PPH 4 stage Protocol Checklist - LARGEvL9.7

Date/Time DocumentaRon of concerns, deviaRons & other informaRon Working together to reduce harm from Postpartum Haemorrhage

Pa=ent addressograph

Postpartum Haemorrhage Management Checklist

Designed to be used in maternity seKngs. This is not a comprehensive guideline
but a checklist to facilitate an appropriately escala=ng mul=disciplinary team

approach to postpartum haemorrhage and as an aid to documenta=on.

Stage 0 Stage 1

PPH Risk Assessment >500ml ongoing blood loss
Complete for all women on admission (including LSCS) SVD & Instrumental deliveries

Most recent Hb = _____ Plt =_____ Result Date: G et Help Time
__ / __ / __ Ini/al
NoKfy midwife in charge

PPH Risk Assessment
Tick if Name: __________________________________________ =me arrived: ___:___
applicable

Antenatal - “Increased risk” if any of the following are met: Request HCA to assist with measurement
Anaemia or bleeding disorder (Hb <95, plt < 100) Other staff present
PPH Post-event Checklist BMI <18 or >35 or Booking Weight <55Kg Designa/on Time Ini/al
Arrived
If low weight/BMI – do you need to calculate the circula=ng blood volume?
≥ 5 previous vaginal births
WHO sign-out completed? Yes / No / NA (Pa=ent did not require care in theatre) Previous uterine surgery
Have all drugs been prescribed and signed for? Yes / No / NA Previous Postpartum Haemorrhage >1L
MulKple pregnancy or esKmated fetal weight >4.5kg
Post-event Re-bleed Risk Assessment A ct Performed by Time
Ini/al
Syntocinon infusion running or required? Yes / No Time expected to finish ___:___ (Mcumeaulsau=vree m Bealosuoredm eLnot)s s
Vaginal pack insitu? Yes / No Planned removal Kme ___:___ Abnormal placental implantaKon

Bakri Balloon insitu? Yes / No Planned removal Kme ___:___ Polyhydramnios Record observaKons
Can NSAID be given? Yes / No / Not yet Time of first dose: ___:___ Known AbrupKon or Antepartum Haemorrhage
LMWH on MEOWS every 10 min
Yes / No
IV access
Thromboprophylaxis plan:
a t least 16 Gauge
P ost-event Monitoring Requirements TEDS Yes / No Please make an on-going assessment of the following
Level of post-event care required (circle applicable)
Post-op bloods (FBC/Coag/U&E) to be taken at Level 1 Level 2 (HDU) Level 3 (ICU) risk factors throughout labour and delivery
Time: ___:___ Plan to transfuse if Hb < _____
Perinatal - “Increased risk” if any of the following are met:



What is the cause of bleeding?

PV loss monitoring required? Yes / No Frequency of monitoring ____________ Suspicion of chorioamnioniKs / Sepsis Tone, Trauma, Tissue, Thrombin (please circle cause(s))
Urine output monitoring required? Yes / No Frequency of monitoring ____________
Labour augmented with syntocinon Time
Yes / No / NA TU trereinae mt assage Performed by Ini/al
Yes / No / NA
MOH stand down Prolonged labour
Any blood/products to return to blood bank?

If the MOH protocol was acKvated before stage 3 or not acKvated at stage 3 then please detail reason(s) why: G ive uterotonics
Instrumental delivery
______________________________________________________________________________________________________ (record on over page & prescribe)
Retained products of concepKon

Does a DaRx form need compleRng? Yes / No I nspect genital tract

If yes record: Plan to measure & record all blood loss E mpty bladder
(for pool deliveries es=ma=on may be required)
- DaKx form number ________________________

- Person responsible for compleKng DaKx form ________________________ C heck placenta &
Yes / No (triggers include MBL ≥1000ml, ROTEM performed, blood products given) Act m embranes
If woman at increased risk is:
B imanual compression
Does the case need highlighRng to OBS Cymru Champion? She suitable for EI blood or 2 units Xmatch? Yes / No
Yes / No IV access required? (at least 16 Gauge) Yes / No


Has the event been discussed with the paKent?

