مجيبيان مهديه دكترزايمان و زنان متخصص

Section II: The following are laminated and displayed in a common area that is readilyaccessible to physicians, nurse midwives, nurses, and other staff who might need theinformation:____WAPC “Algorithm for Postpartum Hemorrhage”____WAPC list of “Uterotonic Agents for Postpartum Hemorrhage”____Diagram of the B-Lynch compression suture technique

Oxytocin for Postpartum

Hemorrhage Protocolrevised October 2008PreambleOne of the associated risks associated with childbirth is a postpartum hemorrhage. In theout-of-hospital setting, early intervention to manage a significant and ongoing hemorrhagecan prevent further blood loss. Oxytocin helps contract uterine smooth muscle andminimizes further uterine blood loss.Requirements1. Fully licensed Technician-Paramedic.2. Certification in postpartum hemorrhage protocol by the Medical Director.3. Certification in administration of intramuscular (IM) medication by the Medical Director.Indications1. Patients at greater than 20 weeks gestation who have delivered a newborn in the outof-hospital environment.and2. Patients experiencing postpartum hemorrhage of greater than 500 ml blood.

Contraindications1. Patient has not completed delivery of fetus(es).2. Patient is less than 20 weeks gestation.Oxytocin for Postpartum Hemorrhage Protocol

Drug Doses and FrequenciesoxytocinIM: 10 IU after the newborn has deliveredIV: in the event of ongoing with significant blood loss, an additional 40 IUcan be added to each 1000 ml normal saline and infused based on theseverity of hemorrhage and patient responseProcedure1. Perform patient assessment and record vital signs.2. Assess that patient meets criteria for this protocol.3. Ensure there are no contraindications to use of this protocol.4. Initiate basic life support treatment measures, including supplemental oxygen.- these take precedence over management using this protocol

.Initiate an intravenous line with normal saline- add oxytocin to the intravenous bag- infuse at a rate based on severity of hemorrhage and patient condition6. Manage the hemorrhage as per appropriate guideline or protocol.7. While basic life support treatment measures and intravenous line are being initiated,and hemorrhage is being controlled, obtain a focused obstetrical history. Include thefollowing details:· antenatal care· expected delivery date· history of current pregnancy (including results of any ultrasounds)· history of prior pregnancies (including history of previous difficulties)8. If baby (last baby), but not placenta, has delivered:· provide appropriate care for mother and newborn· give mother oxytocin IM· assist with delivery of placenta· manage complications, if possible, as per appropriate guideline orprotocol· initiate transport to hospitalOxytocin for Postpartum Hemorrhage Protocol3

9 .If the baby (last baby) and placenta have delivered:· provide appropriate care for mother and newborn· give mother oxytocin IM if not already done as part of step 8· manage complications, if possible, as per appropriate guideline orprotocol· initiate transport to hospital10.If possible, encourage mother to empty her bladder.11.Massage the uterine fundus to promote uterine contraction and lessen the severity ofthe hemorrhage.12.Repeat assessment, including vital signs, level of consciousness, oxygen saturation,and effect of oxytocin.

Documentation RequirementsThe following information must be documented on the patient care report form:1. Patient’s presenting signs and symptoms, including vital signs.2. Indications for protocol use.3. Details of patient’s obstetrical history and current delivery.

4. Dose, route, and time for each oxytocin dose used, and resulting clinical effects.5. Repeat assessment and vital signs, as indicated.6. Changes from baseline, if any, that occur during treatment or transport.7. Signature and license number of EMS personnel performing any transfer of function skills.

Certification Requirements1. Attend in-depth classes and lectures on obstetrics and obstetrical emergencies.2. Demonstrate an understanding of the pharmacology, mechanism of action, andpotential side effects of oxytocin.3. Do an acceptable clinical rotation on a labour and delivery ward.Oxytocin for Postpartum Hemorrhage Protocol4

4. Pass a written examination.5. Pass practical scenarios incorporating variations of the oxytocin – postpartumhemorrhage protocol.6. Certification is by the Medical Director.Recertification Requirements1. Review class and recertification is done every 12 months.2. A record will be kept to document all cases where this protocol is used.

Decertification1. Decertification is at the discretion of the Medical Director or the Provincial MedicalDirector, Emergency Medical Services, Manitoba Health & Healthy Living.Quality Assurance Requirements1. Appropriate quality assurance policies must be in place. The Medical Director ordesignate must review all instances where this protocol is used. As a minimum, thefollowing must be assessed:i) appropriateness of implementationii) adherence to protocoliii) any deviation from the protocoliv) corrective measures taken, if indicated2. Yearly statistics for protocol use compiled and forwarded to Emergency MedicalServices, Manitoba Health & Healthy Living.

Massive Transfusion Protocol for Obstetrical Hemorrhage

I. PRINCIPLE The Massive Transfusion Protocol (MTP) for Obstetrical Hemorrhage is intended for antepartum; intrapartum or postpartum patients deemed candidates based on requirement for massive blood volume replacement. Currently at The University Hospital, University of Cincinnati, an MTP is in place. This protocol has been modified to meet the special needs of the obstetrical hemorrhage patient.

