Pediatrics

MATERNAL Postpartum Hemorrhage

Diagnosis

Loss of > 500mL after vaginal birth, or > 1,000mL after cesarean delivery

Diagnosis

Loss of > 500mL after vaginal birth, or > 1,000mL after cesarean delivery

  1. ATTENTION: This checklist is for ADULT-SIZED maternal patients ONLY

  2. Prepare for crystalloid and blood product resuscitation

  3. Obtain vascular access with 2 large-bore IVs

  4. Call Blood Bank to activate Massive Transfusion with PRBC:FFP:platelet in a 4:2:1 ratio. Ask blood bank to prepare next round when each round is picked up.

    • Give calcium chloride ADULT DOSE 200-500mg/Unit PRBCs, in separate line. Monitor for hyperkalemia
    • Consider giving tranexamic acid early
    • If refractory hemorrhage, consider fVIIa and cryoprecipitate or fibrinogen concentrate
    • 200-500mg/Unit PRBCs

  5. Consider Uterotonics:

    • Methylergonovine (Methergine) ADULT DOSE 0.2mg IM NOT IV, may repeat in 2 hours (AVOID in HTN and pre-eclampsia)
    • Carboprost (Hemabate) ADULT DOSE 0.25mg IM NOT IV, may repeat q 15 minutes up to 8 doses (AVOID in asthma, pulmonary hypertension)
    • Misoprostol ADULT DOSE 800-1000 MICROgrams rectal
    • 800-1000 MICROgrams rectal

  6. Call for rapid transfuser or pressure bags

  7. Warm room, patient and fluids (NOT platelets)

  8. Send CBC, PT/PTT/INR, fibrinogen, calcium, K, ABG

  9. Consider Hemostatics:

    • Tranexamic acid ADULT DOSE 1g
    • If low fibrinogen, give cryoprecipitate ADULT DOSE 10 units or Fibrinogen concentrate
    • If refractory hemorrhage, consider factor VIIa 90 MICROgrams/kg, up to 3 doses
    • 1g
    • 10 units
    • 90 MICROgrams/kg, up to 3 doses

  10. Consider:

    • Arterial line
    • If awake, convert to general anesthesia
    • Embolization in IR
    • TEG/ROTEM monitoring

  11. Possible OB interventions

    • Intrauterine balloon
    • External uterine compression sutures
    • Uterine artery ligation
    • Hysterectomy

  12. Crisis Management (If Severe)

    Notify surgeon, call for help and code cart

  13. Position patient with left uterine displacement

  14. Increase O2 to 100%

  15. Start chest compressions 30:2 compression:ventilation ADULT RATIO (100-120 chest compressions/min)

  16. If cardiac arrest persists for 4 minutes, then proceed with perimortem cesarean delivery or assisted vaginal delivery

  17. Perform advanced cardiac life support including defibrillation if indicated

  18. Call for Transesophageal Echocardiography

  19. Consider ECMO

Patient weight

Between 0.5 kg and 120 kg

Reset the checklist?

Checked steps, the timer and this crisis log are cleared. The patient’s weight is kept.

Finish the crisis?

The timer pauses, and you can review the case and the event log.