Every 4 minutes somewhere in the world a woman dies from postpartum hemorrhage (PPH).  Severe bleeding is the number one cause of maternal death and it is estimated that 75% of those deaths are preventable.  Statistics have shown a significant increase in the incidence of PPH nationally over the last 5 years.  A multidisciplinary task force was established to review the literature, develop, and implement a protocol to decrease the incidence of postpartum hemorrhage in a large, university hospital birth center. The key focus of the protocol is recognition of risk factors, anticipation, and mobilization of personnel.

Proposed change:

PPH by traditional definition is: blood loss > 500 mL following a vaginal birth or > 1000 mL following a C/Section.  A protocol was developed that defines PPH as:  any blood loss that causes a life-threatening physiologic change (e.g., VS change, LOC change).  The protocol identifies Prenatal Assessment & Planning, Admission Hemorrhage Risk Factor Evaluation, Ongoing Risk Assessment, and 4 Stages of Hemorrhage (based on estimated blood loss, VS stability, need for blood products, and surgical intervention).

Implementation, outcomes and evaluation:  

A multidisciplinary team consisting of nursing, physicians, pharmacy, anesthesia, quality, and blood bank/lab personnel was established to propose a protocol to improve the assessment and management of PPH.  Hospital staff were educated so that protocol implementation is standardized no matter where the patient is located in the hospital.  The overall outcome was to decrease the incidence of PPH.

To implement the protocol the following were created: PPH kit in the automated medication cabinets, laminated algorithms for patient care units in table form and flow chart form, computerized physician order set for PPH, estimation of blood loss picture examples, and four seperate staff education presentations posted on patient care units and sent via email.

Since project initiation a decrease in the incidence of PPH rate within 24 hours of delivery has been demonstrated through cumulative statistics based on diagnosis coding.  Statistics reveal a 5% rate of PPH since project implementation (down from 6% in June 2009).

Implications for nursing practice:

Implementation of the protocol has helped staff recognize the importance of assessing each patient for PPH risk and the need to maintain current bloodwork.  In addition, the protocol has given all members of the healthcare team tools for recognizing the need for, and implementing, timely and well-coordinated interventions when faced with this life-threatening and increasingly common complication.

Keywords: postpartum hemorrhage, postpartum hemorrhage risk factors, postpartum hemorrhage interventions