Hello. As part of an ongoing discussion of maternal complications, I'm going to have a discussion about maternal hemorrhage and the implications of that on our clinical practice. Again, I have no disclosures. Here are the learning objectives. You have these, and we will move on. So obstetric hemorrhage is the most common cause of maternal mortality in the world. That's about 25% of all cases of maternal mortality. And it's only second to cardiac-related deaths in the United States. Why do we see this? Well, we see two things are happening. There's a definite disparity in health outcomes related to ethnicity, and there are also increasing rates of many chronic diseases as the obstetric population in the United States ages. We rarely saw 30-year-olds pregnant in obstetrics when I first started my clinical practice. Now we routinely see young 40-ish-year-old patients having their first child. And so because of that, we see much higher incidences of chronic diseases, particularly diabetes and hypertension. And I would say that morbid obesity should be added to this as well, because it is clearly a risk factor for this. Although it hasn't made it to the textbooks yet, I can tell you from clinical practice that it is absolutely a risk factor for this. Part of the problem with morbid obesity, particularly in the obstetric population, is that that leads then to diabetes and hypertension on top of an already bad disease. All of you are living this. I'm not telling you anything that you don't know. We're also starting to see an increase in postpartum uterine atony. I'll talk a little bit about that a bit later. That's related to many inductions and the routine use of oxytocin as a uterotonic during prolonged labors. And we see a much higher rate of C-section. And so C-sections, because it's an operative delivery, much higher risk for bleeding related to the surgery itself, as well as to uterine atony after the operative delivery. When I first started obstetric anesthesia way, way back when in the 1990s, our C-section rate was about 18%. In my current clinical practice, and I'm in the community, I'm not even in a high risk center, our current C-section rate is about 32%. So it is more than doubled in the span of a couple of decades. So there is absolutely more comorbid states, more pathology that we're dealing with on a daily basis in obstetrics. And really, if you don't learn anything else in this next 30 minute lecture, or discussion, I'm sorry, you must understand this. The biggest problem is it's failure to recognize and it's failure to treat. So here's trends in maternal mortality. This is out to 2014. And you can see there's a clear increase in maternal mortality. And this is in the United States. And so you can see that we're not doing a good job of decreasing maternal mortality. This line should be going down. As we start to talk about this, as we identify this, as we have strategies for this, we should be decreasing maternal mortality. And in fact, that is not the case. And in particular ethnic populations, we're seeing huge increases in maternal mortality. And there's a huge disparity in health outcomes between African American and just about any other race or ethnicity in the United States. Now, this isn't particular for California. I can tell you that the data for Wisconsin is no different. Even though we have a small African American population by overall population within the state, that their health outcomes are much poorer than the health outcomes for just about any other ethnic group in the state of Wisconsin. As a matter of fact, Milwaukee, which is our largest city in Wisconsin, has two area codes that have maternal mortality rates that are higher than many of developing third world countries. And so we have a real issue with this in the United States and we need to start talking about it. California really did a great job. They have a maternal bundle related to hemorrhage that came out of California and then ACOG kind of adopted a lot of their bundle parts. I'm going to talk about the ACOG bundle. I present the ACOG bundle because that's the bundle that we use in my clinical practice. The California bundle is just as important and just as good. If that's what you're using in your clinical practice, by all means use that. I actually like the California bundle a little bit better only because it's color coded. It makes it just a little bit easier. It's kind of like the brazil tapes for pediatric resuscitation. The colors will really kind of key you in on where you need to be. It doesn't matter which bundle you use, they both have the same endpoints and the same outcomes. And so as long as you're using a bundle, that's the most important part. When we look at North Carolina, they did a study here in 2005 and they looked at the mortality in the state of North Carolina related to obstetrics. And you can see obstetric cardiomyopathy accounted for about 21% of their deaths, but only 20% of that was preventable. Hemorrhage accounted for 14% of the deaths, second leading cause for mortality in obstetrics. But look at this number, 93% of these deaths were preventable. Let me say that again, 93% of these deaths were preventable. This is failure to recognize and failure to treat on our part. We are part of this