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

1. Aim/Purpose of this Guideline

1.1. This guidance applies to obstetricians, obstetric anesthetists, midwives, nurses and maternity support workers and gives guidance on the recognition and management of a major/massive obstetric haemorrhage.

2. The Guidance
2.1. Definition: Major Obstetric haemorrhage is defined as blood loss>2000ml or rate of blood loss of 150mls/min, or 50% blood volume loss within 3hrs. It can also result in a decrease in Hb>4g/dl, or acute transfusion requirement>4 units. A major obstetric haemorrhage that triggers the massive obstetric haemorrhage protocol is defined as blood loss that is uncontrolled and ongoing with a rate of blood loss of 150mls/minute. 2.2. Communication and Resuscitation must be simultaneous. Trigger Phrase: The lead anaesthetist /Obstetrician leading on management of the major obstetric haemorrhage must communicate to all members of the clinical team involved in the care of the women that the situation has now become a Massive obstetric haemorrhage (MOH). The time that this took place must be noted and documented on the proforma. Any subsequent communication between the clinical 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 staff and 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 that there 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) chart including fluid balance monitoring, if the woman is already in theatre the monitoring will be done by the anaesthetist using the appropriate anaesthetic chart 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 (4 units), FBC and Coagulation screen. Label cross-match tube at patients side from wrist band.
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Start medical management (see below: Drugs to consider). Transfer to theatre early for further resuscitation and possible surgery. Request ODA to set up cell saver. Warm all resuscitation fluids and aim to correct hypovolaemia initially with crystalloids. If a blood transfusion is required and a delay is anticipated in receiving group specific blood, use 0 Rhesus negative blood. Do not use blood filters during resuscitation. They slow infusion Dextrans are hazardous and should not be used in obstetric practice. Restore normovolaemia, Monitor Hb and haematocrit. If bleeding continues: (Request Obstetric haemostatic pack from lab) Contains 6 units of blood, 4 units FFP and one unit platelets. Use coagulation studies and fibrinogen levels to guide the use of further blood products. Re-transfusion of blood from the cell saver should be infused through a leucodepletion filter (see obstetric cell salvage guideline) Monitor heart rate, blood pressure, Blood gases, Urine output ( Foley catheter if not already in situ) Consider Invasive Monitoring to guide therapy (A-line, CVP line). If blood loss continues, prepare either for hysterectomy or if stable, contact interventional radiologist for uterine artery embolisation. (see guideline Massive obstetric haemorrhage the role of interventional radiology) Standard venousthromboprophylaxis should be commenced as soon as possible after haemostasis is secured due to prothrombotic state developing after massive haemorrhage 2.5. Drugs to consider: Oxytocin (PPH, give slow IV bolus and infusion) Ergometrine (PPH, given IM or IV, NOT if raised BP) Carboprost (PPH, deep IM, NOT in asthmatic) Misoprostol PR or PV,(avoid intrauterine if using cell salvage) 2.6. Surgical manoeuvres Bakri balloon B Lynch suture Ligation of internal iliac arteries Consider role of interventional radiology- Occlusion balloon+ Uterine artery embolisation. See separate guideline Hysterectomy

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Patient Label

2.7. References: 1. BJA-CEACCP: Massive haemorrhage in pregnancy volume 5 number 6 2005 2. 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

The audit will take into account record keeping by obstetric, anaesthetic and paediatric doctors, midwives, nurse, students and maternity support workers. The results will be inputted onto an excel spreadsheet The audit will be registered with the Trusts audit department Labour ward and risk management lead consultant Obstetrician

Element to be monitored

Lead

Tool

1. Diagnosis Was a PPH proforma completed Was there an opinion given for the cause of bleeding 2. Communication Was it documented that the trigger phrase Massive obstetric haemorrhage was used Was it documented that the delivery suite coordinator attended Was it documented that the resident anaesthetist attended Was it documented that the attended Obstetric registrar attended 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. Treatment Was initial management as per the MOH proforma Were appropriate uterotonics used Was appropriate fluid/blood replacement documented Was timely surgical intervention implemented 4. Record keeping Was a MOEWS or anaesthetic chart commenced at the recognition of the major/massive obstetric haemorrhage? Was the MOEWS chart appropriately scored All health records of women who have had a major obstetric haemorrhage, will be audited continuously over a 12 month period Page 3 of 10

Frequency

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

All health records of women who have triggered the massive obstetric haemorrhage protocol, will be audited continuously over a 12 month period Reporting A formal report of the results will be received annually at the arrangements maternity risk management and clinical audit forum, as per the audit plan During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity risk management and clinical audit forum and an action plan agreed. Acting on Any deficiencies identified on the annual report will be recommendations discussed at the maternity risk management and clinical audit and Lead(s) forum and an action plan developed Action leads will be identified and a time frame for the action to be completed by The action plan will be monitored by the maternity risk management and clinical audit forum until all actions complete Change in Required changes to practice will be identified and actioned practice and within a time frame agreed on the action plan lessons to be A lead member of the forum will be identified to take each shared change forward where appropriate . The results of the audits will be distributed to all staff through the risk management newsletter/audit forum as per the action plan

