2015 CDC Service Projects Web

*Winning Projects
District I
Massachusetts Section Massachusetts Child Psychiatry Access Project for Moms
(MCPAP for Moms)
District II
Long Acting Reversible Contraception (LARC)
*District IV
South Carolina Section Births Outcomes Initiative (BOI)
*District IX
Reduction of Maternal Mortality in California
*District X
Armed Forces District 2015 Perinatal Safety Initiative
District XII
Obstetric Hemorrhage Initiative
DISTRICT I
MASSACHUSETTS
Massachusetts Child Psychiatry Access Project For Moms

(MCPAP For Moms)
District I
Office of the Chair
Patricia M. Miller MD, FACOG
25 Village Brook Ln
Derry, NH 03038-4867
Office: (603)548-3925
Email: patmiller001@gmail.com
Dear Ms. Williams and Fellow CDC Chairs,
I am pleased to nominate the Massachusetts Child Psychiatry Access Project for Moms
(MCPAP for Moms) for the 2016 Council of District Chairs Service Recognition Award. MCPAP
for Moms is a first in nation, statewide program that helps first-line perinatal care providers address
perinatal depression. All MA Ob/Gyns have access to the free MCPAP for Moms program by
calling 1-855-Mom-MCPAP (855-666-6272) or through the website www.mcpapformoms.org, and
thus all pregnant and postpartum women regardless of insurance coverage are helped.
Perinatal depression is increasingly recognized as a major public health problem that affects as many
as 1 in 7 women. It is under-diagnosed and under-treated, and can have profound negative effects
on the mother, fetus, child and family. Ob/Gyns are appropriately encouraged to screen for
perinatal depression but screening alone does not translate into treatment participation; women and
obstetric providers experience multi-level barriers along the depression care pathway. MCPAP for
Moms addresses many of these barriers with its core components that include:
(1) Trainings and toolkits that provide evidence-based guidelines for providers and their
staff on depression screening, triage and referral, risks and benefits of medications, and
discussion of screening results and treatment options.
(2) Real-time psychiatric consultation and care coordination.
(3) Linkages with community-based resources that include mental health care, support
groups and other resources to support the wellness and mental health of pregnant and
postpartum women
The MCPAP for Moms phone lines went live July 1, 2014. In its first year alone, MCPAP for
Moms has served 553 unique patients, taken over 500 phone calls from providers, provided 641 care
coordination activities, conducted 75 training for front-line perinatal health care providers, and
enrolled a third of all obstetric practices in Massachusetts with efforts on-going. Provider and
patient testimonials speak to the need for and the effectiveness of this innovative and critical
program.
Of particular note and importance, MCPAP for Moms was modeled after the original MCPAP
(MA Child Psychiatry Access Project) program. MCPAP was initiated over 10 years ago to address
the crisis of insufficient child psychiatrists necessary to address the mental health needs of the
pediatric community. This model or some version of it has now been replicated in 32 states in the
U.S. which has led to the National Network of Child Psychiatry Access Programs
(http://nncpap.org/).
As we are aware, there is a similar crisis for women experiencing mental health issues in pregnancy
and the postpartum period. MCPAP for Moms extends the MCPAP model to include perinatal
psychiatrists with the goal of assisting providers caring for perinatal women, with their mental health
needs. Because it is modeled on MCPAP, MCPAP for Moms is similarly feasible and sustainable and
carries the same potential for widespread dissemination and implementation. One of the keys to its
sustainability is its cost efficiency is that it operates on an annual budget of only $8.33 per pregnant
and postpartum woman per year. This translates to $0.69 per month or $600,000 for 72,000
deliveries annually in Massachusetts. Through collaborative advocacy by our psychiatric and
Ob/Gyn communities in addition to other relevant and passionate stakeholders, perinatal
depression has been recognized as an important issue by the MA state legislature, and thus is
included in the state budget, funded by the MA Department of Mental Health. Sustainability of
funding for the program has been assured by the
MA state legislature passing a surcharge on commercial insurers for their share of the cost of the
program.
Important and practical resources created by the MCPAP for Moms team that are beneficial to all
Ob/Gyn providers regardless of District (e.g. tool kit) have been made available through the ACOG
depression web-page (http://www.acog.org/Womens-Health/Depression-and-
Postpartum-Depression). Additionally, a Centers for Disease Control and Prevention (CDC) grant
was recently awarded that will allow for the collection of MCPAP for Moms outcome data including
treatment engagement, treatment rates, and depression outcomes. This will facilitate evaluation of
the depression care pathway from beginning to the most important end point which is the successful
clinical resolution of depression symptoms for the women for which we care.
MCPAP for Moms is a paradigm-shifting, population-based program that addresses multiple barriers
experienced by providers and patients in identifying and treating the critical and epidemic issue of
perinatal depression. It is a cost-efficient model that centralizes the scarce and invaluable expertise
of perinatal psychiatrists as collaborative partners with Ob/Gyns. It facilitates perinatal care
providers having immediate access to psychiatric consultation and care coordination thus allowing
Ob/Gyns to address and optimize the mental health of their patients whom are expecting or within
a year postpartum. As is true of the MCPAP program off of which MCPAP for Moms was modeled,
it has a great likelihood of broad dissemination across all ACOG Districts with advocacy and
support efforts from our fellows.
I believe our MCPAP for Moms leadership team is worthy of recognition for their dedication,
enthusiasm, and tireless efforts. It has been my privilege to promote and advocate for this program,
I greatly look forward to a day when all of our fellows regardless of District or state have access to a
similar resource. I humbly submit ACOG District Is MCPAP for Moms program for consideration
of the Council of District Chairs Service Recognition Award, as it deserves national recognition -
this recognition would facilitate awareness of, and thus early dissemination of, this key and
pioneering program to other Districts.
Sincerely,
Patricia Miller, MD, FACOG

Past Chair, ACOG District I
OVERVIEW
The Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms) is a statewide
program that provides real-time, perinatal psychiatric consultation and care coordination for
obstetric, primary care, psychiatric, and pediatric providers as they attend to the emotional and
mental health needs of their pregnant and postpartum patients. Launched in July 2014, MCPAP for
Moms is the first program of its kind in the nation. MCPAP for Moms is funded by the Massachusetts
Department of Mental Health, and is free to all Massachusetts providers and perinatal women.
The mission of MCPAP for Moms is to promote maternal mental health by helping front-line
providers screen and manage depression in pregnant women and women within a year of their
delivery. MCPAP for Moms addresses the public health crisis of under-diagnosed and under-treated
depression, which can have profound negative effects on the mother, fetus, child and family.
Pregnant and postpartum women with depression have regular contact with health care providers
as such, each visit provides an opportunity to screen for depression and engage women in treatment.
With MCPAP for Moms, providers are supported with real-time access to perinatal psychiatric expert
consultation as well as targeted mental health community-based supports to address the mental
health needs of their patients. MCPAP for Moms supports are also available to fathers, adoptive
parents, grandparents and other family members experiencing perinatal mental health concerns.
CORE COMPONENTS
Trainings and toolkits: Provide evidence-based guidelines for providers and their staff on
depression screening, triage and referral, risks and benefits of medications, and discussion of
screening results and treatment options. All training and toolkit materials are open-source
and available at www.mcpapformoms.org.
Real-time psychiatric consultation and care coordination: Provides consultation with a
perinatal psychiatrist, and subsequent care coordination.
Linkages with community-based resources: Includes mental health care, support groups and
other resources to support the wellness and mental health of pregnant and postpartum
women.
HOW MCPAP FOR MOMS WORKS

Providers in Massachusetts can call MCPAP for Moms at 855-Mom-MCPAP (855-666-6272), Monday-
Friday, 9am-5pm, and speak with a Care Coordinator who will work with the provider to determine
their needs for assisting their patients - i.e., consultation regarding psychiatric care, community care
coordination, or both.
1
Psychiatric consultation: The MCPAP for Moms perinatal psychiatrist provides real-time
consultation via the telephone to medical providers. The consultation may involve diagnostic
support, guidance in regards to medication treatment (when indicated) or concerns regarding
preconception, pregnancy and lactation, psychotherapy and community support needs, and
treatment planning. The MCPAP for Moms psychiatrist works with the provider to assist
him/her in addressing their patient's mental health concerns. The MCPAP for Moms
psychiatrist is also available to see patients for face-to-face consultations, after which they will
send a detailed written assessment that will include treatment recommendations to the
provider.
Care coordination: The Care Coordinator works with providers to assist them in arranging
ongoing mental health support for patients including, but not limited to, psychotherapy
groups, mental health treatment (including prescribers), and family based treatments.
Community supports are specifically matched for each patient to ensure that they are
geographically convenient and work with a patients insurance. In some cases the Care
Coordinator can call the patient/family and provider to ensure that patients have access to
follow-up mental health care.
WHO CAN CALL