problem. Why? Because we typically guide resuscitation. We're the ones that are focused on the patient and the patient's hemodynamics. The obstetricians and the nurses are focused on the delivery and the baby. And it's our imperative, it's our prerogative to involve them in the resuscitation of this patient and make sure that we're recognizing it and that we're leading that resuscitation. And then the rest of these, you can see, you know, a chronic condition, how many of your patients do you see with chronic conditions? Boy, in my clinical practice, that's just about all of them. And in poorly managed chronic condition is also way up there as well. So it's this combination of comorbid conditions that they're presenting with, morbid obesity, diabetes, hypertension, cardiomyopathy, poorly managed, and then superimpose a hemorrhage on it and it's game over. So be really careful with these patients. So let's talk a little bit about anapartum hemorrhage. Most likely cause of anapartum hemorrhage is the placental malplacement. So there's a couple of different kinds. Placenta previa is the most common. I'm not going to get into whether it's marginal, partial, or total. For me, I don't care. All I want to know is do they have a previa? This is diagnosed by ultrasound. You should never be surprised by a previa. Let me say that again. You should never be surprised by a previa because all of these patients are getting ultrasounds now and the ultrasound will identify it and that needs to be communicated in the chart and communicated by your obstetrician. The classic presentation is painless vaginal bleeding. Not always, but often. And again, ultrasound will confirm it. So what do you need to know? You need to know how bad is it, but more importantly, you need to know what the obese plan is. Are they going to let them labor? This drives me nuts. I don't know why you would consider even letting a patient with a previa labor because the delivery of the fetus through the lower uterine segment where that previa could be implanted is just a recipe for disaster. So know what the obese plan is. In our clinical practice, most of the time, unless it's really well-defined and really way away from the cervical os, if they've got a previa, we typically will deliver them operatively. But you have to know what that plan is. In addition to that, know your patient. How many C-sections have they had? This is really important because we know that if you, as you increase your serocerium deliveries, we start to see a major increase in malposition and malimplantation of the placenta to the decidua of the uterus. And so once you hit about two C-sections, you should just assume that the patient has a malposition or a malimplanted placenta. Have a very healthy respect for these patients. These patients will go to ground quickly. So just be very vigilant. So what should we do? How do I manage this in clinical practice? So I usually see this come up from OB. OB will typically refer them to us for a preoperative or pre-anesthesia visit, typically at about 32 weeks. So we'll know that they have a previa, we'll know what the plan is, and then we can have a very candid conversation with them in a non-threatening, non-urgent situation. Airway assessment's really important. Don't forget to go back and look at an airway assessment, particularly if the patient has been pushing for a while, particularly if they're starting to get preeclamptic. That airway assessment can change drastically in the course of 10 or 12 hours. So please do frequent airway assessments. Make sure you do volume assessment, right? You've got to have a good IV in these patients. This is not the time to have a 22 gauge in the anticube that's really positional. You know, this may be the time where you have to go in and start the IV and absolutely get a good 18, 16 gauge even IV in these patients. You want an IV that you can resuscitate through. And that's the way I look at these patients. This is a resuscitation until they've delivered, and I'm sure that they're passed. You know, we talked about the previous C-section, and absolutely make sure that they've got a type and screen. If they come in and they've already got a type and screen, but they're actively bleeding, I call the blood bank and change it to a type and cross as soon as I find out these patients are being admitted. You can consider a trial labor. I'm not a big fan of this. Again, I'm not an obstetrician. I don't get to make that call. I do have a conversation with them. If they are going to do a trial of labor, I'm going to stay in-house, and I'm going to get an epidural in. I'm going to get it in early, and I'm going to make sure it works. If they have to go to an operative delivery, you really have a lot of different options. It really depends on how the patient's doing and how urgent the situation is. If it is active and significant bleeding, I am really hesitant to do anything in their back. I am most likely just going to do a general anesthetic because I'm going to end up having to resuscitate this patient halfway through the case, and I don't want to have to resuscitate a patient that is now getting abundant on the operating room table because their perfusion is so poor to their brain. If the patient's stable and they're not bleeding, a