Just Us: Before, Birth, and Beyond

Season 2, Episode 3: OB Hemorrhage

• MAHEC • Season 2 • Episode 3

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Intro [00:00]: Hi everyone, and welcome back to Just Us Before Birth and Beyond. We're so glad to have you with us today. My name is Katlyn and I am one of the hosts of our podcast, and I am here today to introduce this episode, which I am calling a very meaty episode. So, we are going to talk about OB hemorrhage, and we are touching on everything from. The definition of OB Hemorrhage to what hospital units and systems can do to be prepared for this obstetrical emergency. It is a pretty lengthy episode. We are touching on a lot of different topics. I have Dr. Suzanne Dixon and Dr. Brea Boulevard on the episode today. They do a really great job of introducing themselves sort of at the top of the episode, so I will let them cover that.


But it's just a really good detailed episode. Lots of really great didactic information and we hope you enjoy it. Hi everyone. Welcome back to Just Us Before Birth and Beyond. We are so glad to have you here with us today. My name is Katlyn and I am one of the hosts of our podcast, and I'm here today with another of our hosts, Dr. Suzanne Dixon. And we're going to be talking to Dr. Brea Boulevard, all about OB hemorrhage, everything from the importance of understanding what an OB hemorrhage is, how to manage it, some statistics and new information that's come out, and even some discussion on simulations that can be done in inpatient labor and delivery units for OB hemorrhage. So, let's get started. Dr. Dixon, you want to take a second to introduce yourself? 


Dr. Dixon [01:52]: Hi everybody. Thanks for joining today. I'm Suzanne Dixon, I'm one of the generalists OBGYN physicians over at Naec in Western North Carolina, and I'm also serving as the OB champion for Prenatal Region One for North Carolina, which I've enjoyed very much. This is a very important topic, I think near and dear to all of our hearts. The folks that take care of pregnant patients and the day of delivery and during the postpartum period. And so, it's important for other providers of prenatal care to be up to date and using all the latest information that's available to take the best care of our patients and reduce maternal morbidity mortality from this cause.


Katlyn [02:33]: Thank you, Dr. Dixon, and we'll give Dr. Boulevard. 


Dr. Boulevard [02:37]: All right. Hi, I'm Brea Boulevard. I have been in Western North Carolina working as a physician since 2012 when I came here to be a resident at May Heck, and I learned a lot about being an OB Hemorrhage from Dr. Suzanne Dixon, who was my attending at the time, and now I get to be her colleague. I am an OB hospitalist, meaning I only work in the hospital taking care of pregnant patients, either if they're admitted to the hospital before delivery and then during delivery and postpartum. I'm also serving as the OB-GYN service line leader for the physicians at Mission Hospital, and I'm the medical director of OBGYN at Mission Hospital as well, and I have the great joy of doing OB Hemorrhage simulations with Katlyn throughout our region, and I have been on the OB hemorrhage team at Mission Hospital since 2015, so this is a topic that I think about on a daily basis, and so I'm excited to have this time to speak with you all about it. 


Katlyn [03:44]: Great. Thank you so much for being here and lending us your expertise. I think that we are coming to the end of our work spreading the ob hemorrhage bin throughout the region to the outlying hospital. So, this is a really great time to kind of regroup and look back at that process and give a little synopsis of how that project went. That was a project that was funded by the Maternal Health Innovations Grant in North Carolina, and I think it's been very an arm of it that's been very successful, so I look forward to hearing more about that. Before we get started, just going over some historical context related to postpartum hemorrhage. Dr. Boulevard, can you just give us the official current definition of postpartum hemorrhage?


Dr. Boulevard [04:30]: Sure. So, in several years ago, they changed the definition. So, the definition now is blood loss greater than a thousand milliliters surrounding the time of delivery, regardless of the delivery route. So, if you have a C-section or if you have a vaginal delivery, anything over a thousand vital sign changes or a loss, a decrease of your hematocrit, greater than 30 is defined by ACOG as an obstetric hemorrhage.


Dr. Dixon[05:00]: So, the CDC has recently come out with new maternal mortality rates for the United States, looking back at 20 is the most recent data I believe. And we know that postpartum hemorrhage is the ideology of about 11% of all cases of postpartum maternal mortality in the United States and worldwide. In looking at those numbers from 2020, there has been an increase in maternal mortality.


I think we're the only developed country in the world that is showing an increase in maternal mortality at this time, and our rates went up from 20.1 per hundred thousand from 2019 to almost 24 out of 100,000 in 2020. And two statistics really stand out in that report to me. One is the increase in maternal mortality related to race and ethnicity, specifically for non-Hispanic black women. The rate was 55.3 per 100,000 women in 2020 per maternal mortality. And another statistic that should not have been a surprise to me, but I had not considered it was age as a really major risk factor. The rate for maternal mortality in 2020 was 108 women out of 100,000 who were over 40 experienced deaths related to their pregnancy.


So, these numbers just are staggering and heart-wrenching for us. Those of us who are really day in and day out trying to provide quality experiences for women as they go through their pregnancy and delivery and postpartum days. And also we are constantly trying to look at ways that we can reduce inequities related to race and ethnicity, and also need to consider age in that risk stratification.


So, interestingly, we have had two recent articles published in The Green Journal in January and February of 2023 that really pertain to this work to reduce maternal morbidity mortality from obstetric hemorrhage. The first was the January article entitled Postpartum Hemorrhage Trends and Outcomes from 2000 to 2019, and the second was in February, and it's entitled State Prenatal Quality Collaborative for Reducing Severe Maternal Mortality and Morbidity from Hemorrhage.


The first one really looks back at the trend over the past two decades in the United States for postpartum hemorrhage. They took data from the NIS or nationwide. Inpatient sample and looked at 76.7 million deliveries that occurred in the United States, of which 3% experienced a postpartum hemorrhage. It did show that during that time that they were watching, the rate of hemorrhage increased from 2.7% to 4.3%, which is quite significant. The number of transfusions that were given for the first decade increased triple fold, so from 5.4% to 16.7%. And then for the past few years, that trend for hemorrhage and treated with transfusion has decreased a little bit from 16.7 down to 12.6%.


