CSC Standardized Curriculum USpecialty: OB U

USimulation:U Postpartum Hemorrhage UTarget AudienceU: Residents and Staff (FM and OB/GYN and Emergency Medicine) UContributed by: U MAJ Shad Deering, MD UACGME Competencies Addressed:

- Patient Care - Medical Knowledge - Interpersonal and Communication Skills

URRC Requirements Addressed:

- Understanding and management of obstetric emergencies

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Case Scenarios Primary:

CLINICAL SCENARIO

You have just started your labor and delivery shift. The nurse comes to get you

and says that this patient has just had a precipitous delivery. Patient is a 36y/o G3P2002

who presented in active labor and rapidly delivered a 4000 gram male infant. The

placenta just delivered, but she is continuing to have some bleeding. Oxytocin is running

in IV fluids. She does not have a chart available.

Alternate scenario

CLINICAL SCENARIO

A 21y/o G1P0 was delivered by forceps approximately 2 hours ago. She

presented in spontaneous labor, but required pitocin augmentation for several hours prior

to needing an operative vaginal delivery for fetal distress. She had a second degree

laceration that was repaired, but she has soaked a whole pad in the last 15 minutes and

the nurse would like you to evaluate her.

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Basic Instructions for participants Please read the scenario and then enter the room when instructed by your staff. You may ask questions if you have them, and please remember to:

1. Treat the scenario as real as possible 2. Use mask/gloves/gown as needed 3. Request assistance if needed 4. Ignore the camera 5. Please do not cut the perineum, but indicate if you would make an episiotomy

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Simulation Setup Simulators to be used: The simulator that will be utilized for this is the NOELLE birthing mannequin with the Postpartum Hemorrhage Uterus insert (see photo). In addition, you may also utilize the touch-screen monitors that are attached to the mobile cart if desired. Photos of the NOELLE and the monitor are shown under Room Setup. Room Setup: The room should be set up similar to a delivery room. The simulator is on an examination table, gurney, or bed with the lower torso draped. A delivery table should be available with the basic equipment as listed below. If videotaping is going to be done, then either a staff member will hold this or set up a tripod to the side of the bed or use the camera arm on the cart. Figure 1: NOELLE Birthing Mannequin with Fetal Monitors, Gaumard Scientific, FL

Additional Equipment needed

- Birthing simulator (see above) - Standard delivery table (Bulb suction, Kelly clamps, scissors, etc)

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- Digital video camera (if you desire to record the training) - Chronograph (may use watch with timer or even a second hand)

- Bottle of baby aspirin (to simulate Cytotech) and two syringes to be able to

simulate administering Hemabate and Methergine

- IV bag of fluid with IV line taped to patient’s arm to simulate the first IV

- Plastic placenta in delivery basin on floor or back table (see photo)

- Postpartum Hemorrhage Insert: This insert is placed into the NOELLE abdomen on top of the elevating pillow, which allows for it to be palpated abdominally, and then snapped into the perineum. (Note: this does require you to remove the perineum that is normally on the mannequin by unsnapping it.) In addition, I generally remove the foam pad from the abdominal cover in order to allow for the trainee to feel the uterus better. The fake blood reservoir is placed beside the mannequin’s head and covered with a towel or sheet. (Make sure you have clamped off the downstream tubing before doing this!) After filling up the reservoir, connect the hand pump and pressurize the bag. The uterus has a separate hand pump to control how firm it is. At the beginning of the scenario, allow it be boggy and you can make it firm at the end if they do the appropriate interventions. (See photos)

- PPH insert - Blood reservoir - Hand pumps

Figure 2: Placenta in basin

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Figure 3: Elevating pillow to put in place prior to inserting postpartum hemorrhage insert.

Figure 4: Postpartum Hemorrhage insert (top photo without pump in superior portion)

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Figure 5: Blood reservoir

Optional Equipment:

- Fetal Monitoring: If desired, the vital sign software may be used to demonstrate worsening maternal status during the simulation. Incorporating this into the training helps add to the realism of the scenario as this is heard by the providers during the simulation. In order to do this, after starting up the software, simply load the files as per the walk-through diagram at the specified time intervals.