spinal or an epidural are fine as long as you have a good surgeon, a good obstetrician. Again, this is having to know your practice, having to know what you're comfortable with, what your obstetrical colleagues are comfortable with, know what kind of nursing support you have, do you have somebody that's going to be able to push blood for you if you need to get into a situation, and how good of blood bank support you have. All of those things play into the decision on how you're going to manage the anesthesia. I know I didn't give you a very satisfactory answer, but again, it depends, it depends, it depends, and just be really vigilant. Now, abruption is a little bit different. Abruption is absolutely an obstetric emergency. I've had two abruptions in my clinical career. One of them was the classic sign that she came in with painful vaginal bleeding, put an ultrasound probe on there, saw the abruption, went straight to the OR. The other one came in just not feeling well, and so she actually presented with no symptoms. She was bleeding. It was all kind of back up underneath the placenta, so it had definitely separated. There was definitely an abruption. She had a huge thing of blood back there, and she didn't feel well because she was hypovolemic, and so this can be very difficult to kind of sleuth out unless you have good people really kind of looking at this. Ultrasound is invaluable here, so what happens is there's a separation of the placenta from the decidua. I kind of mentioned that, but be careful because the bleeding can be concealed. It can be tucked up in there, and you can grossly underestimate what their blood loss is. If this isn't treated quickly, if you don't go to the OR quickly and deliver these patients, these patients will get coagulopathic on you right in front of your eyes. They will go into DIC right in front of your eyes, so actually one-third of all OB coagulopathies are secondary to abruption, so be really careful with this. A lot of times they're going to present with these vague feelings. I just don't feel well. I'm really crampy. They're going to bring them in. They're going to put them on the fetal monitor, and the baby's going to look like crap, and you know what? You're going straight to the OR, so how do I manage? Oh boy, before I talk about management of the OR, what are some of the conditions that are associated with that? What did we talk about? Advanced maternal age, multi-parity. We already talked about a lot of these kinds of things. Chorio is a big deal with this. It's not so much for, you know, chorio is just the bad thing, so if you have chorio, you see chorio, make sure that they're getting antibiotics on board right away and have healthy respect for those patients. We talked about comorbid states. Substance abuse is kind of a big deal. We don't have a big issue with meth in our patient population. Our patient population can't afford cocaine, so what we see for substance abuse is tobacco, alcohol, and opioids. That's what we see in our patient populations. Not a lot of meth, fortunately, but a lot of tobacco and a lot of alcohol and a lot of opioids. Trauma can be this, so this can be partner-on-partner trauma, right, so somebody gets mad and, you know, hits them in their belly or whatever, or it can be indirect. It can be related to a motor vehicle crash or those kinds of things, so just have a healthy respect as these patients present. So how do you manage this? Personally, in my clinical practice, I've never labored an abruption. I've had to. We've identified both of them relatively early on, and we went straight to the operating room as soon as we identified the abruption, so I don't have good experience to talk about laboring these patients. I know the textbooks say that you can do that, so I present that to you because that's what the textbooks say. I can't speak to that from any kind of clinical experience because I've always gone straight to the OR, and actually, to be honest with you, I wouldn't want to labor one of these patients. I think it's just a silly idea. I'm not an obstetrician. I freely admit that. I'm not giving obstetric advice, but in my mind, it just seems silly. Why would you even consider laboring these patients? Now, if you're going to operate a delivery, the way you manage the anesthesia is actually based on the patient presentation. In both of the cases that I was in, I actually opted to do a general anesthetic, brought the patients in, you know, got them in, left uterine displacement, good mast seal, good 5, 6, 7, 8 minutes of 100% oxygen, denitrogenate. I had pressers up and ready. I had blood products in the room. Once patient was prepped, draped, surgeon in the room, scalpel in hand, rapid sequence induction with cricoid pressure, intubate. As soon as I see the tube go through the cords, I say go. Get everything in place. Now I got to watch. This is a little bit different. I got to watch, so you have to know what's going on. You want to look for that blood loss. So you have to know your OB. You have to know what your skill set is. You have to know what support you have. If you've got a really stable patient and you've got a really skilled surgeon and you're comfortable with it, I don't see any reason why you couldn't opt for this. I just, in my