POSTPARTUM HEMORRHAGE FROM VAGINAL DELIVERY
Date _____________ Patient ___________________________ Date of birth___________ MR # __________Physician or certified nurse–midwife _____________________________ Last menstrual period _________________Gravidity/Parity___________________________ Estimated date of delivery____________
For hemorrhage of more than 500 mL estimated blood loss, but less than 1,000 mL, from vaginal delivery:
* Start intravenous (IV) line if not present
* Increase IV fluid rate
* Increase IV oxytocin by increasing infusion rate, or by increasing concentration to 40–80 international units/L
* Empty bladder
* Conduct vigorous fundal massage
* Administer 0.2 mg of methylergonovine intramuscularly every 2–4 hours if patient is not hypertensive
* Type and crossmatch 2 units packed red blood cells
* Evaluate for retained product of conception, lacerations, uterine atony, and uterine inversion
* Administer 0.25 mg of 15-methyl prostaglandin F2α intramyometrially or intramuscularly (may repeat every 15–90 minutes for a maximum of eight doses), or 800–1,000 micrograms of misoprostol rectally (1)
If no response by 1,000 mL estimated blood loss:
* Call for help—second obstetrician, anesthesia, and blood bank
* Order stat complete blood cell count and coagulation studies, including hematocrit, platelets, fibrinogen, and prothrombin time and partial thromboplastin time
* Begin blood product transfusion based on clinical signs and judgment
* Establish second large-bore IV line
* Administer oxygen as needed to maintain oxygen saturation greater than 95% (2)
* Consider move to operating room for dilation and curettage or laceration repair
* Consider intrauterine balloon or uterine packing
* Consider warm blanket to prevent hypothermia
* Type and crossmatch 2–4 additional units packed red blood cells and thaw 2–4 units fresh frozen plasma
* Place Foley catheter with urometer
If no response by 1,500 mL estimated blood loss:
* Initiate massive transfusion protocol
* Consider transfusion protocol of packed red blood cells, fresh frozen plasma, and platelets at a ratio of 1:1:1
* Consider uterine artery ligation, B-Lynch sutures, or hysterectomy
1. Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–47.
2. Lyndon A, Lagrew D, Shields L, Melsop K, Bingham D, Main E, editors. Improving health care response to obstetric hem-orrhage: a California toolkit to transform maternity care. Stanford (CA): California Maternity Quality Care Collaborative; 2010.
Standardization of health care processes and reduced variation has been shown to improve out-comes and quality of care. The American College of Obstetricians and Gynecologists has developed a series of patient safety checklists to help facilitate the standardization process. This checklist reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular checklist may be adapted to local resources, standardization of checklists within an institution is strongly encouraged.
How to Use This Checklist
The Patient Safety Checklist on Postpartum Hemorrhage From Vaginal Delivery should be used to guide the process if a patient who is undergoing vaginal delivery experiences an estimated blood loss greater than 500 mL.
Copyright May 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.
Postpartum hemorrhage from vaginal delivery. Patient Safety Checklist No. 10. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:1151–2.