II. CLASSIFICATION OF OBSTETRICAL HEMORRHAGE A. LOW RISK: Minimal bleeding with reassuring maternal/fetal status. Vaginal bleeding, which will be expectantly managed. B. MODERATE RISK: Vaginal bleeding which requires active management. Transfusion of blood products as well as fetal/maternal intervention may be necessary. C. HIGH RISK: Vaginal bleeding which requires active management. Transfusion of blood products as well as fetal/maternal intervention will be necessary. A subset of these patients will require the implementation of the Massive Transfusion Protocol. Antepartum presentation to ER or OB Triage with abruption, previa or accrete and DIC from any source. Intrapartum hemorrhage immediately following 3rd stage of labor. Postpartum hemorrhage occurring during recovery period or on postpartum unit

III. IMPLEMENTATION OF MTP (HAVE A LOW THRESHOLD FOR INITIATION)

A. Criteria for implementation of MTP (any of below) .一 EBL > 2000 cc with ongoing blood loss of >150 cc/min.

Obstetricians under estimate blood loss. (Refer to Box 1: Guidelines for Estimation of Blood Loss)

.二 Hypotension decrease of BP by 20% in the setting of acute hemorrhage

.三 Tachycardia HR >110 in the setting of acute hemorrhage

.四 Mental status changes in the setting of acute hemorrhage

.五 Chest pain/EKG changes in the setting of acute hemorrhage October 22, 2009

Postpartum Hemorrhage Algorithm The following algorithm is based the California Maternal Quality Care Collaborative OB Hemorrhage Protocol.

Stage 0Blood Loss less than 500ml with Vaginal delivery; less than 1000 ml with cesarean section. Stable vital signs•  All women receive active management of 3rd stage Oxytocin IV infusion or 10 Units IM•  Vigorous fundal massage for 15 seconds minimum

 

Stage 1Blood Loss > 500ml Vaginal delivery; > 1000 ml cesarean section15% Vital Sign change -or-HR equal to or greater than 110, BP equal to or less than 85/45 O2 Sat less than 95%, pallor, delayed capillary refill, or decreased urine output. can indicateDecreased urine output, decreased BP and tachycardia may be late signs of compromise•Call for help.•Provide adequate ventilation•Assist airway protection•Establish large-bore intravenous access •Supplemental O2 5-7 L/min by tight face mask•Prepare 2 units of packed red cells. •Evaluate for atony, lacerations, hematoma, inverted uterus , retained tissue, accreta, coagulopathy.•Medication for uterine atony

Oxytocin10-40 units in 1 liter NS or LR IV rapid infusionMethylergonovine (Methergine)0.2 milligrams intramuscular q 2-4 hrs up to 5 doses

Stage 21000-1500 ml estimated blood loss with continued bleeding.•Move to operating room •Transfuse 2 Units PRBCs per clinical signs•Consider thawing 2 Units FFP•Order CBC, PT/INR/PTT, Fibrinogen

Warm blood products and infusions to prevent hypothermia, coagulopathy and arrhythmiasProstaglandin F2 Alpha (Hemabate)250 micrograms intramuscular, intramyometrial, repeat q 15-90 minutes,maximum 8 doses

Prostaglandin E2 suppositories (Dinoprostone, Prostin E2)20 milligrams per rectum q 2 hrs

Misoprostol (Cytotec)1000 micrograms per rectum

Surgical intervention Vaginal Birth:Atony Bimanual Fundal Massage Retained POC: Dilation and CurettageLower segment/Implantation site/Atony: Intrauterine BalloonLaceration/Hematoma: Packing, Repair as Required

Cesarean Birth:Continued Atony: B-Lynch Suture/Intrauterine BalloonContinued Hemorrhage: Uterine Artery LigationHypogastric Ligation (experienced surgeon only)

Stage 3Estimated blood loss gretaer than 1500 ml with continued blood loss.•Activate massive transfusion protocol (MTP),

MTP "Pack", to be sent from the Blood Bank is: o4 units PRBC o2 OR 4 units FFP o1 apheresis pack of platelets

Obtain CBC , PT/INR/PTT, and fibrinogen every 4 hours after the standard MTP "Pack" is given. Laboratory studies should be monitored for at least 24 hours after discontinuing the protocol. Note: 10 units cryoprecipitate should be given for fibrinogen <100mg/dl

•If bleeding continues after 2 MTP packs have been administered, or  women is refusing transfusions (e.g. Jehovah Witnesses) , consider recombinant activated factor VII (rFVIIa, NovoSeven®) 60 mcg/kg. May repeat in 30 minutes •Surgical intervention

B-Lynch Suture/Intrauterine BalloonUterine Artery LigationHypogastric Ligation (experienced surgeon only)Hysterectomy