Providence Clinical Academy Obstetrics Curriculum Knowledge Check JoAnn a 25yearold G1P0 is induced with prolonged oxytocin at term for mild preeclampsia Her admission hematocrit is 39 and her platelet count is 190000µL Systolic blood pressure ranged from 154 to 142 mmHg and diastolic ID: 551642
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Slide1
Postpartum Hemorrhage Case Study
Providence Clinical Academy: Obstetrics CurriculumSlide2
Knowledge Check
JoAnn, a 25-year-old G1P0, is induced with prolonged oxytocin at term for mild preeclampsia. Her admission hematocrit is 39% and her platelet count is 190,000/µL. Systolic blood pressure ranged from 154 to 142 mmHg and diastolic blood pressure from 98 to 88 mmHg prior to admission and during labor.
What risk factors for PPH do you see in this case? Choose all that apply.
Low platelets
Prolonged second stage of labor Use of prolonged oxytocin during the induction Epidural anesthesia History of preeclampsiaOperative vaginal delivery
2016.07
The labor epidural is placed at 5 cm of dilation. The physician uses low forceps for a prolonged (5
hr) second stage and delivers a 9 lb baby. After an uneventful delivery of the placenta, heavy vaginal bleeding ensues. Inspection of the placenta reveals no missing cotyledons and inspection of the lower genital tract reveals no lacerations or source of bleeding. Palpation of the uterus reveals severe atony.
Providence Clinical Academy: Obstetrics
2Slide3
Knowledge Check
Bimanual massage is initiated by the physician and IV oxytocin is infusing at a rapid rate. There is no immediate improvement in uterine tone.
Current vital signs are
: BP 130/75 mmHgP 96 bpm.
What medication should be ordered by physician at this point?Oxytocin IV push Methergine 2 mg IM Hemabate (carboprost) 0.25 mg IVCytotec (misoprostol) 800
2016.07Providence Clinical Academy: Obstetrics
3Slide4
Knowledge Check
Cytotec
is administered and uterus remains atonic. The EBL is 800 mL during the delivery and another 700
mL. Hemabate is ordered and administered. Current vital signs:
BP 119/69 mmHgP 108 bpmWhich of the following interventions would not be appropriate for JoAnn at this time? Choose all that apply.Vital signs and uterine assessment to q 5 minutesWeighing pads to accurately assess blood lossBimanual fundal massage STAT laboratory testing such as CBC, PT, PTT, fibrinogen
Order OB Hemorrhage PackContinue to monitor patient status in the room
2016.07
Providence Clinical Academy: Obstetrics4Slide5
Intervention & Management: Algorithm
STAGE 1
Cumulative Blood Loss
>500ml
vag birth or >1000ml C/S
OR Increased bleeding during recovery or postpartumSTAGE 2
Cumulative blood loss
1500 ml Continued bleedingPulse >120
Decreased BP
STAGE 3
Cumulative blood loss
>1500 ml
OR
Suspicion of DIC
Pulse >140
Decreased BP
2016.07
Providence Clinical Academy: Obstetrics
5Slide6
Stage 1
Cumulative Blood Loss >500ml vag birth>1000ml C/S OR
Increased bleeding during recovery or postpartum
Nursing Care:Establish IV access if not present, at least 18 gaugeIncrease Oxytocin and titrate to uterine toneContinue vigorous fundal massageAssess and empty bladder
Notify LIP/Charge NurseAdminister uterotonics as orderedVital Signs q 5-10 minutes including O2 sat & level of consciousnessWeigh, calculate and record cumulative blood loss Administer oxygen to maintain O2 sats at >95%Type and Screen (if not already done)Keep patient warmDocumentLIP:Methergine 0.2mg IM if not hypertensiveIf hypertensive give *Hemabate 250mcg IM or *Misoprostol 800mcg rectally Deferential Diagnosis - rule out retained products of conception, laceration, hematomaSurgeon: (if cesarean birth and still open)Inspect for uncontrolled bleeding at all levels, especially, broad ligament, posterior uterus, and retained placenta
2016.07Providence Clinical Academy: Obstetrics6Slide7
Stage 2
1500 mL cumulative blood loss and continued bleeding
Pulse >120, Decreased BP
Nursing Care:Start a 2nd IV and administer IV fluids (LR is preferred)Place Foley with urimeter