Also, they looked at peripartum hysterectomy from hemorrhage and that rate went up during the initial decade from 1.4% to 2.4%. So, it doubled, and then it stayed the same for several years, and then for the last three years, since 2016, has decreased again from 2.4% down to 0.9%. It is stated in the article, and it makes sense to me that these decreases in interventions, transfusions, and hysterectomies coincide with the implementation of statewide bundles to address the problem of postpartum hemorrhage in earlier interventions.


So, that shows some progress for sure. This article also identified some risk factors for postpartum hemorrhage. Certainly, the highest risk ones would be a prior cream section with previa or accreta spectrum placenta previa without a prior C-section, and then any antepartum hemorrhage or abruption diagnosis. So, those are the risk factors that are considered the highest risk, but they also list a long induction of labor with Pitocin. High parity, choreo, general anesthesia with a C-section, multiple gestation, poly hydria, or masom. Anything that does increase the size of the uterus, decrease contractility.


Fibroids would be another example of that. Advanced maternal age and then preeclampsia with severe features. A lot of these clinical features are increasing on a population basis in our country, and there's a really nice craft that shows that linear increase for many of these risk factors for postpartum hemorrhage. That's figure three if you want to reference that. That just gives credence to our feeling that the numbers are definitely increasing. This study was also able to stratify folks, so if a patient had one of those previously listed risk factors, their risk for postpartum hemorrhage went up from 2.9 to 3.3%. And if the patient had two or more risk factors, the risk of postpartum hemorrhage increased from 2.9 to 6.5%. So, that is quite an increase. The numbers for intervention with transfusion and hysterectomy also both go up in accordance with whether there was just one risk factor or two or more risk factors, quite a bit.


Unfortunately though, and so, this does give credence to the idea of in our readiness and recognition stage of our intervention, that to risk stratify patients that come in with really high risk for PI pharm hemorrhage, they ought to consider being transferred to higher level maternity care institution that takes care of hemorrhage on a regular basis. However, unfortunately, almost 74% of the postpartum hemorrhage cases in this cohort did not have even one risk factor. So, we do know just from clinical practice that hemorrhage can occur in the absence of any risk factors, and we need to be ready no matter what. The next article that is pertinent to this work is from the February Green Journal, and it is looking at the CM QCC, the California Maternal Quality Care collaborative work.


They were able to institute an OB Hemorrhage bundle back in 2016, I believe, and they compared in this study the hospitals that had initiated the practices to reduce maternal hemorrhage and compared it to a hypothetical equal number of patients from hospital to do not implement the bundle. And so, they were able to show that there was a great reduction in reducing the severe maternal morbidity associated with postpartum hemorrhage. Including transfusions and hysterectomies, and they were able to prevent one maternal death and that they were looking at 480,000 births in each cohort with that. They also used quality adjusted life here as a cost effectiveness threshold marker. So, looking at women that had to have hysterectomies as part of their treatment for their postpartum hemorrhage, assuming that that is going to really impact their quality of life and help for years to come, which we know it does.


They assigned a $100,000 per quality adjusted life year gained, and that is how they were able to say that this was a cost effective in smaller hospitals. So, there is some cost associated with adding this preventative bundle. I think at one point they described it's different depending on the number of deliveries per year at each hospital, but for large hospitals delivering greater than a 5,000 deliveries per year, the cost is about $17 per birth and it can dabble or triple depending on how many deliveries a hospital is doing.

In those really low volume hospitals where the cost effectiveness did rely on the quality adjusted life years gained from avoiding hysterectomies for patients, there was the greatest reduction in postpartum hemorrhage. So, even though it was more costly per patient for the smaller hospitals, there was a greater reduction in hemorrhage of up to 44% for those smaller hospitals compared to the bigger hospitals, it was more like a 6% reduction in hemorrhage.


So, these two articles really deserve a review when you're talking to your institutions about causes and trends for postpartum hemorrhage and evidence-based means that we can employ on a institution level to really prevent further hemorrhage and loss of life, and really improve patient's quality of life as well. All right. And what are some of the complications that can arise related to postpartum hemorrhage that folks might not be thinking about on a daily basis? 


Dr. Boulevard [13:56]: Sure. So, we definitely worry about medical complications of hemorrhage, including volume loss, needing a blood transfusion, renal failure. You can have cardiac arrest related to OB hemorrhage if you're significantly anemic. Need for a postpartum hysterectomy, meaning you would lose any chance at fertility in the future I C U admission. And then obviously death. The things that I think more about for our patients include struggling with breastfeeding, even if for a lower amount of hemorrhage. Struggling with breastfeeding. We know there's higher rates of postpartum depression after a hemorrhage. Hemorrhage treatment can sometimes be traumatic and scary for patients. So, thinking about birth trauma that can happen for patients surrounding their hemorrhage and then trouble with bonding with their baby if they needed extra medical care. Those are some of the things that I think about when I'm caring for patients that maybe aren't strictly medical renal failure, hypo, limbic shock sorts of things. 


Dr. Dixon [15:07]: Yeah, Hemorrhage PTSD is something that we see when we're seeing patients back for their postpartum visits in the office, and there has been a hemorrhage or any kind of emergent interaction intervention for hemorrhage.


Dr. Boulevard [15:18]: Exactly. 


Dr. Dixon [15:19]: And I think support for families as well is important. 

Dr. Boulevard [15:22]: Yeah. I think the ACOG and some other supportive organizations have started thinking about the same, you know, making sure that there's a debrief for families and understanding what signs to look out for, including postpartum depression and postpartum anxiety after a person has experienced a hemorrhage, and then also for the staff who cares for these patients. That has been one of the things we've been working on at Mission is making sure that we do a debrief after every single hemorrhage with our staff to see not only how people are feeling, but also what could have been done better. 


Dr. Dixon [16:02]: Great. Well, I do realize that there has been such an emphasis on this as a cause of maternal morbidity and mortality recently, just probably in the last five to seven years, statewide and across the country, which we are all really appreciative of. Just for some context, I trained in the late nineties and very early two thousands and we did not really talk very much about postpartum hemorrhage or day of delivery hemorrhage. We generally would manage people, actively during the third stage, and I think that our. Induction times were probably not quite as long as they are now because we were in that time of the pendulum swing for C-section rates.


