Chapter 13: Postpartum Hemorrhage and Placenta Accreta Spectrum

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of severe maternal morbidity and mortality worldwide and in the United States.^1,2 Cesarean delivery rate has increased significantly in the last three decades. Consequently, the incidence of placenta accreta spectrum (PAS) has also increased.³

Many education and safety resources have been developed for PPH and have evolved into Obstetric Hemorrhage Bundles. Here are some additional resources for PPH information:

• The Alliance for Innovation on Maternal Health (AIM)—Patient Safety Bundles: Obstetric Hemorrhage⁴

• California Maternal Quality Care Collaborative (CMQCC)⁵—OB Hemorrhage Toolkit v3.0

• The American College of Obstetricians and Gynecologists (ACOG)—Postpartum Hemorrhage,⁶ Practice bulletin number 183

The Obstetric Hemorrhage Bundle at Beth Israel Deaconess Medical Center (BIDMC) emphasizes the following aspects (3Rs):

• Readiness for PPH: mandatory simulation training course, online modules, in-person workshop, PPH cart, quantitative blood loss (QBL), uterotonics (Chapter 5 “Uterotonics”)

• Recognition of PPH in a timely fashion: evaluation tool for obstetric hemorrhage risk (Chapter 34 “Evaluation of Hemorrhage Risks”)

• Response to PPH: BIDMC Massive Transfusion Protocol, guidelines of active management of the third stage of labor, guidelines for uterotonics use for cesarean delivery (Chapter 4 “Oxytocin”), guidelines for obstetric hemorrhage, and guidelines for escalating notification (Chapter 53 “Postanesthetic Care”) and rapid response team for PPH

The New England Center for Placental Disorders at BIDMC is a unique and robust multidisciplinary program for treating patients with PAS disorders. It draws patients from around the region, country, and world. Highly efficient, cooperative, and coordinated teams are the cornerstones of this very successful program.

This chapter will outline some clinical pearls for anesthesiologists who manage scheduled and urgent PAS cases. The latter is the most challenging case for obstetric anesthesiologists. Detailed guidelines and extensive training for the entire obstetric anesthesia team are the preconditions for the success.

PREPARATION FOR PAS CASES

All obstetric anesthesiologists should follow the same protocol for preparing the operating room for PAS cases. The protocol was developed using an iterative improvement technique—after every PAS surgery, the team was interviewed in a structured manner to optimize workflow and logistics. Consistent preparation among the providers can ensure efficient teamwork, especially in a time-limited situation.

BEFORE THE SURGERY

• Anesthesia consult: review the medical history, airway exam, discuss the anesthetic plans, need for blood transfusion, and consent

• Multidisciplinary meeting: attended by Maternal-Fetal Medicine, Obstetric Anesthesia, Nursing, Blood Bank, Urology, Gynecology-Oncology (backups), Neonatal ICU, and Perfusionist

• Patient education

ANESTHETIC OPERATING ROOM PREPARATION

Right Side of Bed

• Arterial line transducer and zeroed

• Infusion pump with large phenylephrine syringe (240 µg/mL), primed

• Infusion pump with large norepinephrine syringe (32 µg/mL), not ...