Has wriWen informaRon been provided to the paKent? Yes / No Treat
Does a formal team debrief need to take place? Yes / No
If bleeding stopped:

Completed by: _____________________________ (Please print) Date: ________ Time: __:__ Loca=on ____________ Planned an acKve 3rd stage management? Yes / No - Please record MBL here ____________ ml

Completed by: ______________________ (Please print)
Copyright © 2016, Public Health Wales Completed by: ______________________ (Please print)
Produced by OBSCymru, acknowledging the work of CMQCC. (Visit www.cmqcc.org for more details)
Date: ________ Time: __:__ Loca=on ____________ Date: ________ Time: __:__ Loca=on ____________
Contact [email protected] for more informaKon or prior to use or amendment.
Page 4 Version L9.7 Jan18 Page 1

Stage 2 >1000mL blood loss OR clinical concern (eg. AbrupKon or concealed bleeding) Record of Uterotonics used Please record all uterotonics used here and prescribe on medica=on or anaesthe=c chart

OR abnormal vital signs RR > 30, HR ≥120, BP ≤90/40mmHg, SpO2<95% Drug Dose (please circle route) Time Drug Dose Time

Progress to here from stage 1 if SVD / instrumental delivery. Re-start here aier stage 0 if LSCS Oxytocin 10 units IM or 5 units IV Carboprost 250microg IM
Other
Get Help Time arrived: Other staff: Time arrived: Ergometrine 500 microg IV or IM (cau=on in asthma) (repeat up to every 15min)
500 microg/5 units IM or IV
MW in charge Name: ________________________________ =me: ___:___ Name: ________________________ Designa=on: ________ =me: ___:___ (cau=on in HTN/PET) 40 units over 4hr IV Carboprost 250microg IM
Obstetrician Name: ________________________________ =me: ___:___ Name: ________________________ Designa=on: ________ =me: ___:___ Carboprost 250microg IM
Syntometrine Carboprost 250microg IM
AnaestheKst Name: ________________________________ =me: ___:___ Name: ________________________ Designa=on: ________ =me: ___:___ Carboprost 250microg IM
Name: ________________________________ =me: ___:___ (cau=on in HTN/PET) Carboprost 250microg IM
HCA Carboprost 250microg IM
Performed by Oxytocin INF Carboprost 250microg IM
Act Time Other Other
Measure & record cumulaKve blood loss Ini/al Misoprostol
Misoprostol
Record observaKons on MEOWS every 10 min
2nd IV access (at least 16 Gauge) & fluid bolus
Take bloods Point of care tests - ROTEM, venous lactate, venous Hb
Lab test - FBC, Coag, XMatch, U&E


Blood & Blood products transfused Measured cumulaRve blood loss
IniRal VBG Test Results IniRal ROTEM Test Results
Time Product given Time Product given
FIBTEM A5 =
Time: Hb = Lactate = (Aim ≥ 12mm) EXTEM CT = Time Blood Loss (ml) Running Total (ml)
(Aim < 75 sec)



Review causes (circle all iden=fied) Tone / Trauma / Tissue / Thrombin Performed by Time
Treat Review uterotonics (record on page 3) Ini/al
Give tranexamic acid (1g IV, if no CI’s) Time
Bimanual compression Performed by Ini/al Empty bladder
Foley catheter inserted
Consider raniKdine Inspect genital tract

Repair genital tract

Check placenta & membranes

If bleeding stopped ensure PPH post-event checklist completed & Management plan wrijen in notes

Completed by: ______________________ (Please print) Date: ________ Time: __:__ Loca=on ____________

If bleeding ongoing transfer paRent to the atre =me arrived: ___:___

Act Performed by Time
Ini/al
Communicate current measured blood loss to team
Working together to reduce harm from Postpartum Haemorrhage
AcKvate MOH protocol

Inform Obstetric and AnaestheKc consultants

Order blood and coagulaKon products as per MOH and ROTEM protocol Total Measured Blood Loss = _______ml

- Do you need to discuss the case with a haematologist? Performed by Time Record of further blood test results (Please do not duplicate records of blood results recorded in stage 2)
Ini/al

Further VBG Test Results Further ROTEM Test Results
Review causes (circle all iden=fied) Tone / Trauma / Tissue / Thrombin



T reat
Review uterotonics (Record on page 3)
Consider repeat tranexamic acid if bleeding ongoing (1g IV, if no CI’s)
C onsider advanced surgical techniques (Document on page 4) Time Taken Hb Lactate FBTEM A5 (Aim ≥ 12mm) EXTEM CT (Aim < 75 sec)

AddiRonal Staff Present: Time arrived: Time arrived:

Name: ________________________ Designa=on: ________ =me: ___:___ Name: ________________________ Designa=on: ________ =me: ___:___
Name: ________________________ Designa=on: ________ =me: ___:___
Name: ________________________ Designa=on: ________ =me: ___:___
O nce bleeding stopped ensure PPH post-event checklist completed & Management plan wrijen in notes

Completed by: ______________________ (Please print) Date: ________ Time: __:__ Loca=on ____________ Page 3
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