Obstetrical providers: This includes obstetricians/gynecologists, midwives, labor and delivery
nurses, and family medicine providers practicing obstetrics. MCPAP for Moms builds the
capacity of obstetric providers to detect and manage depression and other mental health
concerns that may arise among perinatal women in their practices via screening, direct care
management, and assistance with care coordination for ongoing mental health care and
supports. MCPAP for Moms engages and enrolls obstetrical practices on a rolling basis.
Pediatric providers: This includes pediatricians, family physicians, and nurse practitioners who
provide well-child care in the first year of life. MCPAP for Moms helps pediatric providers
detect and refer depression and other mental health issues that may arise among postpartum
women seen in pediatric settings.
Adult psychiatric providers: MCPAP for Moms builds the capacity of adult psychiatric
providers to manage their patients who are planning to or who become pregnant during
treatment via expert consultation with a perinatal psychiatrist to facilitate careful and
thoughtful decisions regarding medication management before, during and after a pregnancy.
Adult Primary Care Providers: This includes both internal and family medicine providers who
practice general adult medicine. MCPAP for Moms assists PCPs in providing ongoing care for
their patients during the postpartum period.
HOW WE HELP PROVIDERS

MCPAP for Moms has created an obstetric toolkit to assist front-line perinatal care providers in
prevention, identification, and treatment of depression. This toolkit contains assessment tools,
2
screening tools and algorithms, and guides on what to do when treatment with antidepressants is
indicated (see Toolkit in Appendix or online at www.mcpapformoms.org). The obstetric toolkit
includes:
Depression Screening Algorithm for Obstetric Providers
Assessment of Depression Severity and Treatment Options
Recommended Steps before Beginning Antidepressant Medication Algorithm
Bipolar Disorder Screen
Antidepressant Treatment Algorithm
Key Clinical Considerations when Assessing the Mental Health of Pregnant and Postpartum
Women
Summary of Emotional Complications during Pregnancy and the Postpartum Period
HOW WE HELP PREGNANT AND POSTPARTUM WOMEN AND THEIR FAMILIES

MCPAP for Moms has developed resources to support the mental health of perinatal women and
their families. These resources, available at www.mcpapformoms.org, include:
Tips sheets for How to Find a Primary Care Practitioner and How to Talk to Your Health Care
Provider.
A searchable database of regional support groups for pregnant and new mothers.
Web-based and social media supports and resources for pregnant and postpartum women,
fathers, perinatal loss, and crisis services.
FACTS AND FIGURES

In its first year, MCPAP for Moms has:
Served 553 unique patients
Taken over 500 phone calls from providers
Provided 641 care coordination activities
Conducted over 75 trainings for front-line perinatal health care providers
Enrolled 30% of all obstetric practices in Massachusetts
OPERATING COSTS
MCPAP for Moms operates with an annual budget of $8.33 per pregnant and postpartum woman per
year. This translates to $0.69 per month or $600,000 for 72,000 deliveries annually in Massachusetts.
COMMUNITY PARTNERS
MCPAP for Moms works in close partnership with Motherwoman and William James INTERFACE
Referral Service. As part of MCPAP for Moms, Motherwoman is actively training health care
leadership in six communities across Massachusetts on strategies to be responsive to the needs of
pregnant and postpartum women living with emotional health concerns. This includes establishing
new perinatal support groups for mothers and families throughout the Commonwealth. INTERFACE
3
developed and maintains the database used by Care Coordinators to match community mental health
resources (e.g., therapist) to women referred to MCPAP for Moms.
SUPPORTING DOCUMENTS AND RESOURCES (please see accompanying Appendix)
TESTIMONIALS
You guys are amazing! I absolutely LOVE this therapist... She is so nice, understanding and I am very
comfortable with out treatment plan. I cannot thank you guys enough. I really really appreciate all
you have done. Mom
I just called the program to look for a referral for counseling for a patient what a wonderful and
easy process.OB/GYN
Oh my gosh the appointment went great! So far I have a really good feeling about receiving therapy
from this place. The woman I met with seems so nice and well educated! Thank you, thank you for
hooking me up with these services. It is such a relief for my whole family that I finally have the
support system I need to deal with my issues in a safe and healthy way! Thank you!Mom
Thanks again. I can't tell you how helpful the MCPAP for Moms consultations have been for me
personally as a psychiatric nurse practitioner working with pregnant moms who are trying to make
the best treatment decisions possible for themselves and their babies.Nurse Practitioner
I had a patient Monday who said she was getting increasingly depressed (about 24 weeks pregnant)
and could not get into her previous counseling/psych office. She scored 21 on EPDS. I called MCPAP
for Moms, got a call back from psychiatrist within the hour, and patient was going to be called and
get an appt to see a psychiatrist this Friday. There is no other service that can offer this to our
patients.Ob/Gyn
It is hard to argue against a program that is so beneficial to moms and families and is cost
efficient!Ob/Gyn
RESEARCH BUILDING ON MCPAP FOR MOMS

MCPAP for Moms leadership was recently awarded a U01 grant from the U.S. Centers for Disease
Control and Prevention (CDC) to test and disseminate a stepped care intervention for perinatal
depression in Ob/Gyn settings. This first-of-its-kind, $2.5 million grant includes a randomized
controlled trial comparing MCPAP for Moms to an enhanced intervention that will include MCPAP for
Moms and some additional collaborative care approaches (including case management, systematic
patient monitoring, stepped care, and implementation assistance among others). This will allow for
the collection of outcome data on MCPAP for Moms (including treatment rates and depression
outcomes), while also testing an enhanced intervention that will build on the MCPAP for Moms
program. This is a particularly noteworthy accomplishment as only one U01 grant was awarded in
U.S. This demonstrates the role of MCPAP for Moms and its leadership in developing and setting the
standard of care to address perinatal depression in obstetric settings.
4
Appendix
Table of Contents
Marketing and outreach materials

o MCPAP for Moms Brochure for Providers .1-2
o MCPAP for Moms Brochure for Mothers....3-4
o Screenshot of MCPAP for Moms website landing page......5
Toolkit materials for Obstetric providers
o Assessment of Depression Severity and Treatment Options................................6
o Summary of Emotional Complications During Pregnancy and Postpartum Period.....7
o Key Clinical Considerations When Assessing Mental Health.8
o Depression Screening Algorithm for OB Providers.9
o Depression Screening Algorithm for OB Providers (w/talking points)..10
o Edinburgh Postnatal Depression Scale (EPDS).11-12
o Bipolar Disorder Screen..13
o Recommended Steps before Beginning Antidepressant Medication Algorithm.14
o Antidepressant Treatment Algorithm..15
Training materials for Obstetric providers
o PowerPoint Presentation for Obstetric providers...16-48
Pediatric provider materials
o Primer for Pediatric providers49-57
o Postpartum Depression Screening Algorithm.58
o Postpartum Depression Screening Algorithm (w/talking points)....59
Media coverage
o MCPAP for Moms feature in CommonWealth Magazine.60-70
o MCPAP for Moms feature in Boston.com.71-73
o MCPAP for Moms feature in WBUR CommonHealth (Bostons NPR Station)...74-75
o Link to MCPAP for Moms feature on WCVB Channel 5 News.76
We help providers 1
address depression in pregnant
and postpartum women
MCPAP for Moms builds on the successful
MCPAP for Moms promotes

Massachusetts Child Psychiatry Access Project
(MCPAP). MCPAP was created in 2004 because There is a growing sense of urgency to
children were unable to effectively access psychiatric maternal and child health by identify better care and treatment approaches
care and pediatric providers were not equipped building the capacity of for perinatal depression (depression occurring
during pregnancy or within one year of delivery).
to manage childrens psychiatric needs. MCPAP providers serving pregnant
assists pediatric providers through telephone
consultation, the availability of face-to-face
and postpartum women and Obstetric and primary care providers often
consultation, care coordination, and ongoing their children up to one year have limited access to mental health resources
and supports needed to address perinatal
education. MCPAP for Moms expands MCPAP after delivery to effectively depression in their patients.
to help front-line perinatal care providers address prevent, identify, and manage
depression and mental health concerns.
depression. MCPAP for Moms is available to provide
real-time psychiatric consultation and care
Funding for MCPAP for Moms is provided coordination to help providers and their
by the Commonwealth of Massachusetts patients. The program is free and available
Department of Mental Health. for all pregnant or postpartum women
throughout Massachusetts regardless of
type of health insurance.
Our goal is to improve outcomes for babies,

855-MOM-MCPAP
mcpapformoms.org children, and families by helping pregnant
Follow us and postpartum women access and engage
in depression treatment.
Copyright 2014 MCPAP. MCPAP consents to the copying, republishing,
855-MOM-MCPAP
redistributing or otherwise reproducing of this work so long as the resultant mcpapformoms.org
work carries with it express attribution of authorship to MCPAP.
Promoting Maternal Mental Health During and After Pregnancy 2
Provider Resources Family Resources MCPAP Educational Services

