Practice of Medicine
Managing Postpartum Hemorrhage
Lauren Hamilton, MD, an obstetrician/gynecologist at Charleston (SC) OB/GYN, shares her expertise in the management of postpartum hemorrhage with our podcast host, Steve Adubato, PhD. By talking through a real-life case that led to a malpractice claim, Dr. Hamilton describes the significance of a timely response when dealing with postpartum hemorrhage, how to predict and prepare for postpartum hemorrhage in advance, the need to be able to quantify blood loss in real time, the importance of a postpartum hemorrhage cart, and much more.
Release Date: 9/20/2023; Recorded Date: 6/15/2023
ADUBATO: Hi everyone, Steve Adubato. More importantly, this is the MagMutual Podcast and we are honored today to be joined by Dr. Lauren Hamilton, an obstetrician/gynecologist at Charleston OB/GYN in South Carolina, and a member of the medical faculty at MagMutual. Dr. Hamilton, great to have you with us.
HAMILTON: Thank you. Thank you for letting me join.
ADUBATO: One of the really fascinating things about this MagMutual Podcast is we’re going to lay out a case study. You are going to lay it out. I was looking over the facts as a non-clinician, saying, “Wow. I’m trying to understand where the issues are, what the problems are and what could have been handled differently. So to our audience of physicians and others connected to physicians who want to understand and care about what went wrong here and what could have been done differently, lay out the basic facts, if you could, Dr. Hamilton.
HAMILTON: Sure. This clinical scenario is a 28-year-old female. She’s a G5P4, meaning she’s had four previous deliveries. This is her fifth baby. She had an induction and it was a failed induction, so she underwent a Cesarean section. I don’t have the chart but apparently it was uncomplicated, but about an hour and a half after the C-section, she started passing liver-sized clots and golf ball sized clots, and the fundus was described as boggy, which means the top of the uterus was not as tight as you want it to be ,because your uterus is a muscle. About two hours after delivery, the physician came down to evaluate the patient and performed a fundal massage, trying to make the uterine tone better, and the vaginal bleeding continued. About five hours after delivery, they transfused one unit of platelets. At five and a half hours, they asked for the massive transfusion protocol, which is a protocol that we use when we need a lot of blood products, and that apparently wasn’t performed. Six hours after delivery, they asked the patient to go back to the operating room for a hysterectomy. Six and a half hours after delivery, they brought the patient to the operating room and seven hours after delivery, they did what’s called a B-Lynch suture, which means they reopen the abdomen and put this suture around the uterus hoping that would stop the bleeding. I guess it did not stop the bleeding because eight hours after delivery the second transfusion of blood products was performed, and then the patient was transferred to a higher level of care, but then ended up dying when she got to the second hospital. The allegations for the case included failure to bring to the OR in a timely fashion despite continuous bleeding, low blood pressure, anemia, labs that were consistent with DIC, and failure to perform a hysterectomy.
ADUBATO: Wow. There’s so many pieces to this, but Doctor, I want to focus in on the timely response issue by the physician and other providers in this case. From your perspective, how important is the timely response issue a), and b), what could have or should have been done differently?
HAMILTON: Timely response is so important when you are facing a postpartum hemorrhage. There’s never a time as an obstetrician or as a nurse on labor and delivery that you are not going to face this scenario. It may not go down the road that it went down in this case, but you’re always going to face some type of hemorrhage. There are things that we can do to kind of predict what patients are at risk and then we can be ready to perform things when a patient is at risk. So in other words, readiness means you look at a patient and you say, “What are your risk factors?” Low risk factors include patients who have never had a C-section, they have one baby (not twins or triplets), they have had less than or equal to four vaginal births, they don’t have a bleeding disorder and they have no history of postpartum hemorrhage. When you look at other patients, there are just kind of stages of what’s called readiness, and when you look at a patient, you should consider: Have they had a C-section? Do they have more than one baby inside of them? Do they have a fever? Do they have an infection that increases their risk of postpartum hemorrhage? Have they had a history of a postpartum hemorrhage? Do they have any kind of disorder that makes them bleed more? Do they have fibroids that would impact the ability of the uterus to contract as it should? Do they have a condition that causes their platelets to be less than 100,000? You should kind of stratify patients when they walk in the door. Every patient that walks in the door on labor and delivery should be stratified into low, medium or high.
ADUBATO: Wow. Again, as a layperson, I’m listening to all of the factors to consider, all of the checkpoints if you will. Tough question: Could this have been avoided?
