Volume 36 Number 4 | August 2022

Tara C. Moon, PhD, MLS(ASCP)CM, Clinical Laboratory Science Journal Research and Reports Editor and ASCLS P.A.C.E.® Committee

Amber N. Vaughn, MS, MLS(ASCP)CM

Tara MoonAmber VaughnMaternal mortality is a significant healthcare concern in the United States.1 We are at the top of the list for highest maternal mortality in industrialized countries1 despite having some of the most advanced technology and health practices. According to the World Population Review, the average U.S. maternal mortality rate is 20 to 66 deaths per 100,000 live births.2 Included in the maternal mortality rates are deaths from and causes that are related to or heightened by pregnancy, childbirth, or in the time frame of 42 days after terminating a pregnancy.2 The most common cause is the unpreparedness of hospitals for maternal emergencies when delivering a child.2 There are established procedures and recommendations for Massive Transfusion Protocols (MTPs), which aid in the management of blood loss during hemorrhage; decrease potential side effects such as acidosis, hypothermia, and coagulopathy; and improve overall patient safety and outcomes.3

Several groups have proposed guidelines for obstetric MTPs.4-11 A summary of these best practices is provided in Table 1. In the United States, the American College of Obstetrician and Gynecologists has recommended several elements of an MTP based on research conducted worldwide12 and includes the early intervention of an obstetric hemorrhage and the quick action of transfusing red blood cells, fresh frozen plasma, and platelet concentrate in a 1:1:1 ratio.12 By rapid transfusion of these products, maternal mortality is decreased.12 Other considerations include the personnel able to initiate an MTP, the amount of blood products to be administered, a dedicated blood bank staff member, and termination of the protocol.9

As of July 1, 2020, the Joint Commission’s (TJC) elements of performance require that accredited hospitals provide proof of the inclusion of specific components explicitly stated in the MTP.13 TJC concluded that the time of treatment for maternal hemorrhages, prevention, and early recognition of a problem had the greatest impact on decreasing complications associated in the labor and delivery room.13 Three of the elements of performance involve the blood bank and the MTP.

First, written procedures must be created discussing the “management of pregnant or postpartum patients who experience a maternal hemorrhage.”13 This includes the use of emergency released blood and the steps to start an MTP.13 Providing essential education and training of the maternal hemorrhage protocol to those involved in treating pregnant and postpartum patients must also be documented.13 The staff should be familiar with the steps and proceedings in the MTP.

Lastly, drills must be performed at a minimum of once a year to identify problems with the protocol.13 This information can be implemented into the quality improvement program and must be multidisciplinary and include all who would be involved in a real obstetric hemorrhage.13 Experts suggest that following the guidelines and recommendations of groups such as TJC and peerreviewed scientific literature can reduce the maternal mortality rate.

We recently surveyed 11 North Carolina hospitals with labor and delivery units. Ninety-one percent of the hospitals surveyed were accredited by TJC, 55 percent were >500 beds, and 73 percent were trauma centers. Our survey revealed discrepancies between current practice and the outlined recommendations for MTPs. Compliance with best practices for MTP was, on average, 12 out of 16 items. Three out of 11 hospitals reported not having any type of MTP for obstetric hemorrhage, and only 36 percent of these facilities reported practicing MTP drills at least once per year.

This survey highlighted room for improvement in the manner that facilities handle obstetric hemorrhages and implement MTPs. This is an area where laboratory professionals can be directly involved in addressing best practice at their facility and improving patient care. At a minimum, leaders of blood banks should be up to date on scientific literature and current recommendations and should inform staff of these practices. Competency should be assessed on an annual basis and should include problem solving questions focused on the obstetric hemorrhage protocol.

Future MTPs may call for additional items such as the implementation of a point of care device to measure fibrinogen levels at the patient’s bedside or the use of cell salvage.14,15 With massive blood loss comes decreased fibrinogen levels. Cryoprecipitate contains almost 10 times the amount of fibrinogen as fresh frozen plasma; therefore, monitoring the fibrinogen levels allows for the appropriate ordering of blood products.14 It ensures that the blood bank laboratory is thawing the correct blood product during a massive bleed to conserve inventory. Additionally, cell salvage, which is currently being used in some cesarean births, could potentially be applied to vaginal births as well.15 Phillips, et al. implemented this practice in their facility for high-risk deliveries in the event of a worse-case scenario.15 Cell salvage provides a quick nd lower cost way to obtain a blood product to avoid an adverse event.

The MTP for obstetric hemorrhages is one component of patient care that requires high quality performance to ensure the safety and care of our maternal patients. There is always room for improvement, and our survey provides evidence to support a careful review of current procedures. Any updates will require collaboration and communication between the laboratory and the hospital staff present at the bedside. Repetition and practice of these protocols is the first step in the improvement of MTPs for obstetric hemorrhage so that they are effective in reducing poor outcomes.