That was considered much more appropriate intervention if an induction was dragging out a little bit longer and maybe for those reasons did not have quite as much hemorrhage. Although I do believe that there are lots of risk factors in the population that are also increasing now, and we just probably frankly did not recognize when there was a hemorrhage during that time. Quite as easily. In my recollection, we did transfuse patients when they were hospitalized after delivery, but it was usually the next day coming around and rounding and realizing that their hemoglobin was a little low and their tachycardic or urine output was a little low, going ahead and giving some blood at that time.


And now we know that by the time a woman starts to display symptoms of hyperemia like that, they've already lost a quarter of their blood volume, which is pretty scary. So, the early recognition and the strict diagnoses criteria and risk stratification, all these things are leading to better recognition of hemorrhage. That being said, I still think the rates are increasing, and I have noticed that over the course of my two decades in practice, and I think anyone that's been in practice for as long as I have would agree.


Dr. Boulevard [17:57]: Dr. Dixon, one of the, the ACOG practice bulletin on postpartum hemorrhage mentioned that there was a 26% increase of obstetric hemorrhage between 1994 and 2006, which was probably part of your time. And I think you're really right about recognition. In 2015 when we really started looking at this, it was all about recognition. Performing a quantitative blood loss instead of using an estimated blood loss, and then treating the hemorrhage appropriately after they had made it to a thousand of blood loss.


And a lot of other hospitals were doing the same thing after recommendations from the California Quality Collaborative or C.M.Q.C.C. And so, adding a hemorrhage cart to your hospital at our hospital, we have a code OBH that's called overhead. We were doing all of those things once we made it to a thousand. And I think not only are the rates increasing, but we're also getting better at doing our quantitative blood loss. And we're just more honest about what's actually happening to pregnant people after they deliver, and we're realizing, like you said, that early treatment is actually better for the patients than waiting to see how much blood they lost the next day.


Dr. Dixon [19:14]: That's right. And I think when we talk about quality measures for examining rates of postpartum hemorrhage statewide, nationally, blood transfusions are one of those markers for whether or not a, a true hemorrhage occurred. But one of the changes that has happened in our quest to try to really decrease incidences of severe maternal morbidity mortality is to go ahead and intervene early with a blood transfusion getting started early when we have ongoing blood loss and there is a quantitative blood loss already of about a thousand mls can avert serious complications like gic, which would just, you know, continue to exacerbate the blood loss problem. So, I know that the rates of transfusions are, should be going up as we're recognizing hemorrhage earlier. 


Dr. Boulevard [20:03]: Yeah, and you know, that was one of the really difficult things in terms of our multidisciplinary team, was really helping other specialties understand the physiology of a pregnant person at term and what their blood volumes are doing, how much increased plasma volume a pregnant person has at term versus a person who's never been pregnant, and I remember even some of our maternal fetal medicine, Doctors were saying, oh, you're going to be transfusing too many people if you transfuse them at 1200 or 1500 at blood loss or I remember events where the anesthesiologist refused to give the blood because they felt like that was excessive. And I think we've made great strides in really having all specialties that care for pregnant patients adopt that early recognition and early transfusion is appropriate and actually decreases the total number of blood products that patient may need if we prevent D I C and say need for hysterectomy if we actually stay ahead of the blood loss and keep their coagulation cascade intact. 


Dr. Dixon [21:13]: So, I would like to just intercede here and make a statement that I'd like to be cut and put at the beginning. So, to be inserted, maybe after Dr. Boulevard gives the definition of postpartum hemorrhage, I'll just state about mortality rates. And then going back to where we were before, we have lots of great resources available at our fingertips, and we will put links to those in the show notes from today that the sources for today's discussion came from acog, the practice bulletin on postpartum hemorrhage, that's number 180 3.


That came out in October of 17. And then the quantitative Blood loss committee opinion, that's number 7 94. That came out in December of 2019. Those are two great resources. Also, ACOG has the obstetric hemorrhage bundle on the Clinical Resource Book website that's easily available with slides to present to your institution and a lot of good information. Also to CDC statistics. And then there have been actually two recent Green Journal articles that are very appropriate to include in this discussion. In January of 2023, there was an article entitled Poston Hemorrhage Trends and Outcomes in the United States from 2000 to 2019, which is a great retrospective look at what's happening across our country.


And then in February, just the most recent journal, February of 2023, there's a state perinatal quality collaborative for reducing severe maternal morbidity from hemorrhage. And that is looking at that CM qcc, the California Maternal Quality Care collaborative effort to reduce maternal mortality and morbidity from hemorrhage. They did a cohort study looking at comparing hospitals that implemented their prevention recommendations compared to a hypothetical group of almost 500,000 patients from hospitals that did not implement the bundle.


Dr. Boulevard [23:11]: And that bundle. Dr. Dixon is on the CM QCC website. I have the link in the show notes that you can make a free account and then download the bundle. And it has an abundance of resources about all different parts of not just implementing an obstetric hemorrhage prevention or treatment policy, but also things about workup of anemia and counseling patients in the postpartum period for those who had hemorrhage for bigger institutions. Making sure that if you're in accreta center, for example, for invasive presentation, what are the things that you need to have in place for that? So, it's really like next level obstetric hemorrhage information. That's all for free. 


Dr. Dixon [24:02]: I love open source resources and that CM QCC has just forever been a leader in the nation as far as reduction of maternal mortality I think.


Dr. Boulevard [24:14]: That's so nice that they share with all of us so that we can do it for ourselves.


Dr. Dixon [24:20]: So, let's talk about why we think this trend is increasing. What is your feeling about risk factors and management of patients through the last couple of decades? 