Trainings and toolkits for MCPAP for Moms is partnering with To access MCPAP for Moms call:
providers and their staff based MotherWoman and the Massachusetts School 855-MOM-MCPAP (666-6272)
on evidence-based guidelines for: of Professional Psychology Interface Referral Monday through Friday
depression screening, triage and Service to develop community resources and 9:00 a.m. 5:00 p.m.
referral, risks and benefits of supports across the state for women with
medications, and discussion of depression. Visit the Mothers and Families A care coordinator will answer the providers
screening results and treatment tab at www.MCPAPforMoms.org for call and help determine the need to consult
options support and resource information. We with a MCPAP for Moms psychiatrist, a care
encourage mothers to talk with their coordinator, or both.
Real-time psychiatric consultation providers about MCPAP for Moms.
and care coordination for Providers can then call MCPAP for Moms The following outcomes may result
obstetric, pediatric, primary care, for consultation. from a telephone consultation. The MCPAP for Moms is available to provide
and psychiatric providers serving MCPAP for Moms psychiatrist may: training on-site at hospitals and obstetric
pregnant and postpartum women and primary care practices. Please e-mail
d Answer the providers question
MCPAP@valueoptions.com to schedule a
d Recommend a face-to-face evaluation training or grand rounds.
Pediatricians should refer moms
with the patient for further assessment
with mental health concerns or
positive screening results to their d
Refer the provider and the patient/family
obstetric or primary care providers to a care coordinator for assistance
who can obtain assistance directly connecting with resources in the patients One in Eight
from MCPAP for Moms. community One out of every eight women
experience depression during
Linkages with community-based pregnancy or in the first year
resources including mental health postpartum. Depression during
care, support groups, and other this time is twice as common
resources to support the wellness as gestational diabetes.
and mental health of pregnant and
postpartum women
What is MCPAP for Moms?
Having a baby 3
is challenging.
MCPAP for Moms is a first in the nation,
statewide program to assist medical professionals
in supporting your emotional and mental health
Every woman
during your pregnancy and the year following deserves support.
birth or adoption.
If you and/or your health care provider are Please visit www.mcpapformoms.org and click
concerned about your emotional and mental the For Mothers and Families tab to learn
health, your provider may decide to call more about:
MCPAP for Moms for:
d Community-based support groups
d A phone consultation with a MCPAP Resources for pregnant and postpartum
d
for Moms psychiatrist to discuss treatment women
options to recommend for you
d Tip Sheets for talking with your
d A one-time visit for you with a MCPAP primary care provider about mental
for Moms psychiatrist. The psychiatrist will health concerns
provide personalized recommendations to you
d Hotlines and social media supports
and your provider
d Resources for fathers and partners
d A list of community-based mental health
resources to share with you d Parenting and family supports including
early intervention and home visiting
d Assistance in identifying
and/or scheduling d Resources for loss related to pregnancy
community-based and/or childbirth
mental health resources
that may include
therapy, a psychiatrist,
or a support group
mcpapformoms.org
2015 MCPAP. MCPAP for Moms consents to the copying, republishing,
redistributing or otherwise reproducing of this work so long as the resultant
work carries with it express attribution of authorship to MCPAP. mcpapformoms.org
Funding for MCPAP for Moms is provided by the Commonwealth
of Massachusetts Department of Mental Health.
MCPAP4MOM_Moms_Brochure_6pg_Final.indd 1 6/4/15 7:31 AM

Having or adopting a baby comes 4
with a lot of life changes and
transitions. These can be stressful
and can affect your health and
the health of your baby. It is very
common to experience anxiety,
crying, difficulty concentrating or
sleeping, sadness or guilt during
this challenging time.
One in eight women report experiencing

depression during pregnancy or in the first
year after giving birth or adopting. It is
very common to have difficulties or feel
depressed during this time. You may be It may also help to talk to friends or family.
thinking: This is supposed to be a happy Your medical providers may notice that you
and exciting time; why am I feeling so arent yourself and ask you about how you are
anxious and sad? This is called perinatal feeling. They may use a screening tool to get a
depression or anxiety. better sense of how you are doing.
Getting help is the best thing Fathers and partners may also suffer One in eight women report experiencing
you can do for you and your from perinatal depression or anxiety. depression during pregnancy or in the
baby. If you are concerned Encourage your partner to ask first year after giving birth or adopting.
about how you are for help.
feeling, talk to your
obstetrician, midwife,
primary care provider, or
your babys pediatrician.
You Are Not Alone

MCPAP4MOM_Moms_Brochure_6pg_Final.indd 2 6/4/15 7:31 AM
5
Assessment of Depression Severity and Treatment Options1 6
EPDS 0-8 EPDS 9-13 EPDS 14-18 EPDS19
EPDS SCORE or
clinical assessment LIMITED TO NO SYMPTOMS MILD SYMPTOMS MODERATE SYMPTOMS SEVERE SYMPTOMS
Reports occasional sadness Mild apparent sadness but Reports pervasive feelings of Reports continuous sadness and
brightens up easily sadness or gloominess misery
Placid - only reflecting inner Occasional feelings of edginess Continuous feelings of inner Unrelenting dread or anguish,
tension and inner tension tension/ intermittent panic overwhelming panic
Sleeps as usual Slight difficulty dropping off to Sleep reduced or broken by at Less than two or three hours sleep
sleep least two hours
Normal or increased appetite Slightly reduced appetite No appetite - food is tasteless Needs persuasion to eat
No difficulties in concentrating Occasional difficulty in Difficulty concentrating and Unable to read or converse without
SIGNS AND concentrating sustaining thoughts great initiative
SYMPTOMS OF No difficulty starting everyday Mild difficulties starting everyday Difficulty starting simple, Unable to do anything without help
DEPRESSION activities activities everyday activities
Normal interest in Reduced interest in surroundings Loss of interest in surroundings Emotionally paralyzed, inability to
surroundings & friends & friends and friends feel anger, grief or pleasure
No thoughts of self-reproach, Mild thoughts of self-reproach, Persistent self-accusations, self- Delusions of ruin, remorse or
inferiority inferiority reproach unredeemable sin
*Signs and symptoms in No suicidal ideation Fleeting suicidal thoughts Suicidal thoughts are common History of severe depression and/
each column may overlap or active preparations for suicide
LIMITED TO NO SYMPTOMS MILD SYMPTOMS MODERATE SYMPTOMS SEVERE SYMPTOMS

Consider inpatient hospitalization Consider inpatient hospitalization
when safety or ability to care for when safety or ability to care for
self is a concern self is a concern
Consider medication Strongly consider medication Strongly consider medication
Therapy for mother Therapy for mother Therapy for mother Therapy for mother
Dyadic therapy for Dyadic therapy for mother/baby Dyadic therapy for mother/baby Dyadic therapy for mother/baby
mother/baby
Community/social support Community/social support Community/social support Community/social support
(including support groups) (including support groups) (including support groups) (including support groups)
TREATMENT Consider as augmentation: Consider as augmentation: Consider as augmentation: Consider as augmentation:
OPTIONS Complementary/ Alternative Complementary/ Alternative Complementary/ Alternative Complementary/ Alternative
therapies (bright light therapy, therapies (bright light therapy, therapies(bright light therapy, therapies (bright light therapy,
Omega-3 fatty acids, Omega-3 fatty acids, acupuncture, Omega-3 fatty acids, acupuncture, Omega-3 fatty acids, acupuncture,
acupuncture, folate, massage) folate, massage) folate, massage) folate, massage)
Support with dysregulated Support with dysregulated baby; Support with dysregulated baby; Support with dysregulated baby;
*Treatment options in baby; crying, sleep, feeding crying, sleep, feeding problems crying, sleep, feeding problems crying, sleep, feeding problems
each column may overlap
problems Physical activity Physical activity Physical activity
Physical activity
Self-care (sleep, hygiene, Self-care (sleep, hygiene, healthy Self-care (sleep, hygiene, healthy Self-care (sleep, hygiene, healthy
healthy diet) diet) diet diet)
1
Information adapted from: Montgomery SA, Asberg M: A new depression scale designed to be sensitive to change. British Journal of Psychiatry 134:382-389, 1979
Limited or no symptoms of depression Severe symptoms of depression

