Beyond monitors: distributed situation awareness in anaesthesia management

To report the outcomes over 14 years of sustained systematic institutional focus on the care of women with major obstetric hemorrhage, defined as estimated blood loss greater than 1,500 mL. A retrospective cohort study of women with major obstetric hemorrhage at our hospital from 2000 to 2014 compares baseline conditions (age, multiparity, prior cesarean delivery, morbidly adherent placenta), morbidity (lowest mean temperature, lowest mean pH, coagulopathy, hysterectomy), and mortality among three time periods (period 1=January 2000 to December 2001, period 2=January 2002 to August 2005, period 3=September 2005 to December 2014). We also describe the systematic changes that helped to sustain our improved outcomes. During the three time periods, there were 5,811, 12,912, and 38,971 births; the rate of major obstetric hemorrhage increased over these periods: 2.1, 3.8 and 5.3 cases per 1,000 births, respectively. Two deaths from hemorrhage occurred in period 1 and none thereafter. Among women who experienced massive hemorrhage, morbidity significantly improved in each successive period: median lowest pH increased from 7.23 to 7.34 to 7.35 (periods 2 and 3 significantly higher than period 1), median lowest maternal temperature (°C) improved, 35.2 to 36.1 to 36.4 (all difference significant), and the rate of coagulopathy decreased, 58.3% to 28.6% to 13.2% (period 3 significantly lower than periods 1 and 2) (all P values <.001). Peripartum hysterectomies were more frequent and more frequently planned over time rather than urgent in each successive period: 0 of 6 to 6 of 18 (33%) to 31 of 64 (48.4%) (P=.044). During period 3, we reorganized the obstetric rapid response team, instituted a massive transfusion protocol and use of uterine balloon tamponade, and promoted a culture of safety in two ways-through more intensive education regarding hemorrhage and escalation (encouraging all staff to contact senior leaders). A sustained level of patient safety is achievable when treating major obstetric hemorrhage, as shown by a progressive decrease in morbidity despite increasing rates of hemorrhage.

In July 2009, the Irish Blood Transfusion Service replaced cryoprecipitate with fibrinogen concentrate to reduce the potential risk of pathogen transmission. Fibrinogen concentrate appears to have similar efficacy in treatment of major haemorrhage but there is limited data about its use in major obstetric haemorrhage (MOH).We aimed at assessing the impact of this change on estimated blood loss (EBL) and blood products use in MOH. <h3>Methodology</h3> Prospective detailed audit of MOH began at our institution in January 2009. Cases are defined by EBL of ≥2.5 l, transfusion of ≥5 units of red cell concentrate (RCC) or treatment of a coagulopathy. EBL and blood products use were compared between those treated for secondary hypofibrinogenemia before and after cryoprecipitate was replaced with fibrinogen. <h3>Results</h3> 59 cases of MOH were identified in 2 years (3.3/1000 deliveries) (table 1). 29 required treatment for hypofibrinogenemia; cryoprecipitate (14) and fibrinogen concentrate (15). Both groups had similar demographics and gestation at delivery. The main causes of bleeding were uterine atony and retained placental tissue. Medical management was similar. Haemostasis was achieved in all cases. <h3>Conclusion</h3> Fibrinogen concentrate in MOH was associated with a reduction in EBL, the use of RCC and octaplas. These cases, however, were diverse and complex and fibrinogen replacement was only one factor in the overall management, but replacement with a small volume bolus that is administered rapidly without thawing may facilitate rapid correction of coagulopathy and earlier haemostasis.

BackgroundDeath is the last point on the spectrum of adverse pregnancy events. Nevertheless, it is essential to know the full extent to which women’s health is affected during or shortly...

The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily.

BackgroundThis study aimed to compare incidence, management and outcomes of women transfused their blood volume or more within 24 hours during pregnancy or following childbirth.MethodsCombined analysis of individual patient data, prospectively collected in six international population-based studies (France, United Kingdom, Italy, Australia, the Netherlands and Denmark). Massive transfusion in major obstetric haemorrhage was defined as transfusion of eight or more units of red blood cells within 24 hours in a pregnant or postpartum woman. Causes, management and outcomes of women with massive transfusion were compared across countries using descriptive statistics.FindingsThe incidence of massive transfusion was approximately 21 women per 100,000 maternities for the United Kingdom, Australia and Italy; by contrast Denmark, the Netherlands and France had incidences of 82, 66 and 69 per 100,000 maternities, respectively. There was large variation in obstetric and haematological management across countries. Fibrinogen products were used in 86% of women in Australia, while the Netherlands and Italy reported lower use at 35–37% of women. Tranexamic acid was used in 75% of women in the Netherlands, but in less than half of women in the UK, Australia and Italy. In all countries, women received large quantities of colloid/crystalloid fluids during resuscitation (>3·5 litres). There was large variation in the use of compression sutures, embolisation and hysterectomy across countries. There was no difference in maternal mortality; however, variable proportions of women had cardiac arrests, renal failure and thrombotic events from 0–16%.InterpretationThere was considerable variation in the incidence of massive transfusion associated with major obstetric haemorrhage across six high-income countries. There were also large disparities in both transfusion and obstetric management between these countries. There is a requirement for detailed evaluation of evidence underlying current guidance. Furthermore, cross-country comparison may empower countries to reference their clinical care against that of other countries.