Dr. Boulevard [24:32]: So, I have spent since starting on the obstetric hemorrhage team at Mission in 2015, we've reviewed all of the hemorrhages that have occurred at our hospital, and I think the trickiest part, especially for example, if I'm in a meeting with administration who doesn't understand obstetrics, but they understand metrics. They say, well, why is your hemorrhage rate so high? And it's so intertwined with so many other parts of pregnancy, labor, and delivery that really, I feel like we're the only ones that can explain how they're all at... what the web is that leads to obstetric hemorrhage.


So, the first thing that I think about is increase in rates of C-section that we are all trying to decrease. So, people who have had multiple C-sections are at a higher risk for hemorrhage, first of all, because their C-section will be more complex the next time around, and they're at a higher risk of invasive plantation or sometimes called the placenta accreta spectrum in creta per creta. And also they're at a higher risk of uterine rupture, which is cause of massive postpartum hemorrhage. So, those patients are at a higher risk of hemorrhage. I think we as providers are trying to prevent those C-sections. So, perhaps we are, as you mentioned previously maybe we're doing C-sections sooner if an induction seemed to be prolonged.


Whereas now we are as patient as possible with people who are being induced and sometimes that may be at their detriment of how much blood they're going to lose at the time of delivery. So, some of the hemorrhages I've reviewed have been patients that did ultimately have a vaginal delivery, but had a very prolonged induction course, and most of them were induced for some medical reason. So, we know increased risk, or there are increased rates of gestational hypertension or hypertensive disorders of pregnancy. Diabetes rates are increasing, which is another reason for induction of labor, and then any fetal issues that require an induction of labor. So, we have to induce more people because they have more medical complications.


And then we try to give them as long as possible because we really want them to have a vaginal delivery. And then either they have a vaginal delivery and maybe have a hemorrhage because it was a prolonged induction or the really sad thing would be if they had a long induction, maybe got to complete, couldn't have a vaginal delivery, needed a C-section, and then also had a hemorrhage on top of that. So, we're trying so hard to prevent one thing. And then maybe the result of that is, for example, a higher hemorrhage rate. And at Mission Hospital, well we've worked really hard to lower our primary C-section rate, meaning people who are pregnant with their first child, the child, the fetus's head down, they're at term and at, there's only one baby. So, those are the. Patients that we're really looking at to try and prevent their C-section. And we have really improved our rates. We're at some of the lowest rates in actually the corporation of H C A, but on the flip side of that, we do have sometimes higher rates of hemorrhage, and I see those things as interconnected.


Dr. Dixon [28:07]: Definitely, in addition to the risk factors that you mentioned regarding C-sections, there are some risk factors that are just in general usually trending up over the last couple decades that do increase a woman's risk or a patient's risk for having a postpartum hemorrhage some of this could be the hypertension spectrum that you mentioned. So, gestational hypertension specifically also preed with severe features for a couple of reasons, because that state in itself does have an effect on your coagulable state, and those patients are usually being treated with magnesium oxide, which does increase the risk of uterine acne after delivery.

Macrosomia and polyhydramnios and gestational diabetes are also on the rise, as are uterine fibroids, so myoma. So, all of these things are increasing in addition to people coming in. Pregnant a little bit older, so our advanced maternal age greater than 35 and specifically greater than 40, does increase the risk as well. 


Dr. Boulevard [29:13]: Yeah, I was just going to say there's the CM. Qcc recently changed some of the risk factors in terms of our risk stratification. So, we choose low, medium, or high risk for hemorrhage. And two things I wanted to mention. One is that obesity has been kind of gone back and forth of, is obesity actually a risk factor for hemorrhage? And I think it's intertwined with obesity is a risk factor for a longer induction and obesity is also a risk factor for C-section. So, I think perhaps obesity in and of itself is not a risk factor for hemorrhage, but it's also can be more difficult to treat a hemorrhage in somebody that's obese if it's difficult to do our postpartum fungal rubs or visualization if they have high vaginal laceration or those sorts of things.


And then in addition, one of the things that we really, I think missed out on with the first OB risk factor stratification was things that happened during labor. So, before we were just saying, okay, you've come into the hospital, we have assigned you as a low risk because you don't have any of these risk factors that are on our list. But we weren't actually reassessing them throughout their labor. So, somebody who came in at 39 weeks for an induction with their first baby with no medical complications, they probably would be a low risk. But if they had prolonged rupture of membranes or a prolonged induction or developed choreo amn, or suspected intra amniotic infection or required a C-section, or sometimes people develop. A hypertensive disorder of pregnancy during their induction or during their delivery and postpartum. None of those things were being added to the risk factors for these patients. And so, we are now trying to assess them every shift. And then one of the things I know we'll go over this soon, but that we're doing at Mission is trying to do a pre-delivery huddle or a kind of like a surgical timeout to say, okay, are there any other risk factors that this patient now has that we need to make sure we address at the time of their delivery? 


Dr. Dixon [31:29]: I think that that is so important, especially when we have changing providers every 12 hours who might not be aware that the patient was actually admitted. Not just the previous shift. And so, having that as part of our checkout is super important. 


Dr. Boulevard [31:46]: Yeah. You know, in all safety, one of the things we talk about at our sims is situational awareness. And I think just like you said, situational awareness is even more important when we're only doing 12 hour shifts. And I know this is not a podcast about shift length, but I do think keeping our situational awareness, especially around hemorrhage and induction time is super important.


Dr. Dixon [32:12]: Definitely. So, let's go back and look at what is recommended by AOC and our state and national recommending bodies regarding reduction of OB hemorrhage. So, there's no little algorithm in the OB hemorrhage bundle that just symbolize all the interventions into four Rs. So, readiness, recognition, response, and reporting. And I think breaking that down does keep it simple for folks to remember on an institutional level, and every provider of obstetric care nurses and nurse midwives and nurse practitioners as well as physicians should be really aware of these and be actively involved in their institution response to this.


And so, the idea is that we want to have. A minimization of variability across institutions and across deliveries within institutions depending on the provider. We want to try to help providers decrease their need for reliance on memory and emphasize patient safety culture, and a team-based approach. And we want to try to redundant efforts. So, let's break that down a little bit to talk about what we're doing in our region. I think when I read the CQ cc's explanation of their approach, we really are covering a lot of the little check boxes that they have in the article that was just published in February in the Green Journal.