MCPAP for Moms: Promoting maternal mental health during and after pregnancy www.mcpapformoms.org
Revision 07.24.14 Tel: 855-Mom-MCPAP (855-666-6272)
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Freeman M., & Cohen L.
Funding provided by the Massachusetts Department of Mental Health
Summary of Emotional Complications During Pregnancy and the Postpartum Period 7
Baby Blues Perinatal Depression Perinatal Anxiety Posttraumatic Disorder Obsessive-Compulsive Postpartum Psychosis
(PTSD) Disorder
What is it? Common and temporary Depressive episode that A range of anxiety disorders, Distressing anxiety symptoms Intrusive repetitive thoughts that are Very rare and serious. Sudden onset of
experience right after childbirth occurs during pregnancy or including generalized anxiety, experienced after traumatic scary and do not make sense to psychotic symptoms following
when a new mother may have within a year of giving birth. panic, social anxiety and events(s). mother/expectant mother. Rituals childbirth (increased risk with bipolar
sudden mood swings, feeling very PTSD, experienced during (e.g., counting, cleaning, hand disorder). Usually involves poor insight
happy, then very sad, or cry for no pregnancy or the postpartum washing). May occur with or about illness/symptoms, making it
apparent reason. period. without depression. extremely dangerous.
When does it First week after delivery. Peaks 3-5 Most often occurs in the Immediately after delivery to May be present before 1 week to 3 months postpartum. Typically presents rapidly after birth.
start? days after delivery and usually first 3 months postpartum. 6 weeks postpartum. pregnancy/birth. Can present Occasionally begins after weaning Onset is usually between 2 12 weeks
resolves 10-12 days postpartum. May begin after weaning Occasionally begins after as a result of traumatic birth. baby or when menstrual cycle after delivery. Watch carefully if sleep
baby or when menstrual weaning baby or when Underlying PTSD can also be resumes. May also occur in deprived for 48 hours.
cycle resumes. menstrual cycle resumes. worsened by traumatic birth. pregnancy.
Risk factors Life changes, lack of support and/or Life changes, lack of Life changes, lack of support Lack of partner support, Family history of OCD, other anxiety Bipolar disorder, history of psychosis,
additional challenges (difficult support and/or additional and/or additional challenges elevated depression disorders. Depressive symptoms. history of postpartum psychosis (80%
pregnancy, birth, health challenges challenges (difficult (difficult pregnancy, birth, symptoms, more physical Prior pregnancy loss. will relapse), family history of psychotic
for mom or baby, twins). Prior pregnancy, birth, health health challenges for mom or problems since birth, less Dysregulated baby-crying feeding, illness, sleep deprivation, medication
pregnancy loss. challenges for mom or baby, twins). Prior pregnancy health promoting behaviors. sleep problems. discontinuation for bipolar disorder
Dysregulated baby-crying feeding, baby, twins). Prior loss. Dysregulated baby-crying Prior pregnancy loss. (especially when done quickly). Prior
sleep problems. pregnancy loss. feeding, sleep problems. Dysregulated baby-crying pregnancy loss.
Dysregulated baby-crying feeding, sleep problems. Dysregulated baby-crying feeding,
feeding, sleep problems. sleep problems.
How long A few hours to a few weeks. 2 weeks to a year or longer. From weeks to months to From 1 month to longer. From weeks to months to longer. Until treated.
does it last? Symptom onset may be longer.
gradual.
How often Occurs in up to 85% of women. Occurs in up to 19% of Generalized anxiety occurs in Occurs in 2-15% of women. May occur in up to 4% of women. Occurs in 1-2 or 3 in 1,000 births.
does it occur? women. 6-8% in first 6 months after Presents after childbirth in 2-
delivery. Panic disorder 9% of women.
occurs in .5-3% of women 6-
10 weeks postpartum. Social
anxiety occurs in 0.2-7% of
early postpartum women.
What Women experience dysphoric Change in appetite, sleep, Fear and anxiety, panic Change in cognition, mood, Disturbing repetitive thoughts Mood fluctuation, confusion, marked
happens? mood, crying, mood lability, energy, motivation, and attacks, shortness of breath, arousal associated with (which may include harming baby), cognitive impairment. Bizarre behavior,
anxiety, sleeplessness, loss of concentration. May rapid pulse, dizziness, chest or
traumatic event(s) and adapting compulsive behavior to insomnia, visual and auditory
appetite, and irritability. experience negative stomach pains, fear of avoidance of stimuli prevent baby from being harmed hallucinations and unusual (e.g. tactile
thinking including guilt, detachment/doom, fear of associated with traumatic (secondary to obsessional thoughts and olfactory) hallucinations. May
Postpartum depression is hopelessness, helplessness, going crazy or dying. May event. about harming baby that scare have moments of lucidity. May include
independent of blues, but blues is a and worthlessness. May have intrusive thoughts. women). altruistic delusions about infanticide
risk factor for postpartum also experience suicidal and/or homicide and/or suicide that
depression. thoughts and evolution of need to be addressed immediately.
psychotics symptoms.
Resources May resolve naturally. Resources For depression, anxiety, PTSD and OCD, treatment options include individual therapy, dyadic therapy for mother and baby, and Requires immediate psychiatric help.
and include support groups, psycho- medication. Resources include support groups, psycho-education, and complementary and alternative therapies including exercise and Hospitalization usually necessary.
education (see MCPAP for Moms yoga. Encourage self-care including healthy diet and massage. Encourage engagement in social and community supports (including Medication is usually indicated. If
treatment website and materials for detailed support groups) (see MCPAP for Moms website and materials for detailed resources). Encourage sleep hygiene and asking/accepting history of postpartum psychosis,
information) and sleep hygiene help from others during nighttime feedings). Address infant behavioral dysregulation -crying, sleep, feeding problems- in context of preventative treatment is needed in
(asking/accepting other help during perinatal emotional complications. subsequent pregnancies. Encourage
nighttime feedings). Address infant sleep hygiene for prevention (e.g.
behavioral dysregulation -crying, Additional complementary and alternative therapies options for depression include bright light therapy, Omega-3, fatty acids, consistent sleep/wake times, help with
sleep, feeding problems- in context acupuncture and folate. feedings at night).
of perinatal emotional
complications.
1 Adapted from Susan Hickman, Ph.D., Director of the Postpartum Mood Disorder Clinic, San Diego; Valerie D. Raskin, M.D., Assistant Professor of Clinical Psychiatry at the University of Chicago, IL (Parents September 1996)
2O'Hara MW, Wisner KL. Perinatal mental illness: Definition, description and aetiology. Best Pract Res Clin Obstet Gynaecol. 2013 Oct 7. pii: S1521-6934(13)00133-8. doi: 10.1016/j.bpobgyn.2013.09.002. [Epub ahead of print]
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Friedman, L., Lundquist R., Freeman M., & Cohen L.
Key Clinical Considerations When Assessing the 8
Mental Health of Pregnant and Postpartum Women
Assessing Thoughts of Harming Baby

Thoughts of Harming Baby that Occur Secondary to Thoughts of Harming Baby that Occur Secondary to
Obsessions/Anxiety Postpartum Psychosis /Suspected Postpartum Psychosis
Good insight Poor insight
Thoughts are intrusive and scary Psychotic symptoms
No psychotic symptoms Delusional beliefs with distortion of reality present
Thoughts cause anxiety
Suggests not at risk of harming baby Suggests at risk of harming baby
Suggests Medication May Not be Indicated Suggests Medication Treatment Should be Considered
Mild depression based on clinical assessment Moderate/severe depression based on clinical assessment
No suicidal ideation Suicidal ideation
Engaged in psycho-therapy or other non- Difficulty functioning caring for self/baby
medication treatment Psychotic symptoms present (call MCPAP for Moms)
Depression has improved with psychotherapy in History of severe depression and/or suicide
the past ideation/attempts
Able to care for self/baby Comorbid anxiety dx/sxs
Strong preference and access to psychotherapy
Risk Factors for Postpartum Depression1

Personal history of major or postpartum Complications of pregnancy, labor/delivery, or infants
depression health
Family history of PPD Teen pregnancy
Gestational diabetes Unplanned pregnancy
Difficulty breastfeeding Major life stressors
Fetal/Newborn loss Violent or abusive relationship
Lack of personal or community resources Isolation from family or friends
Financial challenges Substance use/addiction
Other Considerations During Clinical Assessment

Past history of psychiatric diagnosis History of substance use or substance use treatment
Previous counseling or psychotherapy Anxiety and worry
Previous psychiatric medication Trauma history
History of other psychiatric treatments such as Domestic violence
support groups
How to Talk about Perinatal Depression with Moms1

How are you feeling about being pregnant/a mother?
What things are you most happy about?
What things are you most concerned about?
Do you have anyone you can talk to that you trust?
How is your partner doing?
Are you able to enjoy your baby?
1
This guideline has been adapted from materials made available by HealthTeamWorks and the Colorado Department of Public Health and Environment (CDPHE) http://www.healthteamworks.org/guidelines/depression.html.
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Friedman, L., Lundquist R., Freeman M., & Cohen L.
Depression Screening Algorithm for Obstetric Providers 9
The EPDS should be administered during:

Initial intake or first obstetrics visit
Visit following Glucola test
If high-risk patient,* 2 weeks postpartum
If first EPDS 6 weeks postpartum visit If subsequent
screen EPDS screen
Woman completes the EPDS. Staff tallies

Clinical support score and enters into medical record. Staff Give EPDS to woman
staff explains EPDS informs OB provider of score prior to patient to complete
appointment.
EPDS Score
Provider steps are in this
purple box
Score <10 Score 10 Positive score on question 10
Does not suggest Suggests patient is depressed Suggests patient may be at risk
depression 1. Assess to determine most of self-harm or suicide
appropriate treatment (refer to
Clinical support staff Assessment of Depression Severity Do NOT leave woman/baby in
educates woman about the and Treatment Options and Key room alone until further
importance of emotional Clinical Considerations documents) assessment or treatment plan
wellness has been established.
Always consider comorbid psychiatric
illnesses (e.g., psychosis, substance use) Immediately assess further:
Provide information about
and medical cause of depression (e.g., 1. In the past two weeks, how
community resources (e.g., often have you thought of
anemia, thyroid disorders).
support groups, MCPAP for hurting yourself?
Moms website) to support 2. Have you ever attempted
emotional wellness. to hurt yourself in the
past?
If antidepressant medication is 3. Have you thought about
Contact clinical support staff to
indicated how you could harm
arrange follow-up care if
1. Screen for bipolar disorder (refer yourself?
needed. Give woman
information about community to Bipolar Depression Screen)
resources (e.g., support Document assessment and plan
2. Refer to Recommended Steps in medical record.
groups, MCPAP for Moms
before Beginning Antidepressant
website
Medication Algorithm and
www.mcpapformoms.org), If there is a clinical question, call
and we encourage women to
Antidepressant Treatment
MCPAP for Moms 855-Mom-
engage in social supports. Algorithm
MCPAP (855-666-6272) or refer
If woman is already in 3. Offer psychotherapy to emergency services.
treatment, ensure follow up
appointment is scheduled.
ALWAYS DISCUSS ALL SUPPORT/TREATMENT OPTIONS INCLUDING PSYCHOEDUCATION, COMMUNITY, & PSYCHOSOCIAL SUPPORTS
* High-risk = women with a history of Depression or a positive EPDS Score, or those taking or who have taken psychiatric medications.
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Friedman, L., Hosein S., Lundquist R., Freeman M., & Cohen L.
Depression Screening Algorithm for Obstetric Providers
(with suggested talking points) 10
The EPDS should be administered during: The clinical

