Hemorrhage is one of the leading causes of maternal death in the United States (The Joint Commission, Sentinel Alert Issue 44, 2010). Massive hemorrhage occurs in an approximate 1-2% of all deliveries (Fauzia et al, 2004), thus a patient status can turn critical in a matter of seconds. Risk factors, both known and unknown, complicate the clinical picture of the patient, leaving them at risk for an unexpected outcome and the obstetrical emergency of either intra-partum or post-partum hemorrhage.

While advanced maternal age, maternal obesity, fetal macrosomia and prolonged labor are risk factors contributing to a maternal hemorrhage, it is the complications of pregnancy that place the patient at increased risk of massive OB hemorrhage. These complications include, but are not limited to,  accreta, percreta, increta, placental abruption, placenta previa, development of HELLP syndrome and DIC. These conditions place the patient at risk for a life threatening sequelae of events. In these situations, effective hemodynamic management of the patient is priority.

Evidence identifies the best management for complications such as these begin with a multidisciplinary team approach. Inclusion of nursing staff, physicians (OB and GYN/ONC as needed), anesthesia, transfusion services, laboratory, hematology, respiratory therapy and administration is necessary for optimal patient outcomes.

Case:

The development of a Massive OB Transfusion protocol was initiated at Baylor All Saints – Andrews Women’s Hospital to promote better patient outcomes for the pregnant population experiencing a life threatening hemorrhage at, or following, delivery of an infant. This protocol allows for proactive, interdisciplinary dynamics and collaboration for planning patient care, not only when risk factors are present before delivery but also when a hemorrhage occurs unexpectedly.

The initial implementation occurred in July 2010 in response to an inpatient with multiple risk factors and diagnosed with percreta placental abnormality. We will present a case study of the scenario that unfolded, ultimately ending in a positive outcome for the patient. Additionally, we will highlight case specifics of a second patient with similar risks that did not accept blood products.  Options for this patient population will also be discussed.

Conclusion: Through collaborative efforts of all members of the healthcare team using evidence based practice, this protocol was able to be successfully implemented in a controlled situation. With lessons learned, this protocol can be used when planned and unplanned cases arise to foster positive patient outcomes for patients experiencing massive OB hemorrhage.

Keywords: Hemorrhage, transfusion, emergency, life-threatening