So, it's really confidence building for me as a provider to think that we are on track with what's happening in across in the most successful states across the country. And then I'd like to really hone in on the readiness part because that is what you all have been working on across our region to provide these Sims to our outline hospitals that are a little bit smaller. So, for readiness, what do you think of as a breakdown of how institution can look at this problem and approach it from a systems, almost like a pilot safety checklist, how to be ready for hemorrhage when it occurs? 


Dr. Boulevard [34:10]: Well, I think having access and making sure their nurse leaders and physician leaders are aware of the C M Q CCC recommendations is, and the latest recommendations is the first part to readiness. And then I think about kind of two branches of it. One is what are we doing in terms of patients and their clinical situations? So, are we screening them when they come in to determine what their risk. Their OB hemorrhage risk is, and then are we doing the appropriate things in response to their risk? So, for example, do they get a type in screen, or if somebody is high risk, do they have two IVs?


And are we sure that we have enough blood products for that patient? Should they need them? And then more complex things like do they have a antibody or is this the right place for this person to be delivering? So, if they have so many risk factors that it's not appropriate for them to be at a smaller hospital. Does that person need to be in a different location? And then I also just think about systemic readiness. So, is there a hemorrhage cart? We talk a lot about this, and when we do our sims, we go through the hemorrhage carts with the nurses at each of the hospitals and the physicians just to make sure that the cart has all of the things that they need and that the cart is in a place that is actually accessible, should they need it. And then the bigger level of systems, do they know how to get blood products if they need them? Do they know who to call if things get a little bit more complex than a usual delivery? Who are other staff members in our hospital that can come and help if needed? 


Dr. Dixonn [36:01]: And just simple process of, well, it sounds simple, but it could be more complicated going through and figuring out how to do an alert system in your hospital. And when that alert system is sounded, how can the blood bank be alerted that a massive transfusion protocol needs to be initiated? And like you said, the right people show up. So that's going to be a little bit different in each hospital for sure. And then you did talk recognition. So, risk stratification for patients. We did talk about what we think of as high and then medium risk factors and that the importance of recognizing that that could change over the course of the patient's labor course. And then we mentioned also a quantitative blood loss to have the team that is involved helping with that. How has that gone at mission switching to a quantitative blood loss process rather than estimated?


Dr. Boulevard [36:53]: So, it sounds so simple. Just weigh the blood soaked Chuck's pad or lap sponges or whatever it may be. And then, I mean, the nice thing is, is that the number of grams is equal to the number of milliliters. So, if you weigh a blood clot that's 36 grams, then that's search 36 milliliters. But we know as obstetric providers that it's not as, there's a lot of bodily fluids that are involved. And so, it's not always as simple as just, this is exactly how much blood this person lost. So, we've done a lot of training for our physicians, our residents, our nurses, our scrub techs to make sure that we're quantifying blood appropriately, and doing that at the time of C-section is a little bit different than a vaginal delivery, and it's really been a multidisciplinary effort of not just buying scales and having them in every single room and having dry weights of things so that people know how to calculate the blood loss, but also making sure that the under buttock strip is collecting just blood or noting how much amniotic fluid is in there after the baby is delivered so that we can get an accurate amount of blood loss.


We have started moving towards, if you diagnose or are concerned about a hemorrhage, just switching out the under buttock stripes so that we can really get an accurate blood loss that's not altered by urine or Betadine or amniotic fluid that can all be collected in that under buttock strip, and then really just understanding at the time of C-section. How much fluid are we using for irrigation? When are we finished suctioning, the amniotic fluid, and when can we switch? We switch a canister to after that moment so that we can be more accurate. And there's a lot of technology too that they're trying to get at. Oh, if you take a picture of this lap sponge, how much blood is actually there?

But what we know is that estimating blood loss is not accurate. And in general we do in our sim that maybe Katlyn and I will talk about, we do a little estimated blood loss quiz. Where we have people guess do their estimate of the blood loss and no one ever has gotten it a hundred percent right.


Dr. Dixon [39:21]: Of course not. I think that that has made the biggest difference in our recognition. So, then also you mentioned having a timeout that is standard of practice before a cesarean section for sure. That considering actually doing a timeout before vaginal delivery as well, I think that that would get everyone on the same page. And have the medications in the room if there is an increased risk for hemorrhage that has developed since the initial admission data. So, I think that's a really good idea. And then moving on to response of the third of the four Rs, we really have evolved in a positive way on labor and deliveries across the state and nation using the stages of hemorrhage protocol.


And we will definitely have a link to those in the show notes. But I think what is really interesting about this arm of the intervention, the response arm, is that there have been some new developments, those medications and tools that not everyone is probably aware of. And also that we have implemented a kind of a pre hemorrhage response checklist when a patient is nearing that 1000 milliliters, that we need to be more aggressive in managing that to try to actually prevent the hemorrhage. So, would you like to speak about those newer developments with regard to the arm?


Dr. Boulevard [40:46]: So, I guess I'll speak first to the new medications and device. So, T X A has been now after the... thanks to the woman trial has been studied more in postpartum patients. There was an initial concern that there may be an increased risk of thrombotic events after using T X A in the postpartum period, but there have been multiple studies that have shown it safe for pregnant patients. And so, that is something that, especially for patients that are requiring a C-section, if they go from labor to cesarean section or if they've had multiple C-sections and you're worried about hemorrhage, T X A is not a utero, but it can decrease the risk of D I C and decrease the actual blood loss and amount of decrease of your hemoglobin postpartum.


So, that's something that is very commonly used now. Definitely a mission hospital. The other is the switch from rectal cytec or rectal misoprostol to buccal misoprostol because we found that the rate, the onset of action is much faster. And so, using either 600 or 800 of buccal cytec is now preferred as a treatment for hemorrhage as opposed to rectal C attack. 


Dr. Dixon [42:10]: The J T X A would be one gram IV at the time that the risk is recognized and it can be repeated once as quickly as 30 minutes, but up to 24 hours. Is that correct? 


