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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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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Clinical Guideline for massive obstetric haemorrhage/June 2013/review June 2016
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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
yes All pregnant women
Race yes All pregnant women
SexualOrientation
yes All pregnant women
Marriage / CivilPartnership
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 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
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