Continue assessing frequent vital signs and blood lossI & O Maintain communication with charge nurse Assists anesthesia provider Apply Bair Hugger and SCDs Administer medications as ordered Assist Anesthesia as neededDocumentLIP:Continue uterotonic medicationsMove to the OR- D/C, tamponade balloon, uterine packingOrder OB Hemorrhage PanelType & Cross for 2 units PRBCs or OB Hemorrhage Pack (if patient bleeding is not responding to treatment and interventionsInterventions follow underlying cause for bleedingLaborist Anesthesia:Monitor patient vital signsProvide pain reliefBegin blood replacement as indicated
2016.07
Providence Clinical Academy: Obstetrics
7Slide8
Stage 3
Cumulative blood loss >1500 OR Pulse >140, Decreased BP Suspicion of DIC
Nursing Care:
Maintains communication with team membersAdminister medications as ordered Set up cell saver
Assists anesthesia as neededMonitor cumulative blood loss and update teamDocumentDraw labs LIP:Order OB Hemorrhage PackUterotonics Call for GYN/ONC and/or Adult IntensivistConsider uterine artery ligation, interventional radiology, or hysterectomyAnesthesia:Monitor frequent vital signs and communicate to teamArterial blood gases and repeat OB Hemorrhage PanelPlace central line as needed Continue to administer meds and blood products
2016.07Providence Clinical Academy: Obstetrics8Slide9
APPLY WHAT YOU LEARNED
Postpartum Hemorrhage Case Study
2016.07
Providence Clinical Academy: Obstetrics
9Slide10
Case Study: Background Information
34 y.o. G2 P1001, 39 1/7 weeks
Planned, repeat C/S
A Neg/ Rubella Pos/ Hepatitis B Neg/ RPR non-reactiveUneventful prenatal courseNo pertinent medical history16 g IV placed in left wrist Cefazolin 2 gms IV pre-op
2016.07
Providence Clinical Academy: Obstetrics10Slide11
Case Study: Background Information
What would this patient’s risk factors be for PPH?
What labs should be drawn pre-op?
Prior C/S (Trauma)
CBCType & Screen
2016.07Admission Hct 36.9TySc sentProvidence Clinical Academy: Obstetrics11Slide12
2016.07
Cumulative Blood Loss
0
mL
140
130
120
110
100
90
80
70
60
150
HR 70
1500
1600
1700
1800
1900
2000
2100
2200
BP 105/52
HR 90
1533
C/S delivery
BP 116/68
1536
Oxytocin 20 units in 1 L LR
Case Study
Providence Clinical Academy: Obstetrics
12Slide13
2016.07
Case Study
Cumulative Blood Loss
1000+ mL
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
BP 107/50
HR 76
1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed
1600 – Admit to
recovery room
EBL 1200 ml per anesthesia, < 1000 ml per surgeon
Providence Clinical Academy: Obstetrics
13Slide14
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
1630 – Nursing Note
“large clots expressed MD called to bedside”
1645 Return to the OR
BP 100/48
HR 105
1615- Nursing note
“large clot expressed oozing , fundus boggy firmed with massage “
1615-1620
Methergine 200 mcg IM Misoprostol 800 mcg PR
Cumulative Blood Loss
1000+ mL
Providence Clinical Academy: Obstetrics
14Slide15
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
1700 D&C, EBL noted at 500 ml
1715
Bakri balloon placed
Active bleeding stopped
1715
Hemabate 250 mcg IM
1730
T&C for 4 units
CBC, Coags drawn
BP 98/50
HR 115
Cumulative Blood Loss
1500+ mL
Providence Clinical Academy: Obstetrics
15Slide16
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
Oxytocin
30 units in 500
mL
1840
Hct 32.5
Platelets 129
Fibrinogen 205
1745
Bleeding slowed to minimal
HR 140
Cefazolin
2 gm IV
BP 95/60
Cumulative Blood Loss
1500+ mL
Providence Clinical Academy: Obstetrics
16Slide17
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
HR 150
1945
200 mL noted in Bakri Balloon
Fundus 3-5 cm above umbilicus
Abdomen tender
BP 89/45
2000
Hct 26.9
Platelets 131
Fibrinogen 151
1955
OB at bedside
U/S done – shows large clot
2015
Hct 21 per I-Stat
Cumulative Blood Loss
1700+ mL
Providence Clinical Academy: Obstetrics
17Slide18
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
2045
Midazolam
and
Fentanyl
for sedation
2030
Pt transferred to interventional radiology
“moderate amount of bleeding continues”