Personnel needed:

- Staff to control hemorrhage and maternal mannequin (1)* - Assistants to provide assistance with maneuvers (1) - Staff to film procedure (if desired, 1 – or may use tripod or camera arm on the

cart) *The one assistant can also act as the nurse and administer medications but this is somewhat difficult because they must also update the maternal vital signs.

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Basic Scenario Tips:

- Make sure that the mannequin’s upper torso is tilted up so that any fake blood that runs out of the cervix and does not come out the vagina does not collect in the maternal abdomen.

- Place a towel or absorbent pad in the upper abdomen by the motor/eclampsia

modification piece to ensure that no fake blood gets into the motor or other mechanical parts.

- Remove the foam padding from the abdominal cover in order to allow the

providers to feel the boggy uterus better.

- If the provider tries to do a manual exploration of the uterus, inform them that they will not be able to on this model but that it is normal.

- If they do a visual inspection of the vagina and ask if there are cervical

lacerations, inform them that there are not.

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Case Flow/Algorithm with branch point and completion criteria:

POSTPARTUM HEMORRHAGE SCENARIO – STAFF CONTROLLING HEMORRHAGE

Provider enters room: 1) Start bleeding - bag is filled with 1L of fake blood

2) Start timer 3) Allow the uterus to be “boggy” and not fully inflated

Provider should begin assessment and maneuvers. Respond in the following manner: Possible Maneuvers:

1) Fundal massage: The uterus remains boggy and bleeding continues 2) Inspection of cervix/vagina for lacerations 3) Attempt to manually clear uterus 4) Medications (Hemabate/Methergine/Cytotech)

The uterus remains boggy unless the provider does the following:

1) Performs fundal massage 2) Assesses the cervix for lacerations 3) Administers two different medications correctly (dose and route)

*(If the medications are given incorrectly, either dose or route, the uterus does not become firm and the bleeding continues.)

The scenario ends when any of the following occur:

+ Fundal massage + INSPECTION for cervical lacerations + TWO medications are given correctly OR

- Blood runs out (takes approximately 5-7 minutes) At this point, simply clamp the tube allowing the bleeding. You do not need to do anything with the uterus to make it firm.

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POSTPARTUM HEMORRHAGE SCENARIO – NURSING ASSISTANT Resident enters the room

Inform the resident that the patient’s vital signs are: BP – 120/70 Pulse – 90 bpm Pulse ox – 98% on room air

(Load “Postpartum Hemorrhage Initial” and click “Update”)

Resident should begin assessment and maneuvers.

When the physician asks for a medication to be given, the nursing assistant should

ask the following questions:

- What dose of the medication should be given? - What route should it be administered by?

“Draw up” and administer any medications requested. If cytotec is requested, give

them the baby aspirin. The dose for each pill is 200ug if you are asked.

At 30 seconds the nurse informs the resident of the patient’s vital signs:

BP – 105/80 Pulse – 105 bpm Pulse ox – 96% on room air

(Load “Postpartum Hemorrhage 30 SECONDS” and click “Update”)

At 60 seconds (one minute) the nurse informs the resident of the patient’s vital signs:

BP – 90/50 Pulse – 120 bpm Pulse ox – 96% on room air

(Load “Postpartum Hemorrhage 60 SECONDS” and click “Update”)

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At 120 seconds (two minutes) the nurse informs the resident of the patient’s vital

signs:

BP – 60/30 Pulse – 140 bpm Pulse ox – 90% on room air

(Load “Postpartum Hemorrhage 120 SECONDS” and click “Update”)

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Answers to common questions that come up:

1. The nurse does not know the correct dosage of any of the medications to give. 2. The nurse may call for staff/anesthesia or any other providers, but they do not

arrive before the end of the scenario. 3. The physician is not able to take the patient back to an operating room. 4. The nurse may “increase the pitocin” rate if requested, but this does not have any

effect on the scenario. There is 20 units in the IV bag initially. 5. There are no lacerations seen externally. 6. The resident may inspect the placenta, which is on the back table. 7. The placenta appears intact. 8. There are no materials available for vaginal packing. 9. You do not have the ability to get any additional instruments, there are none

available. 10. You cannot give repeat doses of medications unless they have given the wrong

dose or route. In those cases, you can give the medication again. If they have given the medication correctly, tell the provider you are out.