particular situation, the two situations that I've been in, I just have chosen to do a general anesthetic. Nobody would fault you for it, but just, again, have a healthy respect for this. Now, placental rupture, this should actually not say placental rupture. This should say uterine rupture, so I apologize for that. Uterine rupture is absolutely an obstetric emergency. So where are you going to see this? Typically, it's from a previous urine scar. The scar tissue is not nearly as strong. Once they really get contracting, then those scar tissues tend to rupture. So it can either be from a cesarean delivery or from a myomectomy. We're seeing more and more patients that come in that have had myomectomies. The other place that you can see this is in a TOLAC. I mentioned TOLACs briefly, or VBACs, or a trial of labor after cesarean. We don't do these anymore, thank God, so I don't have to worry about this anymore. But in a big center, particularly a high-risk center, you may let these patients labor, and that's fine. I've done it before. I'm not happy about it, but I've done it before. Where you have to be careful is when they start augmenting these labors. Typically, these cervixes don't dilate normally. They don't dilate kind of correctly, I guess for a lack of a better term. And so they'll augment these labors. Pitocin, actually oxytocin, is not nearly as bad. It's the prostaglandins that actually increase the risk of rupture, which I found really surprising. So I did a lot of reading as we were starting to do some of these procedures and had a discussion with our OBs about this. And so they didn't use prostaglandins and Tolax. They did use pitocin, and I always got nervous when they started using pitocin. So the, excuse me, ureter rupture, that percent, that presentation is really variable, and it depends on the amount of rupture. They can have a lot of retroperitoneal bleeding, and so that can be a cult. We don't see it. These are young, healthy patients. They don't decompensate until the very end. So your key here is your fetal distress. You've got to monitor the baby. The baby is going to show you the signs very early. And so always, always, always watch the baby. Really know what you're looking for, looking at those fetal heart tones, looking at that beat-to-beat variability, and assessing the fetal wellness every time you walk into the room in these patients. So if you do have a uterine rupture, you're going to the OR. It's an emergency laparotomy. The OBs will call this a cesarean delivery with a cesarean hysterectomy. You're going to do a hysterectomy. That uterus is coming out, and it's going to get, so they're going to deliver the baby quick. They're going to clamp the uterine arteries on both sides, and then that buys you a little bit of time. Once they clamp those uterine arteries on both sides of the uterus, you typically stop the most of the bleeding, and you then can start volume resuscitating and giving them blood products, etc., etc., etc. I already mentioned the general anesthetic. I'm not going to belabor that point. Now when we get to postpartum hemorrhage, it's a little bit different the story. The most common cause for postpartum hemorrhage in the United States now accounts for about 80% of the cases is uterine atomy, and what is uterine atomy? It's a poorly contracting uterus after the delivery of the fetus. We typically talk about a boggy uterus. They have a little bit of vaginal bleeding, and what do we do? We give them uterotonics. Well, what's the number one cause for uterine atomy now? It's a long run of uterotonics. In other words, this is an induction. A lady's post-dates, they try some prostaglandin, some Cervidil up at the cervix to ripen the cervix. That doesn't really work, so six or eight hours later, they put that in at midnight. They come back in in the morning before they go to clinic, and they start oxytocin, and they put them all day long, and then it's nine or ten o'clock at night. They finally call it. You go to C-section, and this uterus has just been flailed with oxytocin for a very long time, and you deliver the baby, and the uterus is just beat. It's not going to do anything. It can't contract. You can give all of the oxytocin you want. It's just not going to work. At that point, you're going to have to switch to the prostaglandins. You're going to have to use hemobate. That's the first-line drug. Second-line drug would be methadone. Here's some of the doses, some of the side effects, contraindications. I leave this for you to read. I'm not going to go over this. Most of you know this anyway, but it is important. You have to know where to be very careful with this, particularly with the hemobate, and particularly in reactive airway diseases. This can turn into a really ugly situation really quickly. Remember that hemobate is IM, right? Sorry, hemobate is IM. Both of these are IM. The only one that we give is IV, is oxytocin. Now, if you have retained placenta, that's a different kind of situation, and this can actually cause some problems as well. The definition of retained placenta is at that 30-minute mark. In other words, they haven't gotten all of the placenta out at 30 minutes. Once you hit 30 minutes, that's when you start to see a really significant risk for hemorrhage. The