2140 Bilateral uterine artery embolization.
Hemostatsis achieved. 500 ml blood loss into Bakri Balloon
2015 1 unit PRBCs
2130 1 unit PRBCs
2100 1 unit PRBCs
HR 140
2055
Hemorrhage pack ordered
BP 80/39
Cumulative Blood Loss
2200+ mL
Providence Clinical Academy: Obstetrics
18Slide19
2016.07
Case Study
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
2250
Cryoprecipitate
2300
Cryoprecipitate, and 1 unit PRBCs
HR 125
BP 92/64
2245
4-pack FFP
2225
4-pack FFP
2200
4-pack FFP
2200
Transferred to recovery
Cumulative Blood Loss
2200+ mL
Providence Clinical Academy: Obstetrics
19Slide20
Case Study: Conclusion
The patient remained stable in recovery after the uterine artery embolization with scant lochia rubra then transferred to ICU after recovery
Labs were the following:
0000Hct 30.6, WBC 24.9, Platelets 88, Fibrinogen 1640400
Hct 29.1, WBC 19.1, Platelets 75, Fibrinogen 1990730Hct 28.6, WBC 15.9, Platelets 67, Fibrinogen 226Bakri Balloon removed at noon post-op day #1 with 200 mL blood loss in bag Total EBL = ???Pt transferred in stable condition to postpartum at 1500Discharged to home on post-op day #5
2016.07Providence Clinical Academy: Obstetrics20Slide21
Which of these common mistakes occurred in this case?
Treating postpartum hemorrhage as a diagnosis and not identifying the cause
Underestimation of blood loss
Inattention to vital sign trendsDelay in intervening surgically if neededDelay in laboratory assessmentDelay in instituting blood replacement therapyDelay in moving from “normal delivery” to “life threatening emergency”Poor communication between nurse and OB providers on amount of blood loss, vital signs and other clinical indicatorsLack of communication between OB provider and anesthesia who is managing blood loss and replacement therapy Insufficient preoperative preparation for massive hemorrhage (placenta previa, known or suspected accreta)
2016.07
Providence Clinical Academy: Obstetrics
21Slide22
Case Study Reflection
Underestimation of blood loss- it was difficult to determine cumulative blood loss during this case. The RN should of weighed blood loss and a cumulative total should have been noted.
Inattention to vital signs and delay in instituting blood replacement therapy - the patient was tachycardic an hypotensive, blood replaced was delayed until laboratory values reflected the need for blood replacement.