Initial intake or first obstetrics visit support
Visit following Glucola test staff/
If first EPDS screen If high-risk patient,* 2 weeks postpartum If subsequent provider
6 weeks postpartum visit EPDS screen
speak the
italicized
Clinical support staff explains EPDS text
Emotional complications are very common during Woman completes the EPDS.
pregnancy and/or after birth. 1 in 8 women Staff tallies score and enters Give EPDS to
experience depression, anxiety or frightening into medical record. Staff woman to
thoughts during this time. It is important that we informs OB provider of score complete
screen for depression because it is twice as common prior to patient appointment.
as diabetes and it often happens for the first time
during pregnancy or after birth. It can also impact
you and your babys health. We will be seeing you a
lot over the next months and want to support you. EPDS Score Provider steps are in this
purple box
Score 10 Positive score on question 10

Score <10
Suggests patient is depressed Suggests patient may be at risk
Does not suggest depression of self-harm or suicide
You may be having a difficult time or be
Clinical support staff educates depressed. What things are you most It sounds like you are having a lot
woman about the importance of concerned about? Getting help is the best of strong feelings. It is really
emotional wellness: thing you can do for you and your baby. It common for women to experience
From the screen, it seems like you can also help you cope with the stressful these kinds of feelings. Many
are doing well. Having a baby is things in your life (give examples). You effective support options are
always challenging and every may not be able to change your situation available. I would like to talk to you
woman deserves support. Do you right now; you can change how you cope more about how you have been
have any concerns that you would with it. Many effective support options are feeling recently.
like to talk to us about? available.
Do NOT leave woman/baby in
Provide information about Assess to determine most appropriate room alone until further
community resources (e.g., treatment (refer to Assessment of assessment or treatment plan has
support groups, MCPAP for Moms Depression Severity and Treatment been established.
website) to support emotional Options and Key Clinical Considerations Immediately assess further:
wellness. documents) 1. In the past two weeks, how
often have you thought of
Always consider comorbid psychiatric hurting yourself?
Contact clinical support staff to illnesses (e.g., psychosis, substance use) 2. Have you ever attempted to
arrange follow-up care if needed. and medical cause of depression (e.g., hurt yourself in the past?
Give woman information about anemia, thyroid disorders). 3. Have you thought about how
community resources (e.g., you could harm yourself?
support groups, MCPAP for
Moms website If concerned about the safety of
www.mcpapformoms.org).
If antidepressant medication is woman/baby: You and you baby
indicated deserve for you to feel well. Lets talk
My office staff and I are available 1. Screen for bipolar disorder (refer to about ways we can support you.
to help you and provide ongoing Bipolar Depression Screen)
support. 2. Refer to Recommended Steps before Document assessment and plan in
Beginning Antidepressant Medication medical record. If there is a clinical
If woman is already in treatment, Algorithm and Antidepressant question, call MCPAP for Moms
ensure follow up appointment is Treatment Algorithm 855-Mom-MCPAP (855-666-6272)
scheduled. 3. Offer psychotherapy or refer to emergency services.
ALWAYS DISCUSS ALL SUPPORT/TREATMENT OPTIONS INCLUDING PSYCHOEDUCATION, COMMUNITY, & PSYCHOSOCIAL SUPPORTS
* High-risk = women with a history of Depression, a positive EPDS Score, or those taking or who have taken psychiatric medications.
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Friedman, L., Hosein S., Lundquist R., Freeman M., & Cohen L.
EdinburghPostnatalDepressionScale1 (EPDS) 11
Name: ______________________________ Address: ___________________________
Your Date of Birth: ____________________ ___________________________
Babys Date of Birth: ___________________ Phone: _________________________
As you are pregnant or have recently had a baby, we would like to know how you are feeling. Please check
the answer that comes closest to how you have feltINTHEPAST7DAYS, not just how you feel today.
Here is an example, already completed.
I have felt happy:

Yes, all the time
Yes, most of the time This would mean: I have felt happy most of the time during the past week.
No, not very often Please complete the other questions in the same way.
No, not at all
In the past 7 days:
1. I have been able to laugh and see the funny side of things *6. Things have been getting on top of me
As much as I always could Yes, most of the time I havent been able
Not quite so much now to cope at all
Definitely not so much now Yes, sometimes I havent been coping as well
Not at all as usual
No, most of the time I have coped quite well
2. I have looked forward with enjoyment to things No, I have been coping as well as ever
As much as I ever did
Rather less than I used to *7 I have been so unhappy that I have had difficulty sleeping
Definitely less than I used to Yes, most of the time
Hardly at all Yes, sometimes
Not very often
*3. I have blamed myself unnecessarily when things No, not at all
went wrong
Yes, most of the time *8 I have felt sad or miserable
Yes, some of the time Yes, most of the time
Not very often Yes, quite often
No, never Not very often
No, not at all
4. I have been anxious or worried for no good reason
No, not at all *9 I have been so unhappy that I have been crying
Hardly ever Yes, most of the time
Yes, sometimes Yes, quite often
Yes, very often Only occasionally
No, never
*5 I have felt scared or panicky for no very good reason
Yes, quite a lot *10 The thought of harming myself has occurred to me
Yes, sometimes Yes, quite often
No, not much Sometimes
No, not at all Hardly ever
Never
Administered/Reviewed by ________________________________ Date ______________________________

1
Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item
Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786 .
2
Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002,
194-199
Users may reproduce the scale without further permission providing they respect copyright by quoting the names of the
authors, the title and the source of the paper in all reproduced copies.
12
EdinburghPostnatalDepressionScale1 (EPDS)
Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh
Postnatal Depression Scale (EPDS) is a valuable and efficient way of identifying patients at risk for perinatal
depression. The EPDS is easy to administer and has proven to be an effective screening tool.
Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS
score should not override clinical judgment. A careful clinical assessment should be carried out to confirm the
diagnosis. The scale indicates how the mother has feltduringthepreviousweek. In doubtful cases it may
be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or
personality disorders.
Women with postpartum depression need not feel alone. They may find useful information on the web sites of
the National Womens Health Information Center <www.4women.gov> and from groups such as Postpartum
Support International <www.chss.iup.edu/postpartum> and Depression after Delivery
<www.depressionafterdelivery.com>.
SCORING
QUESTIONS1,2,&4(withoutan*)
Are scored 0, 1, 2 or 3 with top box scored as 0 and the bottom box scored as 3.
QUESTIONS3,510(markedwithan*)
Are reverse scored, with the top box scored as a 3 and the bottom box scored as 0.
Maximum score: 30
Possible Depression: 10 or greater
Always look at item 10 (suicidal thoughts)
Users may reproduce the scale without further permission, providing they respect copyright by quoting the
names of the authors, the title, and the source of the paper in all reproduced copies.
InstructionsforusingtheEdinburghPostnatalDepressionScale:
1. The mother is asked to check the response that comes closest to how she has been feeling
in the previous 7 days.
2. All the items must be completed.
3. Care should be taken to avoid the possibility of the mother discussing her answers with
others. (Answers come from the mother or pregnant woman.)
4. The mother should complete the scale herself, unless she has limited English or has difficulty
with reading.
1
Source: Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item
Edinburgh Postnatal Depression Scale. BritishJournalofPsychiatry 150:782-786.
2
Source: K. L. Wisner, B. L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002,
194-199
13

This algorithm can be used when treatment with antidepressants is indicated, in conjunction with the Depression Screening
Algorithm for Obstetric Providers.
In this algorithm, the provider speaks the italicized text and summarizes other text.
Screen for bipolar disorder1
1. Some people have periods lasting several days or longer when they feel much more excited and full of
energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and
they sometimes do things that are unusual for them, such as driving too fast or spending too much
money. Have you ever had a period liked this lasting several days or longer?
2. Have you ever had a period lasting several days or longer when most of the time you were so irritable or
grouchy that you started arguments, shouted at people, or hit people?
If yes to questions 1 and/or 2
The screen suggests the Continue screen for bipolar disorder1

patient may have bipolar If yes to
3. People who have episodes like this often have changes
If no to both questions 1 & 2
question 3
If you have questions or need in their thinking and behavior at the same time, like
telephone consultation with a being more talkative, needing very little sleep, being
psychiatrist call MCPAP for Moms very restless, going on buying sprees, and behaving in
855-Mom-MCPAP (855-666- ways they would normally think are inappropriate. Did
6272) you ever have any of these changes during your
episodes of being (excited and full of energy/very
irritable or grouchy)?
If no to question 3
Refer to the Recommended Steps

before Beginning Antidepressant
Medication Algorithm
CALL MCPAP FOR MOMS WITH CLINICAL QUESTIONS THAT ARISE DURING SCREENING OR TREATMENT AT 855-666-6272
1
Taken from the Composite International Diagnostic Interview-Based Bipolar Disorder Screening Scale (Kessler, Akiskal, Angst et al., 2006)
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Hosein S., Lundquist R., Freeman M., & Cohen L
.
14
Recommended Steps before Beginning Antidepressant Medication Algorithm

