was timely surgical intervention implemented4. Record keeping

Was a MOEWS or anaesthetic chart commenced at therecognition of the major/massive obstetric haemorrhage?

Was the MOEWS chart appropriately scored

Frequency All health records of women who have had a majorobstetric haemorrhage, will be audited continuously overa 12 month period

Patient Label


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All health records of women who have triggeredthemassive obstetric haemorrhage protocol, will be auditedcontinuously over a 12 month period

Reportingarrangements

A formal report of the results will be received annually at thematernity risk management and clinical audit forum, as per theaudit plan

During the process of the audit if compliance is below 75% orother deficiencies identified, this will be highlighted at the nextmaternity risk management and clinical audit forum and anaction plan agreed.

Acting onrecommendationsand Lead(s)

Any deficiencies identified on the annual report will bediscussed at the maternity risk management and clinical auditforum and an action plan developed

Action leads will be identified and a time frame for the action tobe completed by

The action plan will be monitored by the maternity risk

management and clinical audit forum until all actions completeChange inpractice andlessons to beshared

Required changes to practice will be identified and actionedwithin a time frame agreed on the action plan

A lead member of the forum will be identified to take eachchange forward where appropriate.

The results of the audits will be distributed to all staff through therisk management newsletter/audit forum as per the action plan

4. Equality and Diversitya. This document complies with the Royal Cornwall Hospitals NHS Trust

service Equality and Diversity statement.

b. Equali ty Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.


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Appendix 1

Royal Cornwall Hospital NHS TrustDirectorate of Obstetrics & Gynaecology

Major/massive obstetric Haemorrhage Summary Proforma

Date and time of MOH

Location of delivery RCHT / Penrice / Helston / Home/ St Marys

Mode of delivery NVD / Kiwi Ventouse / Forceps / LSCS / VaginalBreech

Date and Time of delivery

Total blood loss

Time transfer to RCHT (ifcommunity site)

Primary source of bleeding - Uterine atony / retained placenta / genital tracttrauma / Other (pleasestate.

Secondary source ofbleeding -

Uterine atony / retained placenta / genital tracttrauma / Other (pleasestate.

Communication Name Time called /Time arrived

Delivery suite coordinator : /

Obstetric Registrar : /

Obstetric SHO : /

Resident Anaesthetist: /

Consultant Obstetrician: /

Senior Anaesthetist: /

ODP: /

Blood bank informed: /

MSW/Porter on standby forurgent samples/blood collection: /

Massive obstetric haemorrhagetrigger phrase. Yes/NA Time:

Obstetric haemostatic packRequested by Yes/NA Time

Interventional radiologist:

Yes/NA TimeOther personnel please specify:

Time commenced


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Management

Facial oxygen

MEOWS chart/observations

Intravenous access 2 large bore cannulae

FBC , clotting, G&S or cross match & sent

Fundal massageUrethral catheter

Drugs

Bimanual compression

In to theatre (management to continue on greenop sheet)

Use MEOWS chart for observations and, fluid input and output

Summary of fluid replacement

Product Total Volume Given

Normal Saline

Hartmanns

Gelofusine

Blood cross-matched

Blood O Rh - ve

Other i.e. Fresh Frozen Plasma(FFP)/Cryo/ Platelets

Summary Uterotonics used

Product Dose and Route ofadministration

Number of times given

SyntrometrineSyntocinon/ergometrinebolus

Syntocinon infusion

Haemabate

Misoprostal

Serial Haemoglobin (Hb) & Clotting Results

Date / Time

Signature

Hb

WBCPlatelets

Hct

INR

APPT

Fibrinogen

Name..

Signature Date.


