“No Woman Should Die While Giving Life” : A Retrospective Analysis on the Effectiveness of a Maternal Hemorrhage Plan

Purpose:
The goal of our maternal hemorrhage initiative is to decrease hemorrhage related maternal morbidity and mortality through implementation of a standardized and coordinated intervention protocol aimed at improved readiness, early identification, and rapid treatment of maternal hemorrhage

Relevance/Significance:
Massive hemorrhage, defined as blood loss greater than 1500ml, is the most common and preventable cause of pregnancy-related morbidity and mortality worldwide. The American College of Obstetricians and Gynecologists (ACOG) reports that, worldwide, one woman dies every four minutes from postpartum hemorrhage because she does not receive early and aggressive treatment. Furthermore, 90% of hemorrhage- related maternal mortality can be prevented through improved quality of care.

Strategy and Implementation:
In 2011, a multidisciplinary team collaborated to develop a maternal hemorrhage plan (MHP). Components included an admission risk assessment, a hemorrhage protocol with treatment algorithm, a medpack with uterotonics, a cooler packed with acute hemorrhage blood products, massive hemorrhage panel, quantification of blood loss (QBL) using visual posters, a debriefing tool, with debriefing huddles following all hemorrhages, and standardized hemorrhage related doctor's orders sets. Using an interdisciplinary approach, the MHP was introduced utilizing formal education of all stakeholders, on-the-unit inservices, video recorded simulation drills, and ongoing education. In 2013, we joined the Florida Perinatal Quality Collaborative Obstetric Hemorrhage Initiative. Additional protocols were added, including ongoing MHP risk assessments, active management of third stage of labor, QBL using measurement, weighing, and visual posters, hemorrhage cart and supply boxes, and simulation drills.

Evaluation:
Since implementation of the MHP, there has been a notable improvement in all outcome measures, including: a 9% reduction in patients requiring transfusion of more than 2 Units of blood (62 vs. 44); a 67% decrease in massive transfusion rates (0.6% in 2011 to 0.2% in 2014); a 34% reduction in blood product usage (561 units vs. 369 units); and a 27% decrease in ICU admissions (26 vs. 19).

Implications for Practice:
The use of a MHP provides nurses with current evidence based guidelines for care, ensures necessary supplies and equipment are readily available, and by clearly identifying roles for the nursing staff, improves communication. The use of a MHP helps to achieve the highest quality patient outcomes.