References
  1. Melillo G. US Ranks Worst in Maternal Care, Mortality Compared With 10 Other Developed Nations. AJMC. December 3, 2020. Accessed from https://www.ajmc.com/view/us-ranks-worst-in-maternal-care-mortality-comparedwith-10-other-developed-nations, May 25, 2022.
  2. Maternal Mortality Rate by State 2021. World Population Review. 2021. Accessed from https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state, May 6, 2022.
  3. Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian Journal of Anaesthesia. 2014; 58(5):590-595. Accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4260305/pdf/IJA-58-590.pdf, May 5, 2022.
  4. O’Brien K, Shainker S, Lockhart E. Transfusion Management of Obstetric Hemorrhage. Transfusion Medicine Reviews. 2018;32:249-255. Accessed from https://doi.org/10.1016/j.tmrv.2018.05.003, May 25, 2022.
  5. Kogutt B, Vaught A. Postpartum hemorrhage: Blood product management and massive transfusion. Seminars in Perinatology. 2019;73:44-50. Accessed from https://www.sciencedirect.com/science/article/pii/S0146000518301289, May 25, 2022.
  6. Jackson D, DeLoughery T. Postpartum Hemorrhage: Management of Massive Transfusion. Obstetrical and Gynecological Survey. 2018;73(7):418-422.
  7. Lyndon A, Lagrew D, et al. Improving Health Care Response to Obstetric Hemorrhage Version 2.0 A California Quality Improvement Toolkit: California Maternal Quality Care Collaborative. California Department of Public Health. March 24, 2015. Accessed from https://pqcnc-documents.s3.amazonaws.com/aim/aimexpert/PQCNCOBHCMQCCObstetricHemmorhageToolKit20150324%20.pdf, May 25, 2022.
  8. Safe Motherhood Initiative: Obstetric Hemorrhage. The American College of Obstetricians and Gynecologists. 2021. Accessed from https://www.acog.org/community/districts-andsections/district-ii/programs-and-resources/safe-motherhoodinitiative/obstetric-hemorrhage. May 25, 2022.
  9. Appendix D: Samples of Massive Transfusion Event Protocols. CMQCC and California Department of Public Health. 2015. Accessed from https://www.cmqcc.org/content/appendix-dsamples-massive-transfusion-event-protocols, May 5, 2022.
  10. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization. January 1, 2012. Accessed from https://www.who.int/publications/i/item/9789241548502, May 25, 2022.
  11. Henriquez D, Bloemenkamp K, Van Der Bom J. Management of postpartum hemorrhage: how to improve maternal outcomes? Journal of Thrombosis and Haemostasis. 2018;16:1523-1534.
  12. Tanaka H, Matsunaga S, et al. A systematic review of massive transfusion protocol in obstetrics. Taiwanese Journal of Obstetrics and Gynecology. 2017; 56:715-718. Accessed from https://www.sciencedirect.com/science/article/pii/S1028455917302401?via%3Dihub, May 25, 2022.
  13. Provision of Care, Treatment, and Services standards for maternal safety. R3 Report: Requirement, Rationale, Reference; The Joint Commission. August 21, 2019. 24: 1-6. Accessed from https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_24_maternal_safety_hap_9_6_19_final1.pdf, May 25, 2022.
  14. Rani P, Begum J. Recent Advances in the Management of Major Postpartum Haemorrhage- A Review. Journal of Clinical and Diagnostic Research. 2017;11(2):QE01-QE05. Accessed from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376787/pdf/jcdr-11-QE01.pdf, May 6, 2022.
  15. Phillips J, Sakamoto S, et al. How do I perform cell salvage during vaginal obstetric hemorrhage? Transfusion. 2022;1-7. Accessed from https://pubmed.ncbi.nlm.nih.gov/35247224/, May 26, 2022.

Tara C. Moon is a Professor in the Division of Clinical Laboratory Science at the University of North Carolina at Chapel Hill.

Amber N. Vaughn is an Analytical Specialist at Duke University Hospital System in Durham, North Carolina.

Table 1. Best Practices for Obstetric Massive Transfusion Protocols (MTP) 4-11

Medical director should be accessible on-site, on-call, or both.

A minimum of 4 units of red blood cells should be prepared.

Factor VIIa, fibrinogen concentrates, and prothrombin complex concentrates are not recommended for use during an obstetric hemorrhage. Red blood cells, cryoprecipitate, and platelets are recommended.

O negative blood should be used in the emergency release of blood products for an obstetric MTP <50 years of age.

A type and crossmatch sample should be collected from the patient as soon as possible.

The patient’s physician, anesthesiologist, or surgeon should initiate an MTP in the operating room.

A blood bank staff member in charge should handle communication during the MTP.

Blood loss of >1000mL is required to activate an MTP.

The first set of blood products in an MTP should contain: 6 units of uncrossmatched O negative red cells, 4 units of thawed AB plasma, and 1 unit non-group O platelets.

A cooler should be used to transport blood products to the operating room.

Risk factor does determine if crossmatch compatible units are available in an obstetric hemorrhage. Type and hold, type and screen, and type and crossmatch orders are dependent on the risk factor of the patient of a hemorrhage.

Blood bank should be notified as soon as possible upon the admission of a scheduled or nonscheduled birth.

Blood bank staff should record blood products administered to a patient during an MTP on a written log.

If an Rh negative blood shortage occurs and an MTP is activated, the team in Labor and Delivery and the pathologist should be notified immediately for follow up action.

Uncrossmatched blood should be identified by a bright sticker or other similar item notifying the treatment team that it is uncrossmatched when taken to the operating room.

MTPs should be practiced, and drills initiated at least once a year.