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Appendix 2. Governance Information

Document TitleClinical guideline for the management of amassive obstetric haemorrhage

Date Issued/Approved: 31 July 2013

Date Valid From: 31 July 2013

Date for Review: 1 August 2016

Directorate / Department responsible(author/owner):

Dr Catherine RalphConsultant obstetric anaesthetist

Contact details: 01872 253132

Brief summary of contents

This guidance applies to obstetricians,obstetric anesthetists, midwives, nursesand maternity support workers and givesguidance on the management of amassive obstetric haemorrhage

Suggested Keywords:Massive obstetric haemorrhage, postpartum haemorrhage, ante partumhaemorrhage, maternal collapse

Target AudienceRCHT PCT CFT

Executive Director responsible for

Policy: Medical Director

Date revised: September 2012

This document replaces (exact title ofprevious version):

Guideline for the management of a massiveobstetric haemorrhage

Approval route (names ofcommittees)/consultation:

Maternity guidelines groupObs and gynae directorate meeting

Divisional Manager confirmingapproval processes

Name and Post Title of additionalsignatories

Signature of Executive Director givingapproval

{Original Copy Signed}

Publication Location (refer to Policyon Policies Approvals andRatification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Midwifery and obstetric, anaesthetics

Links to key external standards CNST 3.7

Related Documents:


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Training Need Identified? Included in annual TOME day

Version Control Table

DateVersi

on

Summary of ChangesChanges Made by

(Name and Job Title)

April 2008 V1.0 Initial IssueDr Catherine RalphConsultant obstetricanaesthetist

January2011

V1.1Inclusion of massive obstetric haemorrhagetrigger phrase

Dr Catherine RalphConsultant obstetricanaesthetist

April 2012 V1.2 Compliance monitoring tool addedDr Catherine RalphConsultant obstetricanaesthetist

September2012

V1.3 Changes to compliance monitoring only Jan ClarksonMaternity riskmana er

June 2013 V1.4

If a blood transfusion is required and a delay isanticipated in receiving group specific blood, use0 Rhesus negative blood.

Jan ClarksonMaternity riskmanager

All or part of this document can be released under the Freedom of InformationAct 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS Trust

Policy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.


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Appendix 3.Initial Equality Impact Assessment Screening Form

*Please see Glossary

7. The ImpactPlease complete the following table using ticks. You should refer to the EA guidance notesfor areas of possible impact and also the Glossary if needed.

Where you think that thepolicycould have a positive impact on any of the equalitygroup(s) like promoting equality and equal opportunities or improving relations

within equality groups, tick the Positive impact box.Where you think that thepolicycould have a negative impact on any of the equalitygroup(s) i.e. it could disadvantage them, tick the Negative impact box.

Name of service, strategy, policy or project (hereafter referred to aspolicy) to beassessed:Clinical guideline for the management of a massive obstetric haemorrhage

Directorate and service area:Obs and gynae, maternity services

Is this a new or existing Procedure?

Name of individual completingassessment: Jan Clarkson

Telephone:01872 252270

1. Policy Aim* To give to guidance obstetricians, obstetric anesthetists,midwives, nurses and maternity support workers on themanagement of a massive obstetric haemorrhage

2. Policy Objectives* To ensure there is timely recognition and management of amassive obstetric haemorrhage

3. Policy intendedOutcomes* Safe outcome for pregnant or newly delivered women

5. How will youmeasure theoutcome?

Compliance monitoring tool

5. Who is intended tobenefit from the Policy?

Pregnant and newly delivered woman

6a. Is consultation

required with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?

b. If yes, have thesegroups been consulted?

c. Please list any groupswho have been consulted

about this procedure.


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Where you think that thepolicyhas no impact on any of the equality group(s) listedbelow i.e. it has no effect currently on equality groups, tick the No impact box.

EqualityGroup

PositiveImpact

NegativeImpact

NoImpact

Reasons for decision

Age yes All pregnant women

Disability yes All pregnant women

Religion orbelief

yes All pregnant women

Gender yes All pregnant women

Transgender yes All pregnant women

Pregnancy/

Maternity


Race yes All pregnant women

SexualOrientation


Marriage / CivilPartnership


You will need to continue to a full Equality Impact Assessment if the following have

been highlighted:A negative impact and

No consultation (this excludes any pol ic ieswhich have been identified as notrequiring consultation).

8. If there is no evidence that thepolicypromotes equality, equal opportunities

or improved relations - could it beadapted so that it does? How?

Full statement of commitment to policy ofequal opportunities is included in the policy

Please sign and date this form.

Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean

House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ

A summary of the results will be published on the Trusts web site.

Signed Jan Clarkson

Date 16th June 2013