1. OBSTETRIC HEMORRHAGE 10/2010 P ost P artum H emorrhage PPH

13. 1st 2nd 3rd Hemorrhagic Class 1-2 1 . Pulse rising > 100 2 . Decreased Pulse Pressure 3 . Systolic BP < 90 or Decreased by 20 mm Mg Or VS as above w/ No Visible blood loss RetroPeritoneal Hematoma Broad ligament Hematoma Splenic Artery Aneurysm DX with bedside Sono Foley (note initial output) 2 . Fundal massage 3 . Oxytocin 40 units per liter Wide opened 4 . Methergine 0.2 mg IM x1 (may repeat in 2 hrs x1) or Cytotec PO / SL Bleeding from IV/Phlebotomy sites Risk for DIC (Abruption, IUFD, HELLP, Sepsis, Hemorrhagic Shock, AFLP, AFE) STAT LABS: Fibrinogen FDP, CBC, PTT, INR, TYPE & CROSS,LFT’s, Lytes, Creatinine,LDH Inspect Perineum For Bleeding Lacerations and Hematomas OR Mass of tissue @ Introitus ? Was the Placenta intact MD may explore uterus and do bimanual fundal message Resuscitation 1 . Oxygen by mask 2 . 2 large-bore IV needles ( 18 g and @ least one 16G) Consider ART line/ Central Line 3 . Order STAT labs: ISTAT H&H, verify T&S completed. Type and Cross, ABG,Ca, PTT/INR/Ptlts/Fib/FDP/Lytes 4 . Replace EBL 3:1 with warmed crystalloids until PRBC’s arrive TWO Liter rapid infusion can be Diagnostic & Theraputic 5 . Bair Hugger/ IV fluid warmer 6 .Record Q 5 min :BP, pulse, SaO2, RR, CNS Sx 7. Record Urine output Q 30min UNRESPONSIVE TO 2 L OR UNCONTROLLED CLASS 2 THE FOUR T’S TONE Soft, “boggy” uterus Fundus above Umbilicus TRAUMA Genital tract tear Hematoma Inversion of uterus THROMBIN Blood not clotting TISSUE Placenta retained Accessory Lobe Hemabate 0.25 mg IM Q 15 & Bakri Balloon To L&D OR Suture Lacerations, Drain & Pack Hematomas or Replace inverted uterus To L&D OR Manual remove tissue OR D & C To L&D OR / ICU Fresh Frozen Plasma Platelet transfusion PRBC’S transfusion Dx & Tx Cause Estimated 10-15 mins or more away from Surgical Bleeding Control Class 2 Pulse 100-120, Pulse pressure decreased, RR >20, Anxious EBL 900- 1800 Class 3 Pulse 120-140, Systolic BP < 90, RR>30, Anxious & Confused EBL 1800-2400 Class 4 Pulse > 140 , Systolic BP < 90 RR >35,Confused & Lethargic EBL > 2400 HEMORRHAGE PROTOCOL Class 2-3 Transfuse 4 PRBC’s O neg/Non-Cross Matched 4 FFP 1 Plt Prepare for Surgery: Consider Factor VIIa 90-120 mcg/Kg (max 9 mg) Uterine Artery Ligation / Compression Sutures / Hysterectomy / Exploratory Laparotomy UNRESPONSIVE to 1 st lineTx Or Hemorrhagic Class 2 or Worse Consider Interventional Radiology For Uterine Artery embolization ( ONLY If Hemodyamically stable, but persistent slow bleeding) UNCONTROLLED Bleeding

21. Q uantitative B lood L oss QBL

23. Bakri Balloon for Uterine Atony WITH 1 ST & ALWAYS 2 nd Dose of HEMABATE

25. Uterine Artery Ligation For Lacerations

26. B-Lynch For Atony LARGE NEEDLE # 2 CHROMIC

29. Volume Replacement / Transfusion How serious is all of this blood loss? What Blood Products do I do Order?

33. NURSING CHECKLIST

34. Resuscitation 1 . Oxygen by mask 2 . 2 large-bore IV needles ( 18 g or even better if 16G) 3 . DRAW STAT labs when starting the second IV: CBC Type and Cross, PTT/INR/Ptlts/Fib/ 4 . Replace EBL 3:1 with warmed crystalloids until PRBC’s arrive TWO Liter rapid infusion can be Diagnostic & Theraputic 5 . Keep patient warm : Bair Hugger/ IV fluid warmer 6 .Record Q 5 min :BP, pulse, SaO2, RR, CNS Sx 7. Record Urine output Q 30min UNRESPONSIVE TO 2 L OR UNCONTROLLED CLASS 2

39. Hemorrhagic Class 2-3 1 . Pulse rising > 120 2 . Decreased Pulse Pressure 3 . Systolic BP < 90 or NO RESPONSE TO 1st Line Tx AND No Visible blood loss Fundus Firm ?Midline? Floating? RetroPeritoneal Hematoma Broad ligament Hematoma Splenic Artery Aneurysm Dx with Ultrasound OR Atony as Obvious Cause with QBL explaining Vital Signs

40. HEMORRHAGE PROTOCOL ACTIVATED CLASS 2 UNRESPOSIVE TO 1 ST LINE Tx / or PROGRESS To Class 3 Transfuse 4 PRBC’s O neg/Non-Cross Matched 4 FFP 1 Plt Prepare for Surgery: Uterine Artery Ligation / Compression Sutures / Hysterectomy / Exploratory Laparotomy Consider Factor VIIa 90-120 mcg/Kg (max 9 mg)