HAMILTON: I think that probably things can be avoided, yes. I think that there are scenarios where it’s just a catastrophe and things can’t be avoided, but the most important thing is timely response to the patient. What people don’t realize is the massive amount of blood loss that occurs during delivery and how it’s so hard to get ahead of it, so you just really can’t get behind.
ADUBATO: So, in a case like this, and I looked at the allegations, as you said before in a very detailed and helpful setup for this. The allegation of failure to bring the patient back into the OR in a timely fashion despite continuous bleeding. And then there’s the concern about the nurses not recognizing significant bleeding sooner. Could you talk to your physician colleagues about how their interaction and communication and dealing with nurses factors into this equation, because it’s not either/or, is it?
HAMILTON: No. We are so dependent on our nursing and we are so dependent on their opinions. We are a team; We are dependent on anesthesia, we’re dependent on our nurses, we’re dependent on our own knowledge and on other physicians coming in and helping us. At our hospital, we have a program called quantitative blood loss. A lot of times in hospitals, there is estimated blood loss, but studies have shown that we underestimate blood loss tremendously. So we have a system where we quantify blood loss. When a patient delivers, we look at the fluid and then we start at zero and you take the amount of blood that’s lost and you actually weigh it and measure it, so you know how much blood the patient is losing in real time.
ADUBATO: Sorry for interrupting. You’re not estimating, you’re not guesstimating.
ADUBATO: You actually weigh it?
HAMILTON: Yes, you actually weigh it, and that takes a team to do that. Let’s say the patient is delivering, she delivers, you look at all of the fluid right after delivery (because that’s prior to delivery), and then you start adding. So if a patient is sitting there and she’s bleeding, she’s hemorrhaging, you have a bag, and you’re looking in that bag to see how much additional blood is there. In addition, we have lap sponges and things like that, so as they’re getting soaked, there’s another team that goes over and weighs them on a scale and so they can kind of, in real time, tell us the patient has lost 500 cc., the patient has lost 700 cc., the patient has lost 1,000 cc. In addition to that, what’s also most important is — we have different kinds of medications we can give to stop a patient from bleeding, and we used to call out for those medications. The nurse would have to run to the Pyxis, which is the system that distributes the medication. But now, all units should have what’s called a postpartum hemorrhage cart.
ADUBATO: A postpartum hemorrhage cart?
ADUBATO: Does that means it is accessible right there?
HAMILTON: Yes, and so if you have a patient who is medium to high-risk for a hemorrhage, it should be outside the room or in the room, whichever you prefer. In that cart, you have all the instruments that you need in order to determine what’s causing the postpartum hemorrhage, because postpartum hemorrhage can be caused by a variety of things. It’s not just the patient bleeding. It can be that you have a vaginal laceration. It can be that you have a uterine laceration. There are different things that you have to assess for, and so you have to, in real time, as a physician, think to yourself, “Okay, what is happening? Is it that there’s a piece of placenta that’s left inside the uterus and the uterus is trying to expel it?“ There are just so many things that can cause postpartum hemorrhage. You have to have kind of a differential in your head, so when a nurse comes in and says, “Hey, this patient is bleeding a lot,” you walk in, you examine them, you look. You don’t just say, “Okay, this is probably the uterus not contracting the way it should.” You have to think to yourself, “Is there a laceration that I didn’t see when the patient delivered? Is there a retained placental product that I didn’t notice?” And so you have to continuously ask yourself these questions, so you actually kind of rule out one by one, and then you get to the meat of the problem. As you’re doing that, you also have to quantify blood loss, because you have to know if you should be transfusing this patient. Know what her vital signs are. You really can’t wait for labs in a postpartum hemorrhage. You need to be on top of vital signs. So if your patient had a pulse in the 90s and all of a sudden she’s in the 130s, even if you get a CBC at that moment, it’s not really going to quantify the amount of blood that she has lost because it’s so instantaneous. So you really have to treat the vital signs, you don’t treat labs and you don’t wait for labs.
ADUBATO: Dr. Hamilton, I’m very confident that not only your description of the case but your advice, your being very specific and clear on all of the things that should be checked and the changes that should be made, the innovations that are out there and accessible to our physician leaders listening right now, are extremely helpful. Thank you, Dr. Hamilton.
HAMILTON: Thank you.
ADUBATO: So, this has been another very important addition of the MagMutual Podcast. I’m Steve Adubato. From everyone on the MagMutual team, we thank you so much for listening, and thank you, Dr. Hamilton.
HAMILTON: Thanks for having me.
ADUBATO: Catch you next time.
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