Dr. Boulevard [42:22]: That's right. And I think ideally you're giving it within three hours of the delivery, but if the patient's at a risk of D I C, then you should definitely be giving T X A, and then the other is the Jada device. So, this is a suction device that has a vaginal balloon. And so, it's placed in the uterus and it's only used for acne, so it's not exactly the same as a RI balloon. And this is one of the things we've been working on in simulations and teachings with our team at Mission, since it's a new product. But the idea is it looks like a banjo curet, if you know what that is or it looks like a needle. It looks like a needle. So, it's placed in the uterus and then the vaginal balloon is inflate or filled with saline and then placed on suction. And so it actually, instead of expanding the uterus, it actually sucks out the blood and then kind of pulls the myometrium together, and it had been very impressive in terms of positive outcomes for hemorrhage.

Let's see. The second question. Oh, about our new pre hemorrhage treatments we talked about before. I think what's difficult is quantifying the blood loss in the midst of a delivery. So, we are asking a lot of our bedside nurse to document the delivery of the baby. You know, luckily we have a baby nurse, but she's documenting the delivery of the baby.


She's starting the postpartum pitocin, she's getting whatever we may need, like suture or caring for the patient, checking the patient's vital signs, there's a lot to do. And then when we're also trying to quantify blood loss, I think we have all been in situations where we felt like things were fine, and then once everything was calculated, we find out the patient had 1200 ccs of blood loss, for example, also, part of our goal with our more aggressive treatment is that if we haven't weighed everything, then if we think we're at 500, we could be at 900, for example. And we know that a lot of our interventions, for example, the Jada or giving CY attack TXA or nitrogen, really work well. And so, instead of just waiting until they've reached a thousand to treat them for their hemorrhage, doing those things to prevent them from even getting to the hemorrhage mark. And actually at Mission Hospital, since we instituted this at the end of November, our hemorrhage rates have decreased monthly. So, I'm hoping that decrease will continue. 


Dr. Dixon [45:08]: That is so great to hear. And all of these things will be available for reference on the show notes that there are providers that don't have access to that pre hemorrhage prevention checklist. I think that that's going to be really important to implement statewide. And just the final R before we move on to this descriptions is reporting. And I think that has been a real culture change that has helped move us forward with reduction of these incidences, so pedals, both before deliveries and after.

And then when there's been a severe hemorrhage requiring multiple units of blood transfusion or if there was a severe maternal morbidity outcome, having a multidisciplinary team-based review, a meeting that's separate from the time of delivery set aside. And then also having meaningful quality metrics to go back and look at for your institution statewide and then nationwide as well.


I think that that approach is so much healthier and better rather than having it be a provider feeling like they were somehow doing something wrong or to blame and therefore maybe not, maybe subconsciously not being as willing to participate in the quantitative blood loss gathering and the checklist and the team-based care because it seems to be more of a punitive environment moving away from that and more towards a team-based approach where we're using tools that have worked well in other specialties and other complications to improve our outcomes.


Dr. Boulevard [46:40]: And I think empowering the nurses to, when they are filling out the debrief sheets with the provider, empowering them to see their role in OB hemorrhage prevention and see where they can make a big difference in these hemorrhages, I think is really valuable. 


Dr. Dixon [46:58]: Excellent. Well, let's move on to just giving us an insider's view of what the regional Sims have been like. So, for the past year and a half or so, you all have been traveling around to the hospitals in Western North Carolina that do deliver fewer babies than mission hospitals that still can end up having these occurrences, which can be devastating to patient safety and patient care, but also for the staff. I think there's secondary trauma that can occur for the teams taking care of these patients when a big hemorrhage happens and the teams just not prepared for it. There's an interesting statistic posed in the Green Journal article that was from the California Maternal Quality Care Collaborative study in February of 2023, they were looking at cost effectiveness of implementing their safety bundle for hemorrhage prevention. And they looked at a variety of hospitals, those that delivered greater than 5,000 babies per year. And then those that were between 1,005 thousand and then under 1000, and what still what they called cost effective to implement this bundle in the lower than a thousand delivery per year hospitals. But they were using this measure that was the quality adjusted life year gain by each event of SMM or severe maternal moor morbidity that you prevented. They say that you save $100,000 per quality adjusted life here gained. 


So, hospitals would have to really look at the long-term benefit for their patient, not just the cost of the delivery at the time of that admission. In order to call it cost effective for the larger hospitals, it was actually cost savings to implement the plan, but for under a thousand deliveries. Per year, there was some digging deeper to see what the cost effectiveness would possibly be for a hospital system. And you all have gone out to these institutions that are delivering 400 babies per year, between 400 and a thousand a year and there are definitely some unique obstacles and environments that present themselves there. So, can you all just talk a little bit about what your experience has been over the last couple of years with this project? 


Dr. Boulevard[49:13]  : Sure. Well, one of the things that I quickly learned as a person who trained at Mission Hospital and then stayed at Mission Hospital was the algorithms that we have are focused on nurse roles. So, similar to a code, we assign a nurse for QBL, we assign a nurse as a runner, we assign a nurse as a primary nurse, we assign a nurse as a team lead. And when you go to a smaller hospital, there just aren't that many people to assign to those positions. And so, maybe I'm jumping ahead a little bit, but one of the things that I find most enjoyable is figuring out for each hospital, it's great for us to have something that works perfectly at Mission Hospital that was designed for us, but how can we help a smaller team figure out where their strengths are, where their weaknesses are, and how can we make the algorithm and the four Rs work for them specifically with who they have?


And so, I remember at one hospital they said, oh, well we definitely can call our, some of our ER nurses are really good at X, Y, or Z. And so, we would call this person. Whereas other people will say, oh, well we have these extra resources in the OR, and they're the people that would come and help us with blood transfusions or whatever it may be. And so, figuring those things out in terms of the teams was really fun because there's a lot more levels to just, here I am to remind you that you should give Cytotec first and you should use it Buckley, and that once you reach a stage two, you should consider blood transfusion and you should put in another IV. It's easy to read those things in a hemorrhage toolkit, but it's a different thing to actually have even just the time to sit with me and Katlyn . And their nurse manager, for example, and talk through how can we best do this and what have we experienced in the past and what was not working for us. So, for me, that was probably the greatest joy of the simulations, even more than just letting people practice moving through the clinical portions of it. 


