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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

The Use of Postpartum Hemorrhage Protocols in United States Obstetric Anesthesia Units

Abstract Number: S 17
Abstract Type: Original Research

Rachel M. Kacmar M.D.1 ; Barbara M. Scavone M.D.2; Jill M. Mhyre M.D.3; Andrea J. Fuller M.D.4; Paloma Toledo M.D.5


Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. Delays in recognition and management of PPH can lead to maternal morbidity or death. Protocol-driven care has been associated with improved outcomes in many settings, and many have advocated for protocol-driven management of PPH. The objective of this survey was to identify the current level of PPH protocol availability and key components in US academic obstetric anesthesia units.


A survey was developed by an expert panel in this IRB approved study. Domains included: hospital characteristics, availability of PPH protocol, protocol components and utilization patterns. The electronic survey was emailed to 104 directors of US academic obstetric anesthesia units. Univariate statistics were used to characterize survey responses. Probability distributions were estimated using the binomial distribution. Delivery volume and rapid response team (RRT) availability were stratified by PPH protocol availability and compared using a two-tailed t-test. P<0.05 significant.


The survey response rate was 58%. The median rate of PPH was 5% (IQR 3-7%). The median annual delivery volume for units with PPH protocol was 3900 v. 2300 for units without PPH protocol (P=0.002), with no difference in cesarean delivery (CD) rate (P=0.73). A PPH protocol existed in 67% of units (95% CI: 53-78%). Of those without a PPH protocol, 56% planned to create one. A massive transfusion protocol (MTP) existed in 95% of units with a PPH protocol and in 90% of units without (P=0.22).

An 18-guage IV is routinely placed for vaginal delivery in 83% units, and for CD in 88% of the units. Blood is routinely crossmatched (T&C) for elective CD in 18% of responding units, and for 2% of anticipated vaginal deliveries. Crossmatched blood is stored in the blood bank (43%) or at a location of anesthesiologists’ discretion in 38% of the units.

In the setting of massive PPH, 85% of labor and delivery units receive a blood refrigerator or cooler. A fixed blood component transfusion ratio is in place in 79% of the units, with 48% using a 1:1 PRBC:FFP ratio and 35% using a 1:1:1 PRBC:FFP:PLT ratio. A PPH code team or RRT is available in 57% of units, with no difference between units with or without a PPH protocol (56% v. 60% respectively, P=0.77). A dedicated hemorrhage cart exists in 18% of responding units. The most common cart items are supplies for initiating venous or arterial access, and materials for obtaining/sending labs.


We found that while PPH protocols were not universal, MTP protocols were present in nearly all of the responding units. Considerable variability exists in the components of the PPH protocols, specifically as it relates to mobilization and utilization of blood/component therapy and the use of a team to respond to PPH. Future work should evaluate how the presence and components of a PPH protocol may impact maternal outcomes.

SOAP 2013