As an anesthesiologist, I have always said that obstetric anesthesia is the best of times and the worst of times. It often seems that pregnant women are happier to see me than to see their obstetrician, because I am the guy putting in the epidural and taking away their labor pains (aka, Dr. Feelgood). Watching the pregnant patient relax and then literally feeling tension ease in the room is a great thing. However, when you work with a high risk obstetric population, things can go from good to very bad at the blink of an eye.
While modern management of labor and delivery is generally very safe, complications still can occur for the baby and mother. Although losing a patient’s airway during a “crash” cesarean section is a constant fear of OB anesthesiologists, the clear and present danger is obstetric hemorrhage.
Incidence and Risk Factors
Although pregnant women are physiologically well prepared to withstand the “usual” blood loss of delivery (typically 500- 1000 mL), as many as 10% to 15% of deliveries result in excessive bleeding. Obstetric hemorrhage is defined as blood loss exceeding 1500 mL or the need for blood transfusion, and it is the leading cause of maternal mortality. Obstetric hemorrhage has many potential causes, including uterine atony, rapid or prolonged labor, previous pregnancies, uterine infection, failure to deliver the placenta, lacerations of the cervix or vagina, uterine inversion and the retention of products of conception. Factors that may increase a woman’s risk include prolonged active labor, placenta previa, pre-eclampsia, episiotomy, ethnicity (southeast Asian or Hispanic), obesity and multiple pregnancies. Uterine atony, the most common cause of obstetric hemorrhage, occurs when the uterine muscles fail to contract normally after the delivery of both the baby and placenta. When the placenta separates from the wall of the uterus, the blood vessels that supplied it during pregnancy are severed, resulting in uncontrolled bleeding in the absence of normal uterine contraction.
Recent findings published in the British Journal of Obstetrics and Gynaecology detailed the incidence and risk factors for severe obstetric hemorrhage.1 During a five-year period, out of more than 307,000 births considered from national data, researchers identified severe obstetric hemorrhage in 3,501 births, or 1.1% of cases. Women undergoing emergency cesarean delivery had the highest adjusted odds ratio for severe hemorrhage at 3.61 (meaning a 360% increased incidence), followed by those with Von Willebrand’s disease (OR 3.31) and elective cesarean deliveries (OR 2.47). In addition, mothers older than age 40 were more likely to suffer severe hemorrhage than those in the 25-to-29-year age range, with an odds ratio of 1.41. Obstetric hemorrhage was also the topic of a Joint Commission Sentinel Alert published in January 2010.2
Approaches to Treatment
Traditional management of obstetric hemorrhage involves searching for the source of the bleeding and implementing steps to stop it. If bleeding is suspected to originate in the uterus, actions that can be taken include uterine massage, which may stimulate the uterus to contract; uterotonics, such as oxytocin; uterine exploration and curettage; and uterine packing. Laparotomy may be performed if other interventions prove ineffective, with the surgeon undertaking repair of uterine injuries and ligation of the internal iliac artery or branches of the uterine artery. In unresponsive cases, an emergency hysterectomy is performed in an attempt to stop the bleeding.3 All cases of severe obstetric hemorrhage are complicated by rapid rates of blood loss since the uterus at term gets almost 1/5th of the total blood flow of the body, and clotting disorders such as disseminated intravascular coagulation (DIC) are common.
Some hospitals are taking a more aggressive approach to treatment, implementing hospital-specific, standardized protocols and responses to manage obstetric hemorrhage. Members of obstetric hemorrhage teams adhere to a “rehearse to be ready” philosophy, practicing responses to different scenarios in order to be prepared in the event obstetric hemorrhage occurs. Of interest, the Illinois Department of Public Health implemented the Obstetric Hemorrhage Education Project in 2008 to develop and implement protocols to reduce the incidence of maternal morbidity and mortality due to obstetric hemorrhage.
The Merits of a Team Approach
Time is of the essence in order to prevent or minimize harm to the baby and mother, and since the best outcomes are obtained through preparation, St. Vincent Women’s Hospital Indianapolis developed the ‘Heme Team’ as an innovative approach to provide the best care available in ‘Code Red’ situations. In cases of obstetric hemorrhage, a complex series of actions must be performed quickly and correctly by a variety of caregivers, including the obstetrician, anesthesiologist, nurses, surgery personnel, neonatal specialists, laboratory technicians and perfusionists/ autotransfusionists. In order to consistently and correctly perform these series of actions in a coordinated way, the Heme Team was formed to study the situation and develop mechanisms to standardize procedures.
Because of the around-the-clock nature of labor and delivery, preparedness drills are performed at various times to cover all shifts. When a case of obstetric hemorrhage occurs, the obstetrician performs standardized surgical management of the patient while the anesthesiologist performs standard resuscitation procedures. The blood bank provides blood product support and the perfusion team responds to the labor suite to provide both diagnostic and therapeutic support. Perfusionists provide point-of-care diagnostic tests to provide clinicians with near real-time information on the patient’s blood counts and coagulation status. Armed with that information, physicians are able to make smarter decisions about blood component therapy and to gauge and track the rate of bleeding. Perfusionists also provide support via autotransfusion machines, which can recycle the mother’s blood and reduce the need for banked blood products, potentially lowering the risk of transfusion-related complications.4 In the case of a smaller hospital with limited blood bank resources, autotransfusion can be life saving in cases of massive hemorrhage.
Obstetricians and anesthesiologists must be familiar with the risk factors, causes and treatment of obstetric hemorrhage. Most importantly, training and tools for this infrequent but potentially catastrophic complication must be geared to deal with this scenario at any time of the day or night in order to provide mothers and babies with the best outcomes. As part of the Heme Team, physicians and nurses receive instruction and training in a systematic protocol to treat obstetric hemorrhage. Drills and reviews of cases ground the team in real-world practice and encourage all involved to strive for continued improvement. I strongly recommend that all hospitals providing obstetric services develop a similar approach to the management of obstetric hemorrhage as a patient safety measure and to improve the quality of care.
- Al-Zirqi I, Vangen S, Forsen L, et al. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008;115(10):1265-72, 2008.
- Preventing maternal death. The Joint Commission, Sentinel Event Alert; Issue 44: January 26, 2010.
- Bodelon C, Bernabe-Ortiz A, Schiff MA, et al. Factors associated with peripartum hysterectomy. Obstetrics & Gynecology 2009;114(1):115-23.
- Waters JH. Indications and contraindications of cell salvage. Transfusion. 2004;44:40S-44S.