CHAPTER 77 - Major Obstetric Hemorrhage and Disseminated Intravascular Coagulation

Audit on the role of Tranexamic acid (TXA) in Major Obstetric Haemorrhage u2013 the unanswered questions that need addressing.BackgroundThe MBRRACE report examining maternal mortality demonstrated 16% of direct causes of maternal death were from major obstetric haemorrhage (MOH). Guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), based on TXA use in trauma cases (CRASH2 trial), suggest giving TXA in all MOH u22651000ml; however our local policy, like many others, does not yet specify when and how it should be administered.The WOMEN trial is due to publish soon; hopefully answering these (plus many more) questions.MethodsThrough case note review, anonymised data on management and documentation of MOH &gt;2L was collated in respect to when, why and how TXA was given. Although the Obstetric Anaesthetists Association (OAA) state MOH as blood loss u22651.5L, local policy is u22652L. 8 months of data was collected as MOH data is locally categorised by year.As well as TXA dosing and timing, other factors thought to influence cliniciansu2019 decisions to administer TXA are included.Results and DiscussionA retrospective audit of our medium sized (4350 deliveries/yr) maternity unit reviewed 30 out of 31 cases of u22652L MOH. TXA was given in 43% of cases; these demonstrated partial correlation with total blood loss.83% of cases involved anaesthetic support. 68% of anaesthetic charts recorded total blood loss but none recorded incremental losses. The causes of MOH was solely uterine atony in only 30% of cases; the remaining cases related to tissue, trauma or a combination of factors. tTotal tActivation of MOH protocoltAverage blood loss (median + IQR)tTXA giventTXA given &lt;30 minstRequiring blood productsNo. of casest30t9t2.2L(2.1-3.0L)t13t10t10Without local policy in place this audit demonstrated only limited use of TXA with inconsistency in dosing and timing. This is understandable; prior to the CRASH trial all guidelines listed TXA as a medication of last resort. The WOMEN trial will hopefully answer many of our questions; however, in the mean time, updating and circulating our policy should promote earlier administration. Encouraging documentation of cumulative/incremental blood loss will encourage vigilance and enforcing activation of the u2018controlledu2019 major haemorrhage protocol could persuade doctors to be more proactive, rather than reactive.ConclusionsWe keenly await the results of the WOMEN trial; however, until such time, we will encourage a culture of thorough documentation and early, proactive medical management/optimisation in line with AAGBI recommendations.

Background: Blood transfusion is recognised as one of the eight essential components of the comprehensive emergency obstetric care module which has been designed to reduce maternal morbidity and mortality rates after major obstetric hemorrhage and anemia.Methods: This is a prospective observational study conducted between April1, 2016 to September 30, 2018 in department of obstetrics and gynecology, Government Medical College, Patiala. The MNM cases given transfusion were analysed in respect of number of antenatal visits, type of admission, distance of place of first referral unit from tertiary health care facility, amount of blood transfused, indications of blood transfusion, causes of haemorrhage and intervention performed.Results: During this period, there were 123 cases of MNM, 90 patients required blood transfusion and were considered in this study. Maximum number of cases (94.45%) were between 20-35 years of age. Majority of cases were primipara (52.22%). 47.77% cases were in 3rd trimester, 33.33% postnatal cases and 16.66% cases were in first trimester. 88.88% cases requiring transfusion belong to low socioeconomic status. There was no antenatal visit in 80% cases who required blood transfusion. 78.8% patients required more than 4packed red cell transfusions. Haemorrhage was the indication in 60% cases for blood transfusion and anaemia in 40% cases. Postpartum haemorrhage (28.4%) was most common indication for blood transfusion followed by ruptured ectopic pregnancy (27.77%), antepartum haemorrhage (11.11%), rupture uterus (7.4%), rectus sheath hematoma (5.55%), placenta accreta (5.55%) and inversion uterus (3.7%). Surgical interventions were performed in 51 cases.Conclusions: Prevention and timely treatment of anaemia must receive attention by more active participation in term of antenatal check-ups. Skilled management of patients at the first referral units is advocated. There should be familiarity with the local protocol of relevant members of staff for management of massive hemorrhage. All major hemorrhages should be reviewed to ensure that there is no delay in provision of blood products.

