Healthcare News & Insights

Postpartum hemorrhage protocol significantly reduced bleeding severity

A hospital team at Marian Regional Medical Center in Santa Maria, CA, developed a standard postpartum hemorrhage protocol that significantly reduced the severity of bleeding in patients.


This is great news since maternal hemorrhage remains a major source of maternal morbidity and mortality in developed and underdeveloped countries.

The study also led to Dr. Laurence Shields, director of maternal fetal medicine at Marian Regional Medical Center and lead researcher, winning the 2013 Norman F. Grant Award for best research in maternal medicine from the Society for Maternal-Fetal Medicine, according to Healthcare Innovation Center.

Study protocol

The hospital-wide study, which was published in the American Journal of Obstetrics and Gynecology ,  examined 5,813 births.

It broke the protocol down into the four stages of postpartum complications and devised responses for those stages that providers were required to follow to reduce any additional blood loss:

  • Stage 0: normal intrapartum and postpartum course — No intervention required.
  • Stage 1: bleeding greater than expected for normal vaginal delivery (500 mL) — Required a nurse to attend to the patient.
  • Stage 2: bleeding not responding to conservative treatment outlined in stage 1 — Required a second nurse and notification of the on-call nursing supervisor to facilitate assignment of additional nursing and operating room support as needed. It also required the patient’s obstetrician and the on-call anesthesiologist to report to the patient’s bedside, or the operating room if the treating nurse believed that the patient would be better served there. And finally at this stage an obstetric cart equipped with standard instruments for these teams was to be brought in.
  • Stage 3: continued bleeding with actual or expected blood loss >1500 mL — The goal of this stage was to get all available resources working together to reduce any additional blood loss or development of disseminated intravascular coagulopathy (DIC). Additional nurses were also brought in at this stage, as were additional physician support (obstetrical, anesthesia, general or urologic surgeons and interventional radiology). And fixed ratios of blood products in a designated “obstetrical hemorrhage pack” were readied for emergency release from the blood bank.


After implementing the protocol, there was a significant shift in the percentage of patients who were successfully treated at the stage 1 level, which also affected the number of patients who needed intervention at stage 2 level. Prior to using the protocol, just under 50% of patients required stage 2 intervention, but after the training and protocols were put into place, only 8% of patients reached stage 2 intervention.

“Thus, consistent with the goals of the protocol, we noted that training and protocol initiation was associated with a significant shift toward patients requiring less intervention and successfully being treated at a lower acuity level,” wrote Dr. Shields and his co-authors in the study.

In addition, when the use of blood products were evaluated in the 12 months prior to the protocol implementation and compared to the use of blood products 12 months after the interventions were in place, the researchers found a significant reduction in the total number of blood products transfused and the average number of blood products used per month.


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