Dr. Dixon [51:31]: I really enjoyed that part of our simulations too, and I appreciate you Dr. Boulevard, kind of acknowledging that I have personal experience working at two different rural labor and deliveries and I think that that is something that we understand uniquely compared to like a big tertiary hospital like mission. And even previously in this podcast episode, some of the things that y'all talked about, really it takes an extra layer of teamwork and collaboration to make all that possible in hospital sometimes I do back just a little bit...


Dr. Boulevard [52:08]: Yeah you went too far. 


Dr. Dixon [52:09]: You're fine. I want to give the audience an idea of our simulations. Because I do think it's something really unique to Western North Carolina because of this Maternal Health Innovations grant that we have gotten to do this and actually meet the rural units where they are and go out to them and. We really try to pull their hemorrhage policies before we go so we understand what they already have in place and see if there's anything extra that we can bring to the table, whether it's knowledge, whether it's practice, whether it's part of your didactic really does focus so much on communication and that awareness that you mentioned earlier and each unit is so different, and being able to really tailor the simulation to the specific unit has really been a joy for me. As someone, again, who has experienced being a nurse in smaller rural labor and delivery units when they were still open.


Dr. Boulevard [53:05]: So, our SIM is not very complex in terms of the clinical situation, and one of the things that I have a didactic session in the beginning, which is focused on team steps and healthcare communication, which we know improves situational awareness and also I think just makes the providers and the nurses more relaxed about what our goal is with the simulation. So, it's not a quiz, we're not trying to get perfection in terms of our clinical knowledge or outcomes during the simulation. We go through how do you speak up if you have a concern, or if you think there's a safety issue. We talk through what is situational awareness and how can you improve situational awareness in your teams, not only as it pertains to hemorrhage, but also any obstetric emergency.

And then we go through the treatment of hemorrhage and the stages and we will use the actual hemorrhage protocol that each hospital has, and then we kind of tailor it to our OB hemorrhage card, our base, our little cheat sheet, and we try to tailor it to each hospital so that everybody starts off on the same page.


We always try to encourage psychological safety, so ensuring that people know this patient is just going to bleed a lot. That is all that's going to happen, she's not going to seize, her baby is not going to have a shoulder dystocia, you're not going to be doing a hysterectomy in the room, she's not going to code. Just to make sure that people know, okay, we're just doing hemorrhage and these are the hemorrhage treatments, and we're going to practice our communication with each other while we're also getting a chance to remind ourselves of how do we treat a hemorrhage if that's not happening very often in our hospital because we have a lower number of deliveries.


And then also recognizing the SIM is great to practice, but I have always found the most fruitful part of a simulation is the debrief that we do afterwards to review. How did you feel? How did you think the communication went? There's always a portion where someone says, oh, I gave, 400 of Cytec and I should have done 600, which is, that's fine. That's part of it. And then what is really fun is to see, oh wow, we realized that our hemorrhage cart is actually stored way too far away from where our rooms actually are, or Oh, wow. We don't have. The things to draw labs in our hemorrhage cart, that would be really helpful. And just getting the staff's perspective of how the hemorrhage was, that's different from if you were just debriefing an actual hemorrhage that occurred because we're taking in terms of psychological safety, we're taking away any emotional experience that the providers or nurses had if say they had delivered a patient and were still really upset about what occurred if it was a hemorrhage, for example, and then the last thing I'll say is it's especially good for community building because these hospitals often send us patients to mission. And so, it's been really a joy to meet with these physicians or nurses and understand where their patients are coming from. And I just think it builds community that is so necessary in this part of the state. 


Dr. Dixon [56:37]  : I think it also really levels the playing field. There is a pretty good mix of experience in the rural labor and delivery units as far as nurses who have been nurses for a really long time, and then nurses or providers who maybe are just out of school or maybe it's their first time on a labor and delivery unit. And I have really enjoyed, again, even the community building just within the unit and how the nurses are learning from each other and getting to know each other sometimes maybe better than they did before they came into the simulation. I also really love... so we do the simulation one or two times and we kind of let the unit decide. Sometimes we do our debrief and we do have a couple of people who are, oh, we should have done this, or We should have done that. We want to run it again. Which is always exciting to me because it really does immediately show Dr. Boulevard and myself that this is making a difference and it is increasing confidence and teamwork on the unit, which is critical in a true OB hemorrhage situation. Anecdotally, at least two of the units that we had done simulations on have gotten in contact with me maybe a week or so after we did the simulation to let us know that they had a hemorrhage days after we did the simulation, and how much better prepared they felt and how they were able to work better together as a team. Thank goodness we'd come, and I just, every time that happened, I just thought, my gosh, is that coincidental? It has to be coincidental. 


Dr. Boulevard [58:08]: And sometimes too, we've had non-lab delivery nurse involvement. So, trying to, I know we had an ER nurse one time, we had a house supervisor one time, which was also really fun to see and teach and let them get involved so that they can have a better understanding when they may get called to come and help. And then usually after we've done the actual hemorrhage simulation part of it, we do a little quantitative blood loss section as well, which you mentioned earlier in the episode. And that part is always really fun to me too. I think you were talking about all of the different factors that play into quantitative blood loss.


It's hard in our simulations, much less in the chaos of an actual hemorrhage. So, giving them the opportunity to really practice that and understand that, and I don't know how many units we've left and they said, we're going to get some dry weights, you know, printed and laminated and posted on the hemorrhage cart, which is also just another encouraging thing to know that they're adding. You were right. Nobody ever gets all of them right when they do the estimated versus quantitative. But nurses are better at it than doctors. I say this every stimulation too. Of course they're better at it. 


Dr. Dixon [59:29]  : But it's part of, to me the QBL is not just a QBL, it's also part of the teamwork of the whole hemorrhage. So, if we are leveling physicians or midwives and nurses that this is all about care of the patient, it's not actually about what I think the blood loss is or what you think the blood loss is? It's about what is the best thing for the patient. And so, that's what I think is helpful about QBL, not just the counting up of red blood cells.


