by, Donna Weeks
It’s staggering to think that 54 to 93 percent of maternal deaths related to postpartum hemorrhage (PPH) could be avoided.
So what can we do on our units to reduce the number of women with complications, or even death, from an obstetrical hemorrhage?
I have taken part in many discussions about high tech simulation and drills, and we are always asking ourselves:
- How can we have effective drills without a simulation lab and simulation models?
- Can low tech simulation play a beneficial role in decreasing obstetrical hemorrhage?
I recently took part in a pilot program that the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) trialed on postpartum hemorrhage risk assessments, evidence-based oxytocin orders, and hemorrhage drills and debriefing based upon a variety of settings.
Here are a few ideas that I have implemented without utilizing a simulation lab. These easy suggestions may help every obstetrical unit raise awareness of obstetrical hemorrhage and contribute to decreased maternal morbidity and mortality.
First, have a mock code on your unit using your own crash cart. You may be surprised to find out how many nurses are uncomfortable with finding key items in your crash cart. Use a pillow to simulate a gravid uterus and have one nurse demonstrate left uterine displacement while other nurses deliver compressions and ventilations. Additional nurses may find supplies, IVs, and medications in the code cart.
Second, devise a scavenger hunt and ask your staff to find the closest location of items needed during an obstetrical hemorrhage. In many units the OB techs check the hemorrhage cart and the nurses may be less familiar with the items on the cart. They may be leaving the room to get supplies and medications that are already on the cart. In a true emergency this will use up valuable time.
Third, consider efficiencies. Do you have your medications locked in a Pyxis or Omnicell? Do nurses have to remove the uterotonics one at a time? Due to the awareness raised by our hospital’s participation in AWHONNs postpartum hemorrhage project, the day after our medication administration system was installed our pharmacy was notified that we needed a postpartum hemorrhage kit. Now with one selection we retrieve ergonovine maleate (methergine), misoprostol (cytotec), carboprost (hemabate) and oxytocin (pitocin).
Fourth, how do you drill? What about drills in an empty patient room? Have a drill in a patient room with nothing more than a mannequin. Change the scenarios and include the less common situations. With a type and screen being completed on most admitted labor and delivery patients it is not common to be ordering uncrossedmatched blood. I use a scenario that includes a woman presenting to L&D with an obvious hemorrhage. This scenario presents the opportunity to review how and when to retrieve uncrossmatched blood. What is your procedure? Is there special paperwork or forms? During one drill we strongly stressed the time element including how quickly we could generate a medical record number and how much time would be lost if an OB tech was sent for the blood. In our institution uncrossmatched blood may only be released to a physician or nurse. Take the scenario further and include your massive transfusion protocol. Review when and how to initiate the protocol.
Lastly, practice quantification of blood loss until it becomes routine. Use scales, work sheets, and a variety of scenarios to keep staff informed and interested. These can be presented by a charge nurse on any shift without preplanning. It is just one more way to keep obstetrical hemorrhage on the forefront of everyone’s mind. The more awareness we raise the better chance we have of early recognition and intervention. The goal is to have a healthy mother and healthy family.
Donna is a Perinatal Clinical Specialist at JFK Medical Center in NJ. She has always loved OB nursing and also enjoys teaching. She is currently an adjunct instructor at Kaplan University and Walden University. She was the Hospital Lead for AWHONN’s PPH Project.
Citations
Berg, C. J., Harper, M. A., Atkinson, S. M., Bell, E. A., Brown, H. L., Hage, M. L., . . . Callaghan, W. M. (2005). Preventability of pregnancy-related deaths: Results of a statewide review. Obstetrics & Gynecology, 106, 1228–1234.doi:10.1097/01.AOG.0000187894.71913.e8
California Department of Public Health. (2011). The California pregnancy-associated mortality review. Report from 2002 and 2003 maternal death reviews. Sacramento, CA: Author. Retrieved from http://www.cdph.ca.gov/data/statistics/Documents/MO-CA-PAMR-MaternalDeathReview-2002-03.pdf
Della Torre, M., Kilpatrick, S. J., Hibbard, J. U., Simonson, L., Scott, S., Koch, A., . . . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760.doi:10.1055/s-0031-1280856
Resources
Get free postpartum hemorrhage resources from AWHONN.
Learn more about AWHONN’s Postpartum Hemorrhage Project
For more in-depth info and to learn more about how to reduce clinician errors associated with obstetric hemorrhage mortality and morbidity, join AWHONN’s newest implementation community on Postpartum Hemorrhage.