11. When asked to give a medication, if they do not specifically say, then you must ask them what dose of the medication and what route they want it given.

12. You may call for blood products, but none will arrive before the end of the scenario.

13. If asked for vitals at times other than listed in the algorithm, just restate the vitals you previously gave them.

Things to tell the resident ONLY IF THEY ASK: 1. The EBL for the delivery is 500cc. 2. The patient’s beginning hematocrit is 30%

Common pitfalls to monitor for: - Do not allow the provider to insert a needle through the abdomen in order to

administer medications directly to the uterus as this will puncture the inflatable uterus!

- Make sure to clarify all medication orders (dose and route). - Do not allow the provider to use a PDA or notes

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Evaluation Forms POSTPARTUM HEMORRHAGE – ATONY OBJECTIVE GRADING SHEET Resident recognizes postpartum hemorrhage: YES NO Inspects placenta to ensure it appears intact: YES NO Inspects vagina for lacerations: YES NO Inspects cervix for lacerations: YES NO Recognizes bleeding is coming from uterus: YES NO Performs fundal massage: YES NO Administers medication to correct atony: YES NO Methergine Correct dose (0.2mg) YES NO N/A Correct route (IM) YES NO N/A Hemabate Correct dose (0.25mg) YES NO N/A Correct route (IM) YES NO N/A Cytotech (misprostol) Correct dose (800-1000ug) YES NO N/A Correct route (per rectum) YES NO N/A Corrects hemorrhage prior to blood running out: YES NO Total Time Required to Correct Hemorrhage: _________ (seconds)

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POSTPARTUM HEMORRHAGE – ATONY GLOBAL SUBJECTIVE GRADING FORM: 1. The physician recognized the complication of postpartum hemorrhage in a timely manner. Strongly Disagree Neither agree Strongly Agree Or disagree 0 1 2 3 4 5 6 7 8 9 10 2. The physician called for medications in a timely fashion. Strongly Disagree Neither agree Strongly Agree Or disagree 0 1 2 3 4 5 6 7 8 9 10 3. Overall, how well did the physician perform during the hemorrhage scenario? Strongly Disagree Neither agree Strongly Agree Or disagree 0 1 2 3 4 5 6 7 8 9 10 4. How prepared do you feel the physician was for this complication? Strongly Disagree Neither agree Strongly Agree Or disagree 0 1 2 3 4 5 6 7 8 9 10

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ONLINE GRADING FORMS: - Open CSC Sharepoint Website - Open the “Site Forms” under the Grading Links title on the right side of the Home

page - Select your Institution from the list - Select your Specialty - Select the Simulation that you are doing - Enter requested information for the resident and grade their performance - When finished, simply click “submit” Key Teaching Points/Critical Actions to discuss in debriefing:

- Knowledge of risk factors for postpartum hemorrhage are important - It is important to know the correct doses and routes of administration for the key

medications for this emergency.