Dr. Boulevard [01:00:00]: And we make sure to use different materials that we quote, unquote soak the blood in. So, it's also really eyeopening to see the difference in. Maybe a blood of chuck compared to an ice pack that might be used for a postpartum patient. An ice pack that has always.


Dr. Dixon [01:00:18]: It'll trick you that ice pack. So, we've had a lot of fun and we want our listeners to know that this is something that we would love to continue doing to expand into other OB emergencies.

For example, a hypertension situation, eclampsia situation. And it's only a matter of reaching out to us to see about getting a simulation scheduled. We're bringing on another provider. Who's going to help us as well, so we can cover our bases and we'll come to you. Which again, I think is the best and the most fun part, although I do get to strap a mom and Natalie to my belly and actually have it bleed, which is just water, obviously. But that part is fun too, anytime I can get messy at work that's fun. 


Dr. Boulevard [01:01:08]: The next thing we have to do is start our eclamptic seizure acting. So, I've done that before. I can help you, Katlyn . It's a cardiovascular activity be ready. 


Katlyn [01:01:19]: That's okay. I'm going to start running to prepare for my.


Dr. Dixon [01:01:24]: One thing that I wanted to note with regard to these sims is that you all had great participation and some of the institutions that you went to actually after you completed your first,, run through with the group had you come back and do more days. But I do think that you had lower participation from a provider standpoint, so from a physician specifically standpoint. And I just think that that is always gonna be a hard thing to schedule, to take time out for an educational activity. Something that you feel like is basic to your training as an OBGYN.

But there are things that are changing with regard to this effort and every six months or so, I feel like there are new innuendos that we need to stay on top of with regard to the stages of the hemorrhage and the interventions that are most likely to really enable us to prevent hemorrhages. And so, I would just like to really encourage the providers in our region to take a look at these sims as they come across and participate. It may be that in the SIM you are not actually playing the role of the provider because we switch up the role. But it's important for you to be aware of the team dynamics and what's being asked of the rest of the unit when a emergency occurs.


Dr. Boulevard [01:02:40]: Well, so I'm just going to say really quickly, we also actually received that sentiment in a lot of our feedback. So, we do have a survey that we asked participants to fill out after the simulation, and that was something we got a lot from the nurses who were participating, that they really wish that they had had a provider there. And even just to get used to communication styles. And as nurses, especially nurses on small units, we work with the same providers over and over and over again. And if we have the opportunity to understand sort of how they function in a hemorrhage and what they're going for first, and how they address the timing and things like that.

We're going to be better prepared to assist that provider in those situations if we're given the opportunity to kind of understand how they function too. It just comes back to that communication and that teamwork and understanding how everyone's functioning in the room and what expectations are. 


Dr. Dixon [01:03:35]: And we've had some providers that say, oh, well I can only come for a few minutes, and then they end up staying longer because they realize how useful it is. We've had some great; I do want to shout out to the midwives in this region because they have been very eager to be a part of our simulations. And I just wanted to reiterate how important it is that if we are teaching new algorithms or the latest evidence-based treatment, if the physicians are missing out on that, then they're missing out and their nurse is going to be the one that may mention it, for example. And you don't want to be caught off guard and not realize that you are not doing the most up to date recommended treatment again, because we're doing this for our patients. And so, not just the communication but being on the front line of the knowledge that we have about hemorrhage. 


Katlyn [01:04:32]: Agreed. So, for anyone listening, if you are interested in having a discussion about us doing a simulation for your rural labor and delivery, but I would also extend it out to any emergency departments, we would be happy to do maybe a scale down version of the OB hemorrhage simulation for especially the emergency departments in hospitals that no longer have labor and deliveries. We'd be happy to have a discussion about having a simulation there with y'all as well. I'll have my email address down in the notes. This is going to be we're resources listed down below, one of which will be my email address and you are more than welcome to shoot me an email and we can start a conversation about coming out to your unit and sharing the wealth of information that we have here, Dr. Boulevard and Dr. Dixon. 


Dr. Dixon[01:05:25]  : Awesome. Thanks so much for the work that y'all have been doing for the region and it's just a good feeling to be part of this work towards having such positive outcomes for our, the pregnant people in our region. I do have little summaries of each of those articles. Do y'all think it would be reasonable to just y'all can sign off and I can just record those and then we can have them available to use in case, I think this one's going to need to be edited a fair amount.


Katlyn [01:05:51]  : I can just, I was just talking to her about the simulation too, to which I said if anyone is interested, call us, email. I think that's all we have today. Informative episode on OB hemorrhage. Dr. Boulevard, we appreciate time. Thank so for being here with us for doing these role simulations with me. We really appreciate you being here. Appreciate.


Dr. Boulevard [01:06:18]: Well, I love kind of having the opportunity to think through all of the things that I've done personally in the last eight years as it pertains to hemorrhage, and also just thinking about how far we've come and really reflecting on all of those simulations that we did together and thinking of how hard we worked at the beginning to create them, and then the positive outcomes that I feel like we've made, and I'm excited to see what's next.


Katlyn [01:06:47]: Me too. All right. 


Dr. Dixon [01:06:48]: Thank you so much. 


Dr. Boulevard [01:06:49]: Thanks so much. 


Outro [01:06:51]: What another great episode. I really enjoyed the action items that came from this episode. So, there was a lot of discussion around things that providers and birth workers could do, to incorporate this a awareness and attention to the postpartum period, like the postpartum care plan I gave, birth bracelet project touching on how pediatricians can be helpful in the postpartum period.

Just a lot of great information, all of which will be linked in the show notes below. So, if you heard anything on this episode that you want to do a little bit of a deep dive in, please make sure to check out our show notes. We would also really appreciate a five star review, some comments we would love for you to share some of our episodes with others in your network. We also, in our show notes have a survey linked, we would really appreciate your feedback if you wanted to take the five minutes that it might take to fill out the survey. You cannot only give us feedback, but there's al also a. Place to suggest future episode topics. So if y'all wouldn't mind, we would really again appreciate the feedback. And until next time, thank you so much.