2016.07
Providence Clinical Academy: Obstetrics
22Slide23
2016.07
Cumulative Blood Loss
0
mL
140
130
120
110
100
90
80
70
60
150
HR 70
1500
1600
1700
1800
1900
2000
2100
2200
BP 105/52
HR 90
1533
C/S delivery
BP 116/68
1536
Oxytocin 20 units in 1 L LR
Case Study: Stage 0
Providence Clinical Academy: Obstetrics
23Slide24
2016.07
Case Study: Stage 1
Cumulative Blood Loss
1000+ mL
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
BP 107/50
HR 76
1545- Persistent bleeding noted on uterine layer, fundus firm, figure 8 stitch placed
1600 – Admit to
recovery room
EBL 1200 ml per anesthesia, < 1000 ml per surgeon
Stage 1:
Greater than 1000
mL
blood loss with stable vital signs
Exact blood loss unknown as laps have not been weighed
Oxytocin
should be increased
Providence Clinical Academy: Obstetrics
24Slide25
Case Study: Stage 2
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
1630 – Nursing Note
“large clots expressed MD called to bedside”
1645 Return to the OR
BP 100/48
HR 105
1615- Nursing note
“large clot expressed oozing , fundus boggy firmed with massage “
1615-1620
Methergine 200 mcg IM Misoprostol 800 mcg PR
Cumulative Blood Loss
1000+ mL
Stage 2:
Less than 1500
mL
blood loss & continued bleeding & decreased BP/elevated HR
Need a 2
nd
IV
OB Hemorrhage
labs
and at least 2 units of PRBCs should be ordered
Increase
Oxytocin
rate
Give
Hemabate
and repeat all Uterotonics per guidelines
Providence Clinical Academy: Obstetrics
25Slide26
Case Study: Stage 3
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
1700 D&C, EBL noted at 500 ml
1715
Bakri balloon placed
Active bleeding stopped
1715
Hemabate 250 mcg IM
1730
T&C for 4 units
CBC, Coags drawn
BP 98/50
HR 115
Cumulative Blood Loss
1500+ mL
Stage 3:
Greater than 1500
mL
blood loss
2
nd
IV, labs, and PRBCs should have already been ordered
Hemabate
may be repeated q 15-90
mins
x 8
Providence Clinical Academy: Obstetrics
26Slide27
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
Oxytocin
30 units in 500
mL
1840
Hct 32.5
Platelets 129
Fibrinogen 205
1745
Bleeding slowed to minimal
HR 140
Cefazolin
2 gm IV
BP 95/60
Cumulative Blood Loss
1500+ mL
Stage 3:
Greater than 1500
mL
blood loss
Methergine
may be repeated q 2-4 hours x 5 (only given 1x at this point)
Hemabate
may be repeated q 15-90
mins
x 8 (only given x1 at this point)
OB Hemorrhage
blood products
should be ordered
Case Study: Stage 3
Providence Clinical Academy: Obstetrics
27Slide28
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
1945
200 mL noted in Bakri Balloon
Fundus 3-5 cm above umbilicus
Abdomen tender
BP 89/45
2000
Hct 26.9
Platelets 131
Fibrinogen 151
1955
OB at bedside
U/S done – shows large clot
2015
Hct 21 per I-Stat
Stage 3:
Greater than 1500
mL
blood loss
Methergine
may be repeated q 2-4 hours x 5 (only given 1x at this point)
Hemabate
may be repeated q 15-90
mins
x 8 (only given x1 at this point)
OB Panel to be repeated q 30
mins
(this was done 1 hour ago at this point)
No blood has yet been transfused at this time (Type & Cross for 4 units ordered at 1730)
Cumulative Blood Loss
1700+ mL
Case Study: Stage 3
HR 150
Providence Clinical Academy: Obstetrics
28Slide29
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
2045
Midazolam
and
Fentanyl
for sedation
2030
Pt transferred to interventional radiology
“moderate amount of bleeding continues”