Hemorrhage is one of the leading preventable causes of maternal death. The safe use of blood recovery (also referred to as cell salvage) in obstetrics is well established. Blood recovery is the process by which blood is suctioned from the surgical field into a blood recovery device, where the blood is filtered, washed by centrifugation with a saline solution, and then transfused back to the patient. Blood recovery is recommended for elective cesarean sections where there is increased risk of hemorrhage (e.g., placenta previa/accreta, fibroid uterus, history of post-partum hemorrhage, etc.), or significant anemia at time of cesarean section regardless of risk factors for hemorrhage. Blood recovery is also recommended for emergency use in major obstetric hemorrhage from all causes. The safe and effective use of blood recovery requires a dedicated team of trained staff members.

Haemorrhage remains a cause of significant maternal morbidity and mortality. This review summarizes the prevention, management and treatment of obstetric haemorrhage and highlights recent advances and developments. Postpartum haemorrhage is the most common cause of major obstetric haemorrhage and is usually due to uterine atony. Pharmacological treatment has not altered much in recent years with oxytocin and ergometrine remaining first-line options. Although controversy surrounds its advantages over other uterotonics, the use of misoprostol has been increasing, especially in resource-poor countries. Placenta accreta is becoming more common, a sequelae to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have all made their debut in the last decade. Accurate diagnosis and appropriate management of obstetric haemorrhage can reduce maternal morbidity and mortality. This review outlines the current evidence.

Theoretically, Situation Awareness (SA) remains predominantly an individual construct. The majority of the models presented in the literature focus on SA from an individual perspective and in comparison, the concept of team SA has received less attention. SA in complex, collaborative environments thus remains a challenge for the human factors community, both in terms of the development of theoretical perspectives and of valid measures, and also in the development of guidelines for system, training and procedure design. This article presents a review and critique of what is currently known about SA and team SA, including a comparison of the most prominent individual and team models presented in the literature. In conclusion, we argue that recently proposed systems level Distributed Situation Awareness (DSA) approaches are the most suited to describing and assessing SA in real world collaborative environments.

SummaryThe 2002 RCOG survey of training reported that the percentage of obstetric and gynaecology trainees who class their operative training as good or very good has declined from 45% in 1995, to 39% in 2002; reduction in years of training and number of working hours may have further impact on the surgical experience. In this study, we have attempted to assess the level of surgical confidence reported by senior and recently accredited trainees in obstetrics and gynaecology in the UK via an anonymised postal questionnaire. A total of 103 replies were received from 202 questionnaires. Some 99% of the respondents said they felt competent to carry out a simple total abdominal hysterectomy; 61.2% could confidently dissect the ureter and 55.3% could repair major damage to the bladder. However, when managing major obstetric haemorrhage, only 44.6% of respondents felt confident to perform a caesarean hysterectomy; 27.1% could dissect the ureter and 41.7% could apply a B-Lynch suture to the uterus. The level of competence increased with seniority and also with additional time spent in research, subspecialty training or other specialties. There appears to be an appropriate level of confidence in carrying out gynaecological surgical procedures by senior trainees and new consultants. However, surprisingly few respondents were confident in performing any surgical procedure necessary in the management of major obstetric haemorrhage. This may have serious implications in the provision of out of hours senior cover for maternity units in the future.

(Am J Obstet Gynecol. 2019;221:275.e1–275.e12) From 2011 to 2015, postpartum hemorrhage (PPH) was the cause of 11% of pregnancy-related deaths in the United States and the incidence of PPH is increasing. However, as major obstetric hemorrhage is uncommon and unpredictable, often requiring implementation of multiple nonpharmacological interventions after uterotonic administration, it remains difficult to study. Major obstetric hemorrhage requires significant resources.

The aim of this article is to review the efficacy of a modified uterine compression suture in controlling major haemorrhage at lower segment caesarean section. This is a descriptive study of patients who had major obstetric haemorrhage where a compression suture was used to control bleeding at the two obstetrics unit in Cardiff between January 1998 and December 2003 (n = 11).

Background and AimsPlacenta accreta is a spectrum disorder ranging from abnormally adherent to deeply invasive placental tissue. It is frequently associated with major obstetric haemorrhage. Multidisciplinary planning is vital in...