(Discussion should include yet not be limited to the below)
Counsel patient about antidepressant use:

No decision regarding whether to use antidepressants during pregnancy is perfect or risk
free
SSRIs are among the best studied class of medications during pregnancy
Both medication and non-medication options should be considered
Encourage non-medication treatments (e.g., psychotherapy) in addition to medication
treatment or as an alternative when clinically appropriate
Risks of antidepressant use during pregnancy Risks of under treatment or no treatment
of depression during pregnancy
Small, but inconsistent increased risk of birth Increases the risk of postpartum
defects when taken in first trimester, depression
particularly with paroxetine Birth complications
The preponderance of evidence does not Can make it harder for moms to take care
suggest birth complications of themselves and their babies
Studies do not suggest long-term Can make it harder for moms to bond
neurobehavioral effects on children with their babies
Possible transient neonatal symptoms
If pregnant: In your situation, the benefits of taking an antidepressant outweigh the chance
of the things we just discussed.
If lactating: SSRIs and some other antidepressants are considered a reasonable treatment
option during breastfeeding. The benefits of breastfeeding while taking antidepressants
generally outweigh the risks.
SEE ANTIDEPRESSANT TREATMENT ALGORITHM ON BACK FOR GUIDELINES RE: PRESCRIBING MEDICATIONS
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Hosein S., Lundquist R., Freeman M., & Cohen L.
15
96(3), 259269. Antidepressant Treatment Algorithm
(use in conjunction with Depression Screening Algorithm for Obstetric Providers)
Is patient currently taking an antidepressant?
Yes No
Does patient have a history of taking an

antidepressant that has helped?
If medication has helped If patient is on therapeutic
and patient is on a low Yes No
dose for 4-8 weeks that has
dose: increase dose of not helped: consider
Prescribe Use sertraline,
current medication (see changing medication. If
antidepressant that fluoxetine or
table below) questions contact MCPAP
helped patient in the citalopram (see
for Moms for consultation table below)
past (see table below)
To minimize side effects, half the recommended dose is used initially for 2 days, then increase in small
increments as tolerated.
First line treatment (SSRIs)

*sertraline (Zoloft) 50-200 mg fluoxetine (Prozac) 20-60 mg citalopram (Celexa) 20-40 mg escitalopram (Lexapro) 10-20mg
Increase in 50 mg increments Increase in 10 mg increments Increase in 10 mg increments Increase in 10 mg increments
Second line treatment

SSRIs SNRIs Other If a first or second line medicine
*paroxetine (Paxil) 20-60mg venlafaxine (Effexor) 75-300mg bupropion (Wellbutrin) 300-450mg is currently helping, continue it
Increase in 10 mg increments Increase in 75 mg increments Increase in 75 mg increments
Strongly consider using first or
*fluvoxamine (Luvox) 50-200mg duloxetine (Cymbalta) 30-60mg mirtazapine (Remeron) 15-45mg second line medicine that has
Increase in 50 mg increments Increase in 20 mg increments Increase in 15 mg increments worked in past
*Considered a safer alternative in lactation because they have the lowest degree of translactal passage and fewest reported adverse
effects compared to other antidepressants. In general, if an antidepressant has helped it is best to continue it during lactation.
Reevaluate depression treatment in 2-4 weeks via EPDS & clinical assessment
If no/minimal clinical If clinical improvement and
improvements after 4-8 weeks no/minimal side effects
1. If patient has no or minimal side effects, increase dose. Reevaluate every month and at postpartum visit. Refer
2. If patient has side effects, switch to a different med. back to patients provider and/or clinical support staff
for psychiatric care once OB care is complete. Contact
If you have any questions or need consultation, contact MCPAP for Moms if it is difficult to coordinate ongoing
MCPAP for Moms at 855-Mom-MCPAP (855-666-6272) psychiatric care. Continue to engage woman in
psychotherapy, support groups and other non-
medication treatments.
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N., Biebel K., Hosein S., Lundquist R., Freeman M., & Cohen L.
8/20/2015
16
Promoting Maternal Mental Health During and

After Pregnancy
Nancy Byatt, DO, MBA, FAPM

Medical Director, MCPAP for Moms
Assistant Professor of Psychiatry and Ob/Gyn
UMass Medical School/UMass Memorial Health Care
MCPAP For Moms
Disclosure Statement:
Nancy Byatt, D.O., M.B.A.
With respect to the following presentation, there

has been no relevant (direct or indirect) financial
relationship between the party listed above
(and/or spouse/partner) and any for-profit
company which could be considered a conflict of
interest
8/20/2015
17
4
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18
6
8/20/2015
19
1 in 8 women suffer from perinatal depression
Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006.
Perinatal depression is twice as common as

gestational diabetes
Depression
10-15 in 100
Diabetes
3- 7 in 100
Gavin et al. Ob Gyn 2005, Vesga-Lopez et al. Arch Gen Psychiatry 2006. ACOG Practice Bulletin 2013.
8/20/2015
20
Two-thirds of perinatal depression begins before birth
Pregnancy
33%
Before
pregnancy Postpartum
40%
27%
10
Wisner et al. JAMA Psychiatry 2013
Perinatal depression effects mom, child & family
Poor health care

Substance abuse
Preeclampsia
Maternal suicide
Low birth weight

Preterm delivery
Cognitive delays
Behavioral problems
Bodnar et al. (2009). The Journal of clinical psychiatry. Cripe et al. (2011). Paediatric and perinatal epidemiology, Flynn, H. A., & Chermack, S. T. (2008).
Journal of Studies on Alcohol and Drugs,.; Forman et al. (2007). Development and psychopathology, Grote et al. (2010). Archives of general psychiatry,.;
Sohr-Preston, S. L., & Scaramella, L. V. (2006). Clinical child and family psychology review,. ; Wisner et al. (2009). The American journal of psychiatry,
8/20/2015
21
Perinatal depression is under-diagnosed and

under-treated
Treated Women
Untreated women
13
Carter et al. (2005). Australian and New Zealand Journal of Psychiatry, 39(4), 255261; Marcus et al. (2003). Journal of womens health 2002,
13(1), 373380. Smith et al. (2009). General hospital psychiatry, 31(2), 15562.
Barriers to Treatment
Patient Provider Systems
Lack of detection Lack of training Lack of integrated care
Fear/stigma Discomfort Screening not routine
Limited access Few resources Isolated providers
Women do not Unprepared providers,

Underutilization
disclose symptoms of Treatment With limited resources
or seek care
www.chroniccare.org
Poor Outcomes
8/20/2015
22
How can I help Ms. Y?
15
The perinatal period is ideal for the detection and

treatment of depression
80% of depression is treated by

primary care providers
Regular opportunities to screen

and engage women in
treatment
Front line providers have a pivotal

role
8/20/2015
23
In 2010, Massachusetts passed a Postpartum

Depression Act
PPD Commission
PPD Screening Regulation

(if screen must report CPT
S3005, 0-6 months)
MCPAP for Moms Funding
Education 855-Mom- Care

MCPAP Coordination
8/20/2015
24
Providers can call for patient consultations
Psychiatric
providers
Primary
Family
care
Medicine
providers
Obstetric
Telephone Pediatric
providers/ Consultation providers
Midwives
1-855-Mom-MCPAP
Telephone
Consultation
8/20/2015
25
1-855-Mom-MCPAP
Telephone
Consultation
During telephone consult care coordination is

determined based on acuity, severity and need
Contact Provider Patient Contact
Care coordinator will Care coordinator will

identify 2-3 targeted contact mom and work
resources to deliver with her to schedule
via phone or email appointment
Does not involve Care coordinator will

speaking with mom follow up after 1
month
22
8/20/2015
26
Providers can call for patient consultations
Psychiatric
providers
Primary
Family
care
Medicine
providers
Obstetric
Telephone Pediatric
providers/ Consultation providers
Midwives
Detect Assess Engage Triage Treat
Obs 80%
Improved outcomes
& for moms, babies and
families
Psychiatrists 20%
Gilbody, S., Sheldon, T., & House, A. (2008). CMAJ Canadian Medical Association journal journal de lAssociation medicale canadienne, 178(8),
9971003.; Yonkers, K., Smith, M., Lin, H., Howell, H., Shao, L., & Rosenheck, R. (2009). Psychiatric Services, 60(3), 322328.
8/20/2015
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25
Edinburgh Postnatal Depression Scale (EPDS)
Validated in pregnancy and

postpartum
10 items
Asks about self-harm

8/20/2015
28
6 wks
2 wks
1stpre- 26-28 post- post-
natal visit weeks Birth partum partum
Administer Edinburgh Postnatal Depression Scale
Administer EPDS for high-risk patients
Steps after a positive screen
Assess severity and comorbidities

Consider all treatment and support options
Consider patient preference
Rule out bipolar disorder
Consider treatment risks/benefits
8/20/2015
29