2140 Bilateral uterine artery embolization.
Hemostatsis achieved. 500 ml blood loss into Bakri Balloon
2015 1 unit PRBCs
2130 1 unit PRBCs
2100 1 unit PRBCs
HR 140
2055
Hemorrhage pack ordered
BP 80/39
Cumulative Blood Loss
2200+ mL
Stage 3:
1
st
unit of PRBCs given 3 hours after it was ordered
Still only 1 dose of
Hemabate
and
Methergine
given at this time
OB Hem
blood products
ordered
5
hours after start of Stage 3
Case Study: Stage 3
Providence Clinical Academy: Obstetrics
29Slide30
2016.07
140
130
120
110
100
90
80
70
60
150
1500
1600
1700
1800
1900
2000
2100
2200
2250
Cryoprecipitate
2300
Cryoprecipitate, and 1 unit PRBCs
HR 125
BP 92/64
2245
4-pack FFP
2225
4-pack FFP
2200
4-pack FFP
2200
Transferred to recovery
Cumulative Blood Loss
2200+ mL
Stage 3:
Still no other
uterotonics
administered
No labs since 2015
OB Hem Panel to be done q 30
mins
in PPH
Case Study: Stage 3
Providence Clinical Academy: Obstetrics
30Slide31
Knowledge Check
After C/S delivery Sarah is transferred to the OB/PACU.
The 2
nd PP check reveals: BP 99/50Pulse 126RR 20
Temp 98.2° F (oral)The abdominal dressing is C, D, & IFF @ 2 cm below Abdomen palpates slightly distendedPatient complains of slight nausea. What are the possible physiologic reasons for Sarah’s current condition? (choose all that apply)Nausea due to ice chips Tachycardia related to pain, repositioning, and movement during transfer from OB/PACU to postpartum Possible internal bleeding
2016.07
Providence Clinical Academy: Obstetrics
31Slide32
Knowledge Check
At the next assessment:
Sarah’s fundus is difficult to palpate.
Abd dressing C, D, & I Lochia is scant. BP 88/50 mmHg Pulse is 130 bpm.
After administration of an antiemetic, Sarah starts vomiting and her skin is clammy to touch. She says she feels weak and cold.Nursing interventions should include all of the following EXCEPT?Request a bedside assessment by the charge nurse Request a bedside assessment by the physician Request an order to type and crossmatch the patientAdminister additional antiemetics Bolus with IV fluids Prepare to start second IV line for access
2016.07
Providence Clinical Academy: Obstetrics
32Slide33
Knowledge Check
Sarah's physician is at the bedside.
BP 85/30 mmHg
P 140 bpmThere is no new urine outputLochia is scant. ABD dressing is C,D, & I.
The abdomen is distended and the uterus cannot be palpated. Sarah now rates her pain at 7. What should be the next management plan? (choose all that apply)Notify anesthesia and immediately transfer to OR Continue to monitor, blood pressure, and pulse oximetry monitors Run IV of LR wide open to increase her fluid volume Administer 2 units of blood emergently without verification Order OB Hemorrhage labsApply oxygen via non-rebreather face mask
2016.07
Providence Clinical Academy: Obstetrics
33Slide34
Knowledge Check
When the surgery starts, the obstetrician finds Sarah’s abdomen full of blood.
The LIP found the left uterine artery is lacerated. The bleeding is controlled with additional suturing.
After suctioning, the canister contains 1500 mL of blood. Capillary oozing is visible. The lab results will be available in 5 minutes. BP 80/42 mmHgPulse is 140 bpm.
What transfusion orders should be given at this time? (choose all that apply)Transfuse 4 units of PRBC now and anticipate an order for 2 additional unitsTransfuse 1 unit of PRBC pending lab results Thaw fresh frozen plasma and give as soon as available Give 1 unit of pooled platelets Give recombinant factor VIIa
2016.07
Providence Clinical Academy: Obstetrics
34Slide35
Knowledge Check
Sarah’s active bleeding has subsided and there is only slight capillary oozing after the laparotomy.
Initial PACU lab values include:
Hct 20%Fibrinogen 60 mg/dL
Platelets 55,000/µL Core temp 96.2°FBP 104/58 mmHg Pulse 112 bpm. Further management of this patient should include? (choose all that apply)Anticipate that more blood and blood products will be ordered and administered Apply warming unit to the patient (warming blankets such as Bear Hugger®)Strict input and output records Follow PACU protocol
2016.07
Providence Clinical Academy: Obstetrics
35