Background: Obstetric hemorrhage is a significant cause of maternal morbidity and mortality.  Early recognition and prompt intervention are keys to minimizing complications. The rate of maternal deaths in the United States has nearly doubled from 7.6 per 100,000 in 1996 to 13.3 per 100,000 annual births in 2006.  However in California the rate of maternal deaths has nearly tripled from 6 per 100,000 in 1996 to 17 per 100,000 annual births in 2006. What is particularly troubling about both of these trends is the fact that the worldwide maternal mortality rate had decreased over this same time. This troubling statistic served as the impetus to develop the California Maternal Quality Care Collaborative (CMQCC) to end preventable maternal death and injury and to promote equitable maternity care in California. Miller Children’s Hospital Labor and Delivery joined a quality improvement collaborative through the CMQCC to develop an OB Hemorrhage protocol.

 Case: Women in early pregnancy, before 20 weeks gestation are often triaged and treated in the main hospital emergency rooms when presenting for bleeding or threatened spontaneous abortion. This was true in the case of this young woman with a 14 week gestation. Early antepartum hemorrhage (before 20 weeks gestation) can be caused by abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease. Early diagnosis and treatment is essential and often not done urgently or with the thought of life threatening hemorrhage.

 Deteriation of young women can happen suddenly.  Under-estimation of blood loss and misleading maternal response can mask the need for an urgent response. A young woman may maintain a normal blood pressure until sudden and castastrophic decompensation occurs.  It is essential the team in any setting know how to respond quickly and appropriately as time is of the essence.

Conclusion: A well-coordinated team can mean the difference between life and death. In this case, the recognition and education of the OB hemorrhage protocol by the resident resulted in the initiation of the life saving protocol for this young woman. After the episode, the team debrief reinforced the importance of quantifiable blood loss education as well as the implementation of the OB hemorrhage protocol.

Keywords: hemorrhage, antepartum