MANAGEMENT OF POST PARTUM HEMORRHAGE USING ORDER MNEMONIC

The following is a plan for managing massive

obstetric hemorrhage, adapted from Bonner.

The word order is useful mnemonic for remembering the basic outline.

ORGANIZATION

1. Call experienced staff (including

Organization

obstetrician and anesthetist).

2. Alert the blood bank and

hematologist.

3. Designate a nurse to record vital

signs, urine output, and fluids and

drugs administered.

4. Place operating theater on standby.

RESUSCITATION

1. Administer oxygen by mask.

2. Place 2 large-bore (14-gauge)

intravenous lines.

3. Take blood for crossmatch of 6 U

PRBCs, and obtain a CBC count,

coagulation screen, urea level,

creatinine value, and electrolyte

status.

4. Begin immediate rapid fluid

replacement with NS or Ringer lactate

solution.

5. Transfuse with PRBCs as available

and appropriate.

DEFECTIVE BLOOD COAGULATION

1. Order coagulation screen

(International Normalized Ratio,

activated partial thromboplastin time)

if fibrinogen, thrombin time, blood

film, and D-dimer results are

abnormal.

2. Give FFP if coagulation test results

are abnormal and sites are oozing.

3. Give cryoprecipitate if abnormal

coagulation test results are not

corrected with FFP and bleeding

continues.

4. Give platelet concentrates if the

platelet count is less than 50 X 109/L

and bleeding continues.

5. Use cryoprecipitate and platelet

concentrates before surgical

intervention.

EVALUATION OF RESPONSE

1. Monitor pulse, blood pressure, blood

gas status, and acid-base status, and

consider monitoring central venous

pressure.

2. Measure urine output using an

indwelling catheter.

3. Order regular CBC counts and

coagulation tests to guide blood

component therapy.

REMEDY The Cause of Bleeding

1. If antepartum, deliver the fetus and

placenta.

2. If postpartum, use oxytocin,

prostaglandin, or ergonovine.

3. Explore and empty the uterine cavity,

and consider uterine packing.

4. Examine the cervix and vagina, ligate

any bleeding vessels, and repair

trauma.

5. Ligate the uterine blood supply (ie,

uterine, ovarian, and/or internal iliac

arteries).

6. Consider arterial embolization.

7. Consider hysterectomy.