treatment is really straightforward. Just get the placenta out, which can be very stimulating, and so just be really careful about that. You're going to be called in for this. My first go-to is just to give a perinneal dose through the epidural, and my favorite drug for this is 2-chloroprocaine. Just give 5 mils of the 2% 2-chloroprocaine, and within 5 minutes, you'll have really great sacral coverage. They'll relax, they'll open up, and that will open up opportunity for the OB to get in there and really get a good scrape and get that placenta out. I'm not a big fan of analgesics. Some people will give fentanyl. I'm not a big fan of opioids in this particular case. I don't use analgesics in that sense. I will try ketamine. Ketamine's a great drug in this. You have to be really careful. You have to keep below 0.25 percent, excuse me, below 0.25 milligrams per kilogram. If you stay below that, you won't see any of the psychological side effects, the hallucinations, all of those kinds of things. The nice thing about ketamine is it's also a potent analgesic, so you'll get some analgesia related to that. I typically start with 10 milligrams IV, see how that works. I'll give another 10 milligrams IV, and all of a sudden, you start to see their eyes kind of drift a little bit. Then I give a heads up, the finger wave to the obstetric provider, and they'll go in and start that. Ketamine works really well for that. If all of these don't work, you can use nitroglycerin. Be really careful. We're looking at this as a position where you're going to be treating hemorrhage, and now you're giving a vasodilator. It can make that situation really, really awful really, really quick. I use baby nitroglycerin here. That's what I call it. I will give 10 mics at a time. I'll give 10 mics, wait a minute. I'll give another 10 mics, wait another minute, cycle of blood pressure, see what that's done to it. A lot of times, that will relax the uterus enough that they can get in and they can get the placenta out. Now, what happens if you are in a situation where you have maternal hemorrhage? Again, recognize it, treat it, call it. Most people are unwilling to call it. I don't know why. These are young, healthy patients. It's very difficult to diagnose hypovolemia in young, healthy patients. Watch your EBL, watch what's coming out of there, and just call it. You know what? If you're wrong, so what? I'd rather be wrong than fail to call it and have a bad outcome. If you're wrong and you transfuse, what's the bad outcome? I don't know of one. If you don't call it and you don't transfuse and you have a bad outcome, that's a bad deal. Again, the key elements, recognition and prevention, absolutely. I would say recognition and treatment. You got to be ready. Do you have these things in place? We have a massive transfusion protocol. We also have a different thing called an emergency release. An emergency release is just four units. If I call down and say, I'm going to the OR, I need emergency release, the blood bank knows that it's likely the next call is going to be the massive transfusion protocol. Have you done education? Do you know? Does everybody know what they need to do? Does the blood bank know what they need to do? Does OR nursing know what they need to do? Does OB nursing know what they need to do? Do you know what you need to do? You have to actively manage that third stage of labor. Remember the third stage of labor is from the delivery of the fetus to the delivery of the placenta. This is where people get into trouble because a baby comes out, high fives all around. Everybody's really happy. It's this really exciting event. Mom gets baby for skin to skin contact. Everybody's shooting the breeze, smoking and joking, and nobody's really paying attention. 30 minutes later, only half of the placenta is out and you look and there's a liter of blood on the floor. I've seen this happen. Be really careful about this and know what your response is. What's the risks? Again, we talked a lot about the placental malposition. We talked a little bit about BMI. I talked about morbid obesity and the comorbid conditions that go along with that. Then, of course, anybody that's got a clinically significant feeling disorder. People that are medium risk are prior sections or any uterine surgery. We talked about myomectomies. We talked about myomectomies, but don't forget cervical cones, leaps, those kinds of things, multiple gestations. Again, BMI greater than 40. That's the majority of my clinical practice now. Then, anybody that's got a low platelet count immediately goes to high risk. If they're medium risk, which is most of my patients, they absolutely should have a type and screen. If I have any doubt in my mind, I just call and change it to a type and cross. Now, intrapartum. That was prepartum. Intrapartum, if they've got choreo, that automatically puts them at medium risk. If they've got prolonged oxytocin, technically it's 24 hours. I would say that once you hit 16 hours, you really need to be thinking about this. This absolutely changes them. We're prolonged second stage. I talked about pushing for two or three hours. Then, of course, anybody on MAG, that means they're preeclamptic. How do you do this? Again, you have to actively manage the third stage