Intrapartum Hemorrhage

Information from Meriter:

PPH is a leading cause of maternal morbidity and mortality.  In December 2019 Meriter introduced QBL to replace EBL as a patient safety measure.  Visual estimation of blood loss (EBL) has shown to be extremely inaccurate and underestimate actual blood loss by 33-50%, especially when a large volume of blood is lost.  Although measures to improve the accuracy of calculating blood loss have been implemented, remember QBL is not 100% accurate, however it is far more accurate than EBL.

The QBL process adopted at UPH- Meriter is based on AWHONN and CMQCC recommendations.

For Vaginal Births:

• Measure fluid/blood loss in under buttocks drapes before placenta (provider to look and announce volume in bag to RN).  Most of this volume is amniotic fluid and urine

• Measure fluid/blood loss in under buttocks drapes after placenta (provider to look and announce volume in bag to RN)

• RN subtracts before placenta volume from after placenta volume.

• In addition, RN weighs all blood- soaked laps, sponges, and clots used during delivery.  Volume in under buttocks bag plus weighed items = Delivery QBL

• The nurse continues to measure blood loss in recovery until transfer to Postpartum.

• QBL is documented in Delivery Summary and verbalized during hand-off report to PP RN

Additional measures adopted to reduce PPH morbidity and mortality

• In December 2019 a PowerPoint addressing PPH was developed and sent to all providers and nursing staff as preparation for simulation training

• If you have not viewed the PPH – OB Training video click on the link below.  https://forms.office.com/Pages/ResponsePage.aspxid=zUshq5ebu0GqnUbPENgi_YVAR1y1t_hPoDTmC1tFfRUNlFaUDJPNTc2Qjc4TE5XSTlHVExHVEMxNCQlQCN0PWcu

• PPH identified as a simulation training topic for 2020-2021.  All nursing staff are required to attend a simulation session.  PPH education and simulation is also part of new RN orientation.

• Nurses received ongoing education on OR QBL as part of the 2020 OR Education Training

• PPH carts are available on 4N, 5N, and 6N

• Dry weight cards are readily available in each OR, LDR and in PPH carts.  Dry weights are subtracted from wet weight to ensure greater QBL accuracy.

• TXA is now stocked in each Omnicell in the Birthing Center so we no longer need to wait for pharmacy to prepare it.

• A PPH checklist is in the top drawer of each PPH cart.  The checklist is also present  on a ring with the other OB checklists found in each patient room in Triage, 3N, 4N, 5N and 6N

• The main OR and main PACU have a copy of the PPH checklist, dry weight cards and a scale for weighing items to be consistent with QBL  practices in OB

• Uterotonic agents are stocked in areas outside the Birthing Center where delivery may occur including the ED, 4T OR, HVU and ICU.

• Coming:  Neptune Waste Management System for OB ORs; EPIC auto-calculator for QBL (April 2021)

For Cesarean Birth:

• Measure/record amount of fluid loss in canister before placenta (mostly amniotic fluid)

• Measure/record amount of fluid loss in canister before irrigation

• Subtract before placenta volume from before irrigation volume= adjusted canister volume

• Weighs all blood- soaked laps, sponges, towels, clots during case (subtract dry weight)

• Add adjusted canister volume to weight of laps, sponges etc. = Cesarean Birth QBL

• RNs use OR QBL Worksheet to assist with recording/documenting QBL

• Measurement of blood loss continues in PACU until transfer to postpartum

• QBL is documented in Delivery Summary and verbalized during hand-off report to PP RN

References:

• AWHONN, Quantification of Blood Loss Practice Brief Number 1, January 2015. JOGNN 44, (1),158-160

• ACOG, December 2019, Quantitative Blood Loss in Obstetric Hemorrhage, Practice Bulletin No. 794

• CMQCC – OB Hemorrhage Took kit V. 2.0, 2015.