- Be able to execute the critical actions as outlined on the evaluation form

- Know the differential for postpartum hemorrhage

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Suggested time length for modules: The actual simulation itself only takes approximately 5-7 minutes to complete. Debriefing will take between 5-10 minutes depending on the provider’s performance One way to shorten the time required to train is to have several providers go through the simulation individually, usually a group of 3-5, and then bring them into the room together afterwards and do a group debrief and instruction period. Brief Didactic: Postpartum Hemorrhage (PPH): A postpartum hemorrhage (PPH)is defined as either a 10% decrease in hematocrit between admission and the postpartum time period or the need for a blood transfusion. (ACOG 1998) The average blood loss at vaginal delivery and cesarean have been reported as 500mL and 1000mL respectively, but the estimated blood loss (EBL) at delivery is often significantly underestimated, often by as much as 50%, so you have to take into account both the estimated blood loss and the patient’s clinical picture. Also, remember that the hematocrit does not drop immediately in response to hemorrhage and will not equilibrate until nearly 12 hours later. So, the bottom line is, treat the patient not the labs. While there are definite risk factors associated with PPH, many of, such as obesity, placenta previa, placental abruption, etc, cannot be prevented. Because of this it is imperative that you recognize risk factors and are prepared should a PPH occur. Incidence: The incidence of PPH differs based on the type of delivery. PPH occurs after approximately 4% of vaginal deliveries and around 6% of cesarean deliveries and for women who have had a previous PPH, the risk of recurrence is as high as 10%. (Hall, 1985; Bonnar, 2000) Clinical Picture: Blood loss may be obvious at either vaginal or cesarean delivery. At times, though, it may be masked by amniotic fluid. As blood loss continues, however, the patient will become tachycardic and then hypotensive. She may also complain of shortness of breath, chest pain, or have an altered level of consciousness. Risk Factors: There are multiple risk factors for a patient developing a postpartum hemorrhage. Some of these include the following: Previous postpartum hemorrhage Multiple pregnancy Preeclampsia Prolonged second or third stage of labor Episiotomy Obesity Placenta abruption/previa Chorioamnionitis Birthweight > 4000gms Coagulopathy

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(Adapted from Bukowski, 2001) Causes: While there are multiple possible etiologies for PPH, the most

common causes are uterine atony, retained placental tissue, and vaginal or perineal lacerations. Because of this, your initial treatment will be directed at ruling these out and treatment them should they be present.

Prevention: Active management of the third stage of labor, which includes early cord clamping, oxytocin after delivery of the baby, and controlled cord traction, will prevent around 60% of PPH. (Bukowski, 2001) In addition to this, recognizing possible risk factors for PPH will allow you to have the proper personnel and equipment available should it occur. Treatment: The treatment of PPH should include efforts to both stabilize the mother and correct the underlying cause. The initial steps that should be taken are: Call for help (staff/anesthesia) IV access/fluid bolus (crystalloid) O2 by facemask Monitors (ensure you have someone to check BP/pulse) Place a foley catheter (when stabilized) to monitor urine output Determine cause - Think of risk factors Check uterine tone Manually explore uterus for retained products. Examine for lacerations See the Figure 1 and Table 1 at the end for a treatment algorithm common medications that are used for treatment. Use of Blood Products: The use of blood products in patients who experience a significant postpartum hemorrhage can be life-saving. Patients who refuse blood transfusions, such as Jehovah’s witnesses, are at increased risk for maternal mortality from postpartum hemorrhage, with one study reporting a 44-fold increase in the risk of death from hemorrhage in this population. (Singla, 2002) However, because a transfusion involves some risk to the patient in terms of viral infection and transfusion reactions, treatment should be carefully considered and the appropriate products ordered. The most commonly used blood products on labor and delivery include packed red blood cells (PRBC), platelets, fresh-frozen plasma (FFP), and cryoprecipitate. Packed red blood cells (PRBCs): Most patients who suffer a significant hemorrhage will first receive a transfusion of PRBCs. They are indicated when a patient is hemodynamically unstable due to hemorrhage, especially if the hemoglobin level falls to less than 8 or 9 gm/dL. (Strong, 1997) While red blood cells are critical to transport oxygen to tissues in the body, care must be taken to monitor the patient for pulmonary

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edema when multiple transfusions are required. In general, you can expect the patient’s hemoglobin and hematocrit to increase by 3% and 1gm/dL per unit transfused. Platelets: Platelets should be transfused when there is evidence of hemorrhage as a result of either thrombocytopenia or platelet dysfunction. It may also be given in the face of massive transfusion of PRBC’s and abnormal bleeding as a dilutional thrombocytopenia can occur in this situation. While a patient is considered thrombocytopenic if their platelet count falls below 100,000/mmP

3P, there is generally no

problem with surgery (i.e. cesarean section) as long as the level does not fall to below 50,000/mmP

3P. When a patient has a platelet count of less than 20,000/mmP

3P, then they

should be prophylactically transfused to prevent spontaneous bleeding. A single unit of platelets will increase the patient’s platelet count by approximately 7500/mmP

3P.

