Best Practices: Making death from postpartum hemorrhaging a 'never event'

The rate of women dying from childbirth in the U.S. is rising steadily and is now up to more than 600 women annually. Many factors contribute to maternal deaths, but postpartum hemorrhaging is one of the leading culprits.

For hospitals, preventing and treating postpartum hemorrhaging is tricky but not impossible. The right protocols and training can dramatically improve outcomes, as changes at Morristown (N.J.) Medical Center in recent years have shown.

As a destination for high-risk pregnancies, the hospital was already prepared to deal with postpartum hemorrhaging, said Donna Poplawski, a certified registered nurse who manages its maternity center.

Then, Morristown joined the Association of Women's Health, Obstetric and Neonatal Nurses' Postpartum Hemorrhaging Project, which began in 2014, and its processes and outcomes for treating postpartum hemorrhaging improved even more.

“We're quicker to respond,” Poplawski said. “We're much better about monitoring hemorrhaging.” Time is of the essence; medical literature indicates that quick detection and more rapid treatment saves lives.

Even before AWHONN's project kicked in, Morristown had massive transfusion and fourth-stage of labor policies in place. It had a postpartum hemorrhaging protocol, and clinicians and staff also practiced in monthly drills on a talking, bleeding mannequin named Noelle. That way, in real life, if a mother started hemorrhaging, everyone knew which IVs to get out and which medicines to use, Poplawski said.

Under AWHONN's project, Morristown beefed up its response and adopted several new strategies.

One of the biggest changes in protocol was quantifying blood loss. Postpartum hemorrhaging is defined as when a woman loses at least a half liter of blood after giving birth vaginally or a full liter after giving birth through cesarean section.

But diagnosing postpartum hemorrhage is often subjective and “based on inaccurate estimates of blood loss,” the federal Agency for Healthcare Quality and Research has noted.

“Most providers of obstetric care are underestimating blood loss,” said Dr. Margaret Dow, a laborist and an assistant professor of OB-GYN at the Mayo Clinic in Rochester, Minn., who was not involved in the Morristown project. The problem, she said, was “chronic” and “ubiquitous.”

To better measure blood loss, Morristown Medical Center swapped out green delivery drapes for sets with clear calibrated pouches. Staffers also learned to measure how much blood soaked into towels or gauze during a hemorrhaging event.

But even with calibrated drapes, accurately measuring blood loss during delivery is “tricky,” Poplawski said, because other fluids besides blood are emitted as well.

As a result, “it's difficult to correct for the normal fluids present at delivery,” Dow said.

At Morristown, these changes have resulted in extra work for hospital clinicians and staff, Poplawski said. They received additional training, including a 20-minute online tutorial explaining quantitative blood loss, followed by a brief test.

The hospital also began carrying out risk assessments for mothers before, during and after childbirth. They checked for risk factors such as blood disorders and bleeding during pregnancy. During delivery and after, they would assess mothers and their labs again, keeping an eye out for minute changes.

The hospital also tapped “champions,” almost all of them nurses, who led the way in implementing the changes and explaining to others. “Staff are much more willing to listen to their peers than when the management comes down,” Poplawski said. The hospital also began debriefings following hemorrhage events.

Since Morristown joined the project, stays of postpartum hemorrhage patients in the ICU dropped from eight days to 1.5, Poplawski said.

AWHONN's project involved 58 hospitals in Washington, D.C., Georgia and New Jersey, which had to apply to participate. Over the course of 18 months in 2014 and 2015, those hospitals received coaching from a panel of quality improvement experts as well as feedback and analysis for data they submitted monthly. Clinicians were also invited to take part in online learning activities.

The right education and preparation for postpartum hemorrhaging, as well as access to surgical treatment if medical management fails, are key to improving outcomes for postpartum hemorrhaging, Dow said.

“We have so many options to treat it. Maternal death from postpartum hemorrhaging should be a never event.”