4. Equality and Diversity

a. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement.

b. Equality Impact Assessment

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

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Appendix 1

Royal Cornwall Hospital NHS Trust Directorate of Obstetrics & Gynaecology Major/massive obstetric Haemorrhage Summary Proforma Date and time of MOH Location of delivery Mode of delivery RCHT / Penrice / Helston / Home/ St Marys NVD / Kiwi Ventouse / Forceps / LSCS / Vaginal Breech

Date and Time of delivery Total blood loss Time transfer to RCHT (if community site) Primary source of bleeding - Uterine atony / retained placenta / genital tract trauma / Other (please state. Secondary source of Uterine atony / retained placenta / genital tract bleeding trauma / Other (please state. 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 for urgent samples/blood collection: Massive obstetric haemorrhage trigger phrase. Obstetric haemostatic pack Requested by Interventional radiologist: Other personnel please specify: Time commenced
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/ / / / / / /

/ Yes/NA Yes/NA Yes/NA Time: Time Time

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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 massage Urethral catheter Drugs Bimanual compression In to theatre (management to continue on green op sheet) Use MEOWS chart for observations and, fluid input and output Summary of fluid replacement Total Volume Given

Product

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 of Number of times given administration Syntrometrine Syntocinon/ergometrine bolus Syntocinon infusion Haemabate Misoprostal Serial Haemoglobin (Hb) & Clotting Results Date / Time Signature Hb WBC Platelets Hct INR APPT Fibrinogen Name.. Signature Date.

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Appendix 2. Governance Information

Document Title Date Issued/Approved: Date Valid From: Date for Review: Directorate / Department responsible (author/owner): Contact details: Clinical guideline for the management of a massive obstetric haemorrhage 31 July 2013 31 July 2013 1 August 2016 Dr Catherine Ralph Consultant obstetric anaesthetist 01872 253132 This guidance applies to obstetricians, obstetric anesthetists, midwives, nurses and maternity support workers and gives guidance on the management of a massive obstetric haemorrhage Massive obstetric haemorrhage, post partum haemorrhage, ante partum haemorrhage, maternal collapse RCHT PCT CFT Medical Director September 2012 Guideline for the management of a massive obstetric haemorrhage Maternity guidelines group Obs and gynae directorate meeting

Brief summary of contents

Suggested Keywords: Target Audience Executive Director responsible for Policy: Date revised: This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards Related Documents:

{Original Copy Signed} Internet & Intranet Intranet Only

Midwifery and obstetric, anaesthetics CNST 3.7

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Training Need Identified? Version Control Table Date April 2008 January 2011 April 2012 September 2012 June 2013

Included in annual TOME day

Versi Summary of Changes on No V1.0 Initial Issue Inclusion of massive obstetric haemorrhage trigger phrase

Changes Made by (Name and Job Title) Dr Catherine Ralph Consultant obstetric anaesthetist

Dr Catherine Ralph Consultant obstetric anaesthetist Dr Catherine Ralph V1.2 Compliance monitoring tool added Consultant obstetric anaesthetist Jan Clarkson V1.3 Changes to compliance monitoring only Maternity risk manager If a blood transfusion is required and a delay is Jan Clarkson V1.4 anticipated in receiving group specific blood, use Maternity risk 0 Rhesus negative blood. manager V1.1

All or part of this document can be released under the Freedom of Information Act 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 Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

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Appendix 3.Initial Equality Impact Assessment Screening Form

Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical guideline for the management of a massive obstetric haemorrhage Directorate and service area: Is this a new or existing Procedure? Obs and gynae, maternity services Name of individual completing Telephone: assessment: Jan Clarkson 01872 252270 1. Policy Aim* To give to guidance obstetricians, obstetric anesthetists, midwives, nurses and maternity support workers on the management of a massive obstetric haemorrhage 2. Policy Objectives* To ensure there is timely recognition and management of a massive obstetric haemorrhage 3. Policy intended Outcomes* 5. How will you measure the outcome? 5. Who is intended to benefit from the Policy? 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure. Safe outcome for pregnant or newly delivered women

Compliance monitoring tool

Pregnant and newly delivered woman

*Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the Positive impact box. Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the Negative impact box.
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Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the No impact box. Equality Group Age Disability Religion or belief Gender Transgender Pregnancy/ Maternity Race Sexual Orientation Marriage / Civil Partnership Positive Impact yes yes yes Negative Impact No Impact Reasons for decision All pregnant women All pregnant women All pregnant women

yes yes yes yes yes

All pregnant women All pregnant women All pregnant women All pregnant women All pregnant women

yes

All pregnant women

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 policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal 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

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