Fresh-frozen plasma (FFP): This is extracted from whole blood and contains both significant amounts of fibrinogen as well as multiple clotting factors. This is given when disseminated intravascular coagulation (DIC), vitamin K deficiency, or clotting factor deficiencies related to liver disease (and therefore vitamin K dependant clotting factors) are present. It can be expected to increase the patient’s fibrinogen level by 10-15 mg/dL per unit transfused. The goal of treatment with FFP in the presence of DIC or hypofibrinogenemia is a fibrinogen level of at least 100 mg/dL. It is important to think ahead when you encounter a significant postpartum hemorrhage as it takes at least 30 minutes for this blood product to be thawed and made available in most blood banks. (Of note, this is the only blood product with clotting factors V, XI, and XII.) Cryoprecipitate (Cryo): This blood product is a fraction of FFP that is rich in factors VII, XIII and fibrinogen, as well as von Willebrand’s factor. Because of the small amount of volume of each unit as compared to FFP (40mL vs 250mL) it is a more efficient way to raise the patient’s fibrinogen level. (This may be important in a patient with DIC with pulmonary edema secondary to fluid overload from multiple transfusions of PRBCs where you need to increase the fibrinogen level, but need to give as little additional volume as possible.) One unit of cryoprecipitate will increase the patient’s fibrinogen level by 10-15 mg/dL. In general, cryoprecipitate is given specifically for the treatment of von Willebrand’s disease, factor VII deficiency, or hypofibrinogenemia. See Table 2 for a comparison of all the different blood products Complications of Blood Transfusions: While the transfusion of blood products is often life-saving in obstetrics, there are risks involved and these are important to discuss with patients when they are required. Adverse reactions: Adverse reactions that may occur with the transfusion of blood products generally either involve acute reactions or transmission of infectious agents to the recipient.

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Acute hemolytic transfusion reaction: This is most commonly a result of a clerical error resulting in the transfusion of incompatible blood products. It usually presents with a fever, which may be accompanied by nausea, emesis, dypsnea, back pain, and discomfort at the infusion site. It may progress to shock, disseminated intravascular coagulation (DIC), or acute renal failure. The incidence of this type of reaction is, however, only 1:25,000. The risk of a fatal acute hemolytic reaction is much less at 1:600,000. (Menitove, 2000) If there is any suspicion of a hemolytic reaction, then the transfusion should be stopped and the blood product returned to the blood bank with a description of the possible reaction. Supportive care of the patient is indicated as well. Febrile non-hemolytic transfusion reaction: This type of reaction occurs approximately in 1:5,000-1:10,000 transfusions. (Menitove, 2000) When this occurs, the patient will generally experience a headache, shaking chills, or a fever within an hour of the transfusion beginning. If this occurs, then the transfusion should be stopped and the blood product sent back to the laboratory for testing. A hemolytic reaction should be ruled out by demonstrating no evidence of hemolysis (i.e. absence of hemoglobinemia, hemoglobinuria, and a negative direct antiglobulin test). Patients should receive acetaminophen for the fever and given supportive care.

Anaphylactic reaction: Anaphylactic reactions, which are characterized by urticaria, angioedema dypsnea, nausea or abdominal cramping, and even shock, occur approximately 1:150,000 units of blood transfused. (Menitove, 2000) When this occurs, you should again, stop the infusion and send the products to the laboratory. Treatment of the patient involves stabilizing the airway and administering antihistamines and epinephrine as needed. Infections: Although all blood products are screened prior to administration to patients, the possibility of acquiring an infection, usually viral, still exists. Current estimates of these risks can be found in Table 3 below.

