In case of obstetric bleeding, there should be a detailed emergency management plan with instructions for diagnosis and evaluation. Each institution should develop a contingency plan to meet its needs and adjust it according to its capabilities. In all cases of bleeding, it is important to help patients and their families with reassured information, timely information and other resources to support them. The first package, the Obstetric Hemorrhagic Patient Safety Package, was originally published on the website. Then, in 2015, a more detailed paper was published simultaneously in four influential journals: Anesthesia & Analgesia,17 Obstetrics and Gynecology,18 Journal of Obstetric, Gynecologic, & Neonatal Nursing,19, and Journal of Midwifery and Women`s Health.20 Obstetrics is the most common complication of childbirth, but much of the bleeding-related morbidity and mortality is considered preventable.21, 22 Areas for improvement include better detection and quantitative assessment of blood loss, increased attention to clinical signs of bleeding, faster restoration of blood volume, and greater emphasis on decisive intervention.23 The goals of the bleeding bundle include limiting the proportion of severe bleeding episodes, reducing the need for transfusion of blood products, and reducing the frequency of coagulopathy. The “Readiness” section of the bleeding package contains a list of supplies and systems needed to prepare for bleeding, para. B example a bleeding cart and bleeding medications. The Detection and Prevention section contains the assessments that must be made for each patient, para. B example an accurate measurement of cumulative blood loss.
The procedure includes phased contingency plans for obstetric bleeding. Finally, reporting and system learning provide recommendations for conducting multidisciplinary reviews after severe bleeding episodes, including guidance for debriefing and perinatal quality improvement committees (Figure 3). In response to the increase in maternal mortality and morbidity in this country, it is imperative at the national level to identify and assess the causes of these deaths, as well as to identify preventable factors. Remarkable progress has been made in the state of California, where more than 10% of U.S. births take place. Data published between 2002 and 2004 on maternal mortality in California documented 207 deaths, nearly 40% of which were potentially preventable.13 Three conditions were the most preventable: obstetric bleeding, deep vein thrombosis, and preeclampsia/eclampsia. In response to these findings, the California Maternal Quality Care Collaborative has created free online “toolkits” that are accessible to everyone. The toolkits include a collection of articles, guidelines, implementation guides and educational materials with the aim of preventing death among part-time workers. The first toolkit that was published was on obstetric bleeding.
Many hospitals in California have used the toolkit to implement efforts in their facilities to actively reduce maternal bleeding, as well as the resulting morbidity and mortality. Over the next five years, maternal mortality in California dropped dramatically relative to the national maternal mortality rate, which continued to rise from 2008 to 2013 (Figure 2). Like the bleeding beam, the document is divided into four subgroups: preparedness, detection and prevention, response, and system report/learning. The “Readiness” section contains diagnostic criteria and guidelines for antihypertensive drugs, including dosages and administration. The Detection and Prevention section contains protocols for measuring and assessing blood pressure. The response includes management plans for patients with severe hypertension and eclampsia. Again, reporting and system learning include recommendations for multidisciplinary reviews, including debriefings (Figure 4). Four years after leading the efforts in California, Dr. Eliot Main has issued a call to action to bring similar resources and infrastructure to the national stage. Representatives from various organizations met in Atlanta in 2012 to develop a collaborative approach to optimize maternal health and improve maternal care. The group has set priorities for the implementation and use of obstetric safety efforts. These meetings led to the formation of the National Partnership for Maternal Safety (NPMS), which is hosted by the Council on Patient Safety in Women`s Health Care.
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