of labor. You have to be giving oxytocin. We're really good at this. We do this in the operating room all of the time. It's not unusual for us to have a leader bag of LR with 20 units of PITS sitting on the cart. This is exactly what I do. As soon as baby comes out, I watch active stage, third stage of labor. Placenta comes out. It goes into the big basin on the side. I look at the obstetrician and say, PITS coming your way. I don't even ask. I just tell them. They usually just give me a thumbs up and then they keep going. Then, I hang that leader and run it wide open for 500 mils. Then, at the 500 mil point, I look over the screen and I assess what the uterus looks like. Typically, in my practice, it's already back in. Then, I ask them, how does your uterus feel? They'll squeeze it and they'll say, yeah, it's nice and firm. Then, I'll slow it down a little bit. Now, stage one, important. There's three stages. When you're in stage one, I always learned back in the day that for a vaginal delivery, you would lose about 500 mils of blood. For a C-section, you would lose about 1,000 mils of blood. Anytime you're losing more than that, you're already at stage one. What do you do? Again, have a good IV access. If I've got a patient that I know has a previa or that has a diagnosis of an abruption and would go into the OR, I absolutely start a second IV. I absolutely get two good large bore IVs in them because you're going to resuscitate these patients. Patients aren't happy about it. I understand that, but you know what? I'm not in the business of making them happy at this point. I'm in the business of saving their lives. Resuscitation is absolutely paramount in that discussion. I have to get that IV in. We're the IV experts. You're likely going to have to start that. You can run some crystalloids. I like having a line that has crystalloid without oxytocin in it. You know that one of the side effects of oxytocin, particularly if you give the big bolus, is hypotension. If you're trying to resuscitate a patient in a line that's already got oxytocin in it, you're kind of shooting yourself in the foot. That's why you need a second IV. Fundal massage is important. Don't forget to remind the nurses to do that. Again, here are our uterotonics. Remember that hemobate and methogen have to be given IM. This is IV. Then you can use Cytotec. This is something that we don't do. It's something that either OB or the OB nurses will do. When you get to stage two, now we're talking about any blood loss up to 1500. It doesn't matter how you got there, or you've given two uterotonics and you're still losing a little bit of blood. At that point, you're at stage two. You know what? At stage two, you transfuse. Don't wait. Just start to transfuse. Tell them to thaw some FFP. Now we're going to get into likely stage three, where we're going to get into a massive transfusion protocol. According to their protocol, again, you start by giving two to four units. That's our emergency release. In their protocol, their protocol is a little different from ours from, say, a trauma or something. It's six to four to one. That's important. Make sure that you know this ratio. In OB, it's a little bit different. We don't do two to one to one. We do six to four to one. It's really three to two to one kind of a thing. Six, four, one. That three, four, six, four, two would be that. Platelets are not as important. The FFP is really important. The PAX cells are really important. You don't want to dilute out the platelets. That's why they usually only do one unit of platelets. Remember that. Again, the oxytonics are here. We're doing the massive transfusion protocol. You're continuing all of these other medications and get some help. You're going to need some help in the OR. You're going to need somebody, at least one person, just to give blood. You're going to need to be managing the resuscitation and the hemodynamics related to that. What do you want to do? You also want to start drawing some labs so that you know where you're at least starting. This is the emergency release. You're given two to four units. Then you get into this and you get the six to four to one. Stage four is cardiovascular collapse. This may be an AFE. There's a whole other discussion on AFE. Massive hemorrhage, cardiovascular collapse. Really, this is just like you would do anything, any kind of massive transfusion protocol or any kind of trauma. You just do the best you can. You keep doing everything that you can. This is where you break out the epi and then leave a fed and all the other things that go along with that. Again, they have to get that uterus out. That's the point of bleeding. That's your surgical. Professionals are taking care of that for you. That's all I have for maternal hemorrhage. It's kind of scary. Hopefully, you're never in that position, but please be prepared to be in that position because prior planning makes all the difference in the world. With that, I will stop our discussion. We'll have an opportunity to have more of this discussion during the workshop. We'll talk about the maternal safety bundles there as well. Thank you for your time.

maternal hemorrhage

ethnic disparities

C-sections

safety bundle

uterine atony

massive transfusion

multidisciplinary teamwork