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FIGURE 1: TREATMENT ALGORITHM FOR POSTPARTUM HEMORRHAGE

CONSIDER PPH RISK FACTORS

ACTIVE MANAGEMENT OF 3P

RDP STAGE OF LABOR

POSTPARTUM HEMORRHAGE OCCURS

DETERMINE ETIOLOGY OF HEMORRHAGE

Palpate Uterus Not palpable Not Firm Firm Check for and Treat Treat Uterine Atony Check for lacerations Uterine Inversion if present - Uterine massage - Medications “-“ “+” (See Table 1) - Surgery or Uterine artery embolization Repair lacerations (if stable enough) Check for retained placental fragments “-“ “+” Coagulopathy? - Manual removal - D&C if needed “-“ “+” - Consider placenta accreta, increta, percreta Surgical Treat Treatment Coagulopathy

- Call for help (staff/anesthesia) - Obtain IV access - Start IV fluids (crystalloid) – 1L BOLUS - O2 by facemask (10L)

- Check vital signs (BP/Pulse/Pulse oximetry) - Place a foley catheter to monitor urine output - Send labs (CBC, PT/PTT/Fibrinogen) - Blood products (PRBC, FFP, Cryoprecipitate)

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Table 1: Medications for Postpartum Hemorrhage MEDICATION DOSE CONTRAINDICATIONS Methylergonovine (Methergine)

0.2mg IM OR into myometrium Q2-4 hours

Hypertension, preeclampsia, asthma, Raynaud’s syndrome

Prostaglandin F-2alpha (Hemabate)

250ug IM OR into myometrium Q15 minutes (up to 8 doses)

Asthma, renal disorders, pulmonary hypertension

Misoprostol (Cytotech, PGE-1)

600ug-1000 ug per rectum x 1 dose

Known hypersensitivity to NSAIDs, active GI bleeding

Table 2: Common blood products Blood product Contains Indications Volume

(mL) Effect

Packed red blood cells

Red cells, some plasma

Increase red cell mass

300

Increase Hct 3%/unit

Increase Hgb 1gm/unit

Platelets Platelets, some plasma, few RBC/WBC

Hemorrhage from thrombocytopenia

50

Increase platelet count by

7500mmP

3P/unit

Fresh frozen plasma

Plasma, clotting factors

Treatment of coagulation disorders

250

Increase total fibrinogen 10-15mg/dL/unit

Cryoprecipitate Fibrinogen, factors V, VIII,

XIII, von Willebrand’s

factor

Hemophilia A, von Willebrand’s

disease, hypofibrinogenemia

40

Increase total fibrinogen 10-15

mg/dL/unit

Table 3: Incidence of viral infection after transfusion (per unit infused)

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INFECTION RISK

Hepatitis B 1:63,000 – 1:233,000 Hepatitis C 1:120,000

HIV 1-2 1:676,000 HTLV 1:640,000

*Modified from Menitove, 2000 References: Bonnar J. Massive obstetric haemorrhage. Baillieres Best Pract Res Clin Obstet Gynaecol, 2000; 14:1-18. Bukowski R, Hankins, GDV. Managing postpartum hemorrhage. Contemporary OB/GYN 2001 Sept; 46:92-102. Hall MH, Halliwell R, Carr-Hill R. Concomitant and repeated happening of complications of the third stage of labor. Br J Obstet Gynaecol 1985; 92:732-738. Menitove JE. In Cecil Textbook of Medicine, 21 P

stP ed, Goldman (ed), W.B. Saunders Co,

2000. Singla AK, Lapinski RH, Berkowitz RL, Saphier CJ. Are women who are Jehovah's Witnesses at risk of maternal death? Am J Obstet Gynecol. 2001 Oct;185(4):893-5. Silver R, Depp R, Sabbagha RE, Dooley SL. Placenta previa: aggressive expectant management. Am J Obstet Gynecol 1984; 150:15. (*Didactic reprinted with permission from Labor and Delivery Essentials, © Shad Deering, 2002)