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Deadly Deliveries? – Working as a Team to Make a Difference in
Preventing and/or Treating Obstetrical Hemorrhage
Charlene Miranda-Wood, MS, RNC-OB
February 2012
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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Objectives
• Apply the fundamentals of using Failure Mode Effects Analysis (FMEA) to drive change in your perinatal department to prevent/treat obstetrical hemorrhage
• Identify obstetrical hemorrhage risk factors and mechanisms to communicate risk to all health care providers in your perinatal department
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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What is Your Best Guess? • Blood volume
– EBL vs QBL
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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Meet Mrs. Lochia
• 30 y.o. G 3 P 2 0 0 2
• 31 2/7 weeks twin gestation (IVG dating)
– diamniotic and dichorionic
• c/o uterine contractions every 5 minutes and loss of mucous plug
• Pain – mild
• Location – suprapubic
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Previous medical history
– Previous admit at 24 5/7 gestational weeks for shortened cervix at 1.3 cm
– One month prior cervical length was > 4 cm
– Medications during hospital course
• Received Betamethsone x 2
• Nifedipine 10 mg q 6
• Vaginal progesterone with 8% Crinone, nightly
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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Discharged home after 4 weeks in hospital
– Continued on
• Nifedipine 10 mg q 6
• Vaginal progesterone nightly
– Past deliveries – NSVD and Vacuum assisted delivery
• no complications
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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Current admission for PTL
• Started on Magnesium Sulfate for both neuroprotection and PTL
• Despite interventions proceeded to dilate
• Twin A and Twin B delivered without difficulties
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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Emergently transported to OR
• Repeat D&C
• Bakri balloon placement, vaginal packing
• Massive transfusion protocol – 4 U PRBCs
– 4 U FFP
– 1 U Plt
– 1 U Cryoprecipitate
• H/H 9.7/28.2 Plt 127 Fibrinogen 231
• Blood loss – 3000 ml
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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POD # 2 - Bakri balloon removed in two steps
POD # 4 – Discharged home in stable condition
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• How did we get to where we are today?
• Nurse Champion
• Creating a Team – Physician Champion
– Analyst
– Pharmacy
– Blood Bank
– Lab
– Admissions
• CMQCC – First Cohort
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Developing the Plan
– Development and Implementation of Standardized OB Hemorrhage Risk Assessment
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Developing the Plan
– Development and Implementation of a process to quantify and document cumulative blood loss
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Developing the Plan
– Development and implementation of OB hemorrhage equipment and supplies
• OB hemorrhage cart
• Sterile equipment
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Development and implementation of “doe packs” in OBER
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Development and implementation of OB hemorrhage medication packs
– Pitocin
– Misoprostol
– Methergine
– Hemabate
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Development and implementation of blood requisition and transfusion protocols for obstetrical patients
– Rapid infusion protocol
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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• Implementation and Education
• Skills Fair
– Collection of pre-learning packet
– Quantification of blood loss
– Blood bank
– Lab – rapid infusion labs
– OBET
– OB hemorrhage cart
– Policies and procedures
– Post learning crossword puzzle
• “Go Live”
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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We know we have made a difference for the women and families that have entrusted us with their lives and the lives of their babies.
http://www.youtube.com/watch?v=wgi24wPaWbs&feature=plcp&context=C3b5c70eUDOEgsToPDskIjM_NOLZ7-aDKTwZk112s6
NK8q, Deadly Deliveries AWHONN CA STATE Feb 2012.pdf
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