Obstetric Hemorrhage Checklist Example

Complete all steps in prior stages plus current stage regardless of stage in which the patient presents.

Postpartum hemorrhage is defined as cumulative blood loss of greater than or equal to 1,000mL
or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours. However,
blood loss >500mL in a vaginal delivery is abnormal, and should be investigated and managed
as outlined in Stage 1.

Recognition:
 
Call for assistance (Obstetric Hemorrhage Team)
     
Designate: Team leader Checklist reader/recorder Primary RN
     
Announce: Cumulative blood loss Vital signs Determine stage

Stage 1: Blood loss >1000mL after delivery with normal vital signs and lab values. Vaginal delivery
500-999mL should be treated as in Stage 1.

Initial Steps:
Oxytocin (Pitocin): 
  Ensure 16G or 18G IV Access
10-40 units per 500-1000mL solution
  Increase IV fluid (crystalloid without oxytocin)
  Insert indwelling urinary catheter Methylergonovine (Methergine): 
0.2 milligrams IM (may repeat);  
  Fundal massage
Avoid with hypertension
Medications: 15-methyl PGF2α (Hemabate, Carboprost): 
  Ensure appropriate medications given patient history 250 micrograms IM (may repeat in q15 minutes,
  Increase oxytocin, additional uterotonics maximum 8 doses); Avoid with asthma; use
with caution with hypertension
Blood Bank:
  Confirm active type and screen and  Misoprostol (Cytotec): 
consider crossmatch of 2 units PRBCs 800-1000 micrograms PR 
600 micrograms PO or 800 micrograms SL
Action:
  Determine etiology and treat
Tone (i.e., atony)
  Prepare OR, if clinically indicated   Trauma (i.e., laceration)
(optimize visualization/examination) Tissue (i.e., retained products)
Thrombin (i.e., coagulation dysfunction)

Stage 2: Continued Bleeding (EBL up to 1500mL OR > 2 uterotonics) with normal vital signs
and lab values

Initial Steps:
  Mobilize additional help
  Place 2nd IV (16-18G)
  Draw STAT labs (CBC, Coags, Fibrinogen)
  Prepare OR Tranexamic Acid (TXA)
Medications: 1 gram IV over 10 min (add 1 gram vial to  
100mL NS & give over 10 min; may be
  Continue Stage 1 medications; consider TXA
repeated once after 30 min)
Blood Bank:
  Obtain 2 units PRBCs (DO NOT wait for labs. Transfuse per clinical signs/symptoms)
  Thaw 2 units FFP
Possible interventions:
Action: • Bakri balloon
  For uterine atony --> consider uterine balloon  • Compression suture/B-Lynch suture
or packing, possible surgical interventions • Uterine artery ligation
  Consider moving patient to OR • Hysterectomy
  Escalate therapy with goal of hemostasis

Huddle and move to Stage 3 if continued blood loss and/or abnormal VS

Safe Motherhood Initiative

Revised June 2019
 Stage 3: Continued Bleeding (EBL > 1500mL OR > 2 RBCs given OR at risk for occult bleeding/
coagulopathy OR any patient with abnormal vital signs/labs/oliguria)

Initial Steps:
  Mobilize additional help Oxytocin (Pitocin): 
10-40 units per 500-1000mL solution
  Move to OR
  Announce clinical status   Methylergonovine (Methergine): 
(vital signs, cumulative blood loss, etiology) 0.2 milligrams IM (may repeat);  
  Outline and communicate plan Avoid with hypertension

Medications: 15-methyl PGF2α (Hemabate, Carboprost): 

250 micrograms IM  
  Continue Stage 1 medications; consider TXA
(may repeat in q15 minutes, maximum 8 doses) 
Blood Bank: Avoid with asthma;
  Initiate Massive Transfusion Protocol   use with caution with hypertension
(If clinical coagulopathy: add cryoprecipitate,   Misoprostol (Cytotec): 
consult for additional agents) 800-1000 micrograms PR 
Action: 600 micrograms PO or 800 micrograms SL
  Achieve hemostasis, intervention based on etiology Tranexamic Acid (TXA)
1 gram IV over 10 min (add 1 gram vial to
  Escalate interventions
100mL NS & give over 10 min; may be repeated
once after 30 min)

Possible interventions:
• Bakri balloon
• Compression suture/B-Lynch suture
• Uterine artery ligation
• Hysterectomy

Stage 4: Cardiovascular Collapse (massive hemorrhage, profound hypovolemic shock, or amniotic

fluid embolism)

Initial Step:
  Mobilize additional resources Post-Hemorrhage Management
• Determine disposition of patient
Medications:
  ACLS • Debrief with the whole obstetric care team
• Debrief with patient and family
Blood Bank:
• Document
  Simultaneous aggressive massive transfusion

Action:
  Immediate surgical intervention to ensure
hemostasis (hysterectomy)

Revised June 2019

Safe Motherhood Initiative