Five Easy Steps to Save Lives and Promote Healthy Families

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.

DonnaDonna 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.

Nurses Save Lives

by, Christine Douglass, RN
Florida Hospital Heartland Medical Center

As a charge nurse on a busy Labor & Delivery unit I am responsible for the nurses on my team that work each day with me. On one particular day we had a patient who was scheduled for a repeat cesarean section for her second baby. Everything was going fine with her recovery in PACU, until I heard an unfamiliar alarm sounding on the unit.

I looked up at the fetal monitor board to see if the monitors indicated anything wrong. I saw that the patient in room 202, who was also in PACU, had a blood pressure of 70/40 and a heart rate of 160. I ran into the room and asked the nurse if she had seen the monitor.

She stated that she had just given the patient IV pain medication and that was why her heart rate was high and blood pressure was low. I said that is unusual for that to happen, it looks more like she is going into shock. I told her to start a second IV line and open both line wide. I checked her fundus to find out that her uterus was boggy and when massaged a mountain of clots came out.

I rang the call bell and asked OB tech to get the scale to weigh the clots and had another nurse, who had since come into the room, to call the doctor and get me an order for methergine. Methergine was given and in 15 minutes more clots were expressed and weighed. By this time we had weighed a total of 1200-1300 mls, not including the 800 mls she had lost in the OR. I asked the nurse to call the doctor back and when she did she said to prep the patient and take her to the OR, the doctor was on her way to the hospital. The patient was taken to the OR and given several units of blood and FFP.

Her uterus was saved for the time being and she was sent to the ICU for the night to be closely monitored. Two days later when she returned to our unit she told me her side of the story. She stated that while everything was happening to her she felt like she was above the room looking down and then she saw her grandparents sitting on a park bench. She told them that she wanted to stay with them and they told her she had to return to take care of her little girls. When she left she told me that we were her angels and we had saved her from death and she appreciated all we did for her and her family.

Later that day the doctor thanked me for “catching” the change in vital signs before she had gotten any worse and that I had probably saved her life. It makes be proud to be able to save someone’s life and reaffirms to me that I made the right career choice many years ago. I love what I do.

Standardizing Postpartum Oxytocin Administration

by, Jennifer Doyle, MSN, WHNP-BC
Director, AWHONN Executive Board
APN, Women’s Service Line
Summa Health
Akron City Hospital
Akron, OH

Photo: Jennifer Doyle assessing and caring for fellow colleague Amy Burkett, MD, FACOG.

Somewhere in a Labor and Delivery unit, a woman gives birth.  A family is born. A nurse remains at the bedside.  A sentinel, who assesses, plans, and intervenes.  The nurse is equipped with knowledge and skills to holistically care for mom and baby.  The nurse’s primary focus is to promote bonding and breastfeeding. However, despite a safe birth, risk remains.  Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality.  It is often preventable.

As a labor and delivery staff nurse, there were countless occasions when I held vigil at the side of my patients after they gave birth.  I was prepared with an array of resources to treat PPH. In part, this included uterine massage, oxytocin, methylergometrine, carboprost, and misoprostol.   As a nurse caring for a woman in the immediate postpartum period, my goal was to assess maternal bleeding and avoid PPH, or treat early if it occurred.  I would often stand at the bedside, pondering how much oxytocin I should administer to this new mother, and for how long. Continue reading