EPDS scores range 0 - 30
< 10 Depression unlikely
10 Possible depression
13 Probable depression
Source: Cox, J.L, Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10- item Edinbugh Postnatal Depression Scale
. British Journal of Psychiatry 150:782-786. Source: K.L. Wisner, B.L. Parry, C.M. Piontek, Postpartum Depression N Engl J Med vol. 347, No 3, July 18, 2002. U
sers may reproduce the scale without further permission providing they respect copyright by quoting the names of the authors, the title and the source of the p
aper in all reproduced copies. Edinburgh Postnatal Depression Scale (EPDS).
8/20/2015
30
Baby Blues Depression
2 wk 2 wks
Mood lability Guilt, feeling worthless
High emotionality Suicidal thoughts
Impacts functioning
Assess for other comorbidities and medical causes
PTSD and other anxiety disorders
Eating disorders
Substance abuse
Medical causes
Check TSH, CBC, B12, Vitamin D, and folate

32
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31
Risk of harm to baby
OCD/anxiety Postpartum Psychosis
Good insight Poor insight

Thoughts are intrusive Psychotic symptoms
and scary Delusional beliefs or
No psychotic symptoms distorted reality
Thoughts cause anxiety present
Low risk High risk

33
High Suicide Risk Lower

Risk Assessment Risk
History of suicide attempt No prior attempts

High lethality of prior attempts If prior attempts, low
lethality & high
Recent attempt rescue potential
Current plan No plan
Current intent No intent
Substance use No substance use
Lack of protective factors Protective factors
(including social support)
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32
Key clinical considerations after a positive screen
Severity
Patient preference
Bipolar vs. unipolar depression
Education about various treatment and support

options is imperative
36
8/20/2015
33
Meds not Medication Meds

indicated Assessment indicated
Mild depression Moderate/severe depression
No suicidal ideation Suicidal ideation
Able to care for self/baby Difficulty functioning caring for

self/baby
Engaged in psychotherapy Psychotic symptoms present
Depression has improved with psychotherapy History of severe depression and/or

in the past suicide ideation/attempts
Strong preference and access to Comorbid anxiety

psychotherapy 37
Linkages with support groups and community

resources
Support the wellness and mental health of

perinatal women
8/20/2015
34
Can refer moms to www.mcpapformoms.org

8/20/2015
35
Ask women what type of treatment they prefer
There are effective options for treatment

during pregnancy and breastfeeding.
Depression is very common during

pregnancy and the postpartum period.
There is no risk free decision.
Women need to take medication during

pregnancy for all sort of things.

8/20/2015
36
Imperative to address bipolar disorder
Bipolar
Disorder
23%
Unipolar
Depressive
Other Disorders 7% Disorder
69%
Wisner et al. JAMA Psychiatry 2013
Bipolar disorder increases risk of postpartum

psychosis
1-2/1000 women
>70% bipolar disorder
24 hrs 3 weeks postpartum
Mood symptoms, psychotic

symptoms & disorientation
R/o medical causes of delirium

Psychiatric emergency
4% risk of infanticide with postpartum

psychosis
8/20/2015
37

8/20/2015
38
Treatment - Recommended Steps Before Beginning

Antidepressant Treatment
No decision is risk free
Vs.
SSRIs are among the best studied classes of medications

used in pregnancy
Byatt et al. Acta Psych Scand 2013.

8/20/2015
39
Case of Ms. Y
Absolute risk of birth defects when antidepressants

taken in first trimester is small
Data is inconsistent, paxil has most been controversial
Byatt et al. Acta Psych Scand 2013.

8/20/2015
40
Possible transient neonatal symptoms with exposure

to antidepressants
Transient and self-limited syndrome that may occur in up to

30% of neonates
No data to support taper in third trimester
Moses-kolko et al JAMA 2005, Warburton et al. Acta Psychiatr Scand 2010.
Absolute risk of persistent pulmonary hypertension

(PPHN) appears small
Baseline rate of 1-2 per 1000 births, may increase to 3-4 in

1000 births
Chambers et al. NEJM 2006, Kallen et al. Pharmacoepidemiol Drug Saf 2008, Andrade et al. Pharm
Drug Saf 2009.
8/20/2015
41
Small increase risk of preterm labor & low birth

weight
Depression can also increase risk of preterm labor

and low birth weight
Huybrecht, 2014; Ross 2013
Studies do not suggest long-term neurobehavioral

effects on children
Nulman et al. AJP 2012, Croen et al. AGP 2011, Rai et al BMJ 2013.
8/20/2015
42
There is no such thing as no exposure
Need to balance and discuss the risks and benefits of

medication treatment and risks of untreated depression
Antidepressants treatment algorithm

Antidepressant Currently
Yes No
Is it helping? No Has a past

Yes med been
helpful?
No Yes No
Continue
meds
Is dose Use past med New med or call
maximized? that worked MCPAP For Moms
for Consultation
Yes No
Change med or call Increase

MCPAP For Moms dose
for Consultation
8/20/2015
43
Treatment - Antidepressant Treatment Algorithm
Start antidepressants at a low dose

and increase in small increments every 2 days
SSRIs Starting & Increment Dose Target Dose

(mg/day) (mg/day)
sertaline (Zoloft) 25 75-200
citalopram (Celexa) 10 20-40
escitalopram (Lexapro) 5 10-20
fluoxetine (Prozac) 10 20-80
Tell women only to increase dose if tolerating

Otherwise, wait until side effects dissipate before increasing
8/20/2015
44
General side effects of antidepressants
Temporary
Nausea
Constipation/Diarrhea
Lightheaded
Headaches
Long-term
Increase in appetite/weight gain
Sexual side effects
Vivid dreams/insomnia
Direct patients to take medication with food to decrease side effects

59
After starting antidepressant re-administer EPDS
Re-administer EPDS
and reevaluate
after 2 weeks
Little/no improvement Improvement

(EPDS >10) (EPDS < 10)
Increase Reevaluate
medication monthly
60
8/20/2015
45
Prescribing principles for pregnancy and

breastfeeding
Use what has worked

(considering available reproductive safety information)
Use lowest EFFECTIVE dose
Minimize switching
Monotherapy preferable
Be aware of need to adjust dose
Discourage stopping SSRIs prior to delivery
Breastfeeding generally should not preclude

treatment with antidepressants
SSRIs and some other antidepressants are considered a

reasonable option during breastfeeding
8/20/2015
46
Sertraline, paroxetine, & fluvoxamine have lowest

passage into milk

8/20/2015
47
Please call us with any questions as we are to here to

help you
1-855-Mom-MCPAP
www.mcpapformoms.org
Pre-enrollment survey please complete

8/20/2015
48
In summary, our aim is to promote maternal and

child health by building the capacity of front line
providers to address perinatal depression
Please contact us
www.mcpapformoms.org
Call 1-855-Mom-MCPAP
Nancy Byatt, DO, MBA, Medical Director

Nancy.Byatt@umassmemorial.org
Kathleen Biebel, PhD, Program Director

Kathleen.Biebel@umassmed.edu
Shums Alikhan, BA, Program Assistant

Shums.Alikhan@umassmed.edu
Copyright MCPAP for Moms 2014 all rights reserved. Authors: Byatt N, Lundquist R,
Broudy C, Marsh W. Funding provided by the Massachusetts Department of Mental
Health.
Thank you!
49
MCPAP for Moms: A Primer for Pediatric

Providers
Authors: Biebel, K., Byatt, N., Ravech, M., & Straus, J.
Copyright @MCPAP for Moms 2015 all rights reserved

50
MCPAP for Moms: A Primer for Pediatric Providers

MCPAP for Moms aims to improve outcomes for babies, children, and families by helping
pregnant and postpartum women access and engage in depression treatment.
Pediatric providers in Massachusetts are well acquainted with the Massachusetts Child Psychiatry
Access Project (MCPAP), created in response to the widespread lack of access to child psychiatry.
MCPAP has been broadly accepted by pediatric primary care clinicians, and is recognized as
enhancing the capacity of pediatric providers to treat children and adolescents with behavioral
health issues.
In 2014, MCPAP launched a new program, MCPAP for Moms, to promote maternal and child health
by building the capacity of providers serving pregnant and postpartum women and their children up
to one year after delivery to effectively prevent, identify and manage depression. MCPAP for Moms
aims to help pediatric providers screen mothers and fathers for postpartum depression within the
context of well-child care.
MCPAP for Moms aims to:

Implement universal screening for depression during pregnancy and postpartum for the
approximately 72,000 women who deliver babies in Massachusetts each year;
Increase access to mental health care among pregnant and postpartum women; and,
Improve mental health outcomes for mothers and fathers, and thereby improve outcomes
for babies and families.
Why is postpartum depression important to pediatric providers?
Postpartum depression (PPD) is a widespread problem that can complicate birth,1 infant,2 and child
outcomes.3-5 Perinatal depression - depression before, during, and in the year following pregnancy
- can have far-reaching, harmful effects for all family members. One in five women screen positive
for depression during their first postpartum year.6 One in three fathers in families struggling with
maternal depression experience PPD themselves.7Depression in fathers may present differently
than in mothers. Men with depression are more likely to report substance abuse and disturbances
in work and social functioning.8Adoptive parents have similar rates of depression as birth parents
during the postpartum period.9,10 Individuals with a family history of depression, substance abuse,
or a personal history of depression are at increased risk for perinatal depression.11Large health
disparities in the U.S. place low-income and racial and ethnic minority families at increased risk for
parental depression, stress, and poorer child outcomes compared to affluent families.12
Birth outcomes can be adversely affected by depression in pregnancy,1,13-16 and PPD can have a
long-term impact on child outcomes. PPD is associated with attachment insecurity,3 difficult
infant/childhood temperament,3,17 developmental delay, and impaired language development.4,5
Treatment of maternal depression until remission is associated with decreased psychiatric
symptoms and improved functioning outcomes among offspring.18,19 Despite the profound negative
effects on mother and child, some of which improve with depression treatment,18,19 the vast
majority of women with PPD go untreated.20-23
What is known about PPD screening in pediatric settings?
Most perinatal care or obstetrical settings only see women and screen for PPD at the 4-6 week
51
postpartum visit.24Pediatricians providing care for children under the age of five may be the only
medical provider many mothers see during the childs first year of life.25,26 PPD can be identified in
pediatric settings during the first postpartum year.23 Training pediatric providers to detect and
address PPD can enhance pediatric providers impact on maternal mental health,27 carrying the
potential to have a trans-generational impact.
How does MCPAP for Moms help pediatric providers and practices?
MCPAP for Moms can help pediatric providers in two distinct ways. MCPAP for Moms can support
pediatric providers as they provide well-care to infants and their families. MCPAP for Moms can
also assist pediatric providers when they need support around perinatal mental health concerns as
they care for pregnant and postpartum teenagers.
MCPAP for Moms encourages all pediatric providers to screen for postpartum depression in:
mothers and fathers of infant patients during well-child visits; and
pregnant or postpartum women receiving primary care from a pediatric provider
Available screening instruments include the Patient Health Questionnaire (PHQ-2 or PHQ-9: a
validated questionnaire to screen and measure depression and its severity),28 or the Edinburgh
Postnatal Depression Screen (EPDS - a widely-used and validated 10-item questionnaire to identify
women experiencing depression during pregnancy and the postpartum period).29 The PHQ-2 is part
of the Survey of Wellbeing of Young Children (SWYC).30 The PHQ-2, PHQ-9, and EPDS can be found
in the Appendix or at www.mcpapformoms.org/toolkits/pediatricprovider.aspx.
Can I bill for screening?
If you are using the SWYC with the embedded PHQ-2, you can bill using 96110. For other screening
tools, at this time, please consult the infants insurer.
When an infant is the patient.
Well-child visits provide an ideal opportunity to detect and address PPD. As pediatric providers are
most often not providing primary care to mothers, their main role is one of screening and referral.
MCPAP for Moms can help pediatric providers screen for and address PPD and other mental health
concerns during well-child visits. PPD screening is recommended for mothers and fathers as part of
well-child visits (and at other times if indicated) at:
Within first month
2 month visit
4 month visit
6 month visit
9-12 month visit
MCPAP for Moms provides a Depression Screening Algorithm for Pediatric Providers During
Well-Child Visits (see Appendix), which offers step-by-step guidelines for administering and
responding to a PPD screen. While the majority of mothers and fathers will not screen positive for
PPD, the postpartum period can be challenging, and depression and other mental health concerns
can arise at any time.
52
The babys behavior offers a window into the emotional state of the family. Problems of crying,
sleep and feeding are intimately intertwined with perinatal emotional complications, both as cause
and result. Parents mood affects the baby, and babys mood affects the parent. Time spent in the
primary care setting addressing these issues in the context of evaluating the parents emotional
wellbeing can be a first step in treatment.
For all parents with a positive screen:

1. If the parent is already in mental health treatment, refer to/notify* parents mental health
provider.
2. Give parent information about community resources (e.g., support groups, MCPAP for
Moms resource card, and MCPAP for Moms website-www.mcpapformoms.org).
3. Refer to/notify* parents PCP and/or OB/GYN for monitoring and follow-up. You may
recommend that the PCP or OB/GYN call MCPAP for Moms if they have clinical questions
about the parent.
4. Engage natural supports* and encourage parent to utilize them. Most likely you will have
only one parent in the office when a screen is positive. A depressed parent who is alone or
feeling alone is at higher risk for suicide. It is important for someone else in the parents life
to be aware of the presence of depression and be able to step in to help.
5. If the pediatric provider has clinical questions, call MCPAP or MCPAP for Moms (855-MOM-
MCPAP/855-666-6272).
6. Assess if there is an acute crisis or safety concern. If there is a crisis or safety concern, refer
to parents local Emergency Services. For MassHealth members, contact the local
Emergency Services Program at 877-382-1609.
We recommend and expect that pediatric providers and their office staff will refer parents to an
adult provider such as her PCP or OB/GYN. If there is difficulty referring women to their PCP or
OB/GYN, pediatric providers may call MCPAP for Moms for assistance in identifying mental health
providers in the parents community.
MCPAP for Moms recommends that pediatric providers document the screening result in the
medical record as you would with other risk factors that may affect the child health such as
substance use or domestic violence. MCPAP for Moms recommends that pediatric practices
continue to use their current strategies for appropriately documenting potentially sensitive family
information.
When a pregnant/postpartum young mother is the patient.
MCPAP for Moms recommends that pediatric providers caring for pregnant teens or postpartum
young mothers screen for depression during pregnancy and in the postpartum period. New
mothers should also be screened for PPD during well-child visits. Questions that arise specific to
mental health concerns during screening and/or providing care for a pregnant teen or postpartum
young mother should be directed as follows:
For perinatal psychiatry questions. Pediatric providers can call MCPAP for Moms (855-MOM-
MCPAP/855-666-6272) to speak with a MCPAP for Moms perinatal psychiatrist for consultation
regarding mental health care. If it is determined that the patient needs additional mental health
services (e.g., a therapist, a support group), a MCPAP for Moms Care Coordinator can work to
* Obtain parents consent

53
identify and/or schedule services. Additional information on PPD during pregnancy is available at
www.mcpapformoms.org.
For general child psychiatry questions. Pediatric providers can call their MCPAP regional hub to
speak to a MCPAP child psychiatrist for a consultation and/or the MCPAP Care Coordinator to
identify and/or schedule mental health services for the mom. MCPAP and MCPAP for Moms
psychiatrists and Care Coordinators will work together to consult on cases, and identify
appropriate mental health resources.
Antidepressant medications and lactation.
Considerations for lactating women:
SSRIs (and some other antidepressants) are considered a reasonable treatment option
during breastfeeding.
When antidepressants are indicated, the benefits of breastfeeding while taking
antidepressants generally outweigh the risks.
Most psychiatric medications are passed into breast milk, though in very low amounts.
The benefits of other psychiatric medications, including benzodiazepines, antiepileptics,
stimulants, and antipsychotics, may outweigh the risks of the medication during
breastfeeding.
It is important to consider the risk of untreated illness to the mother-baby dyad and balance
this with the risk of medication use during breastfeeding.
It is crucial that evaluation of the risks and benefits of medication use during breastfeeding
is done on a patient-by-patient basis and considers the needs of the family.
Recommendations are ideally made collaboratively with well-informed patients and family
members.
Monitor for side effects in nursing infants.
We also recommend the NIH website LactMed, which contains information on medications to which
breastfeeding mothers may exposed. Providers can also download the LactMed app for mobile
devices. We encourage providers to call MCPAP for Moms for any questions regarding the use of
antidepressants or other psychiatric medications during breastfeeding. Pediatric providers can also
visit the MCPAP for Moms website for additional information and treatment algorithms.
MCPAP for Moms Pediatric Toolkit.
The MCPAP for Moms Pediatric Toolkit provides information to support pediatric providers as they
detect and screen for mental health concerns. We recommend pediatric providers review the
toolkit. The complete MCPAP for Moms Pediatric Toolkit can be found at
www.mcpapformoms.org under Provider Toolkit/MCPAP for Moms toolkit Pediatric
Provider.
Assessment Tools. Highlights the range of depression and mental health concerns that may occur
postpartum, possible treatment options, and key issues to consider when assessing mental health
status during the postpartum period.
Key Clinical Considerations When Assessing the Mental Health of Pregnant and
Postpartum Women. Provides key information/concepts to consider when assessing the
mental health of pregnant and postpartum women.
54
Summary of Emotional Complications During Pregnancy and the Postpartum Period.

An overview of the range of emotional complications that can occur during pregnancy and
postpartum including Baby Blues, Perinatal Depression, Perinatal Anxiety, Posttraumatic
Disorder (PTSD), Obsessive-Compulsive Disorder (OCD), and Postpartum Psychosis.
Screening Tools & Algorithms. Includes depression screens and a depression screening algorithm
designed for pediatric providers.
Patient Health Questionnaire 2 (PHQ-2)
Patient Health Questionnaire 9 (PHQ-9)
Edinburgh Postnatal Depression Scale (EPDS)
Postpartum Depression Screening Algorithm for Pediatric Providers during Well-
Child Visits. Provides guidance on administering the PHQ-2, PHQ-9 or EPDS and next steps
depending on the score. Side one is a simplified version of the algorithm. Side two provides
more detailed information including talking points and suggested language re: how to
discuss the screen and resultant scores with a parent.
Community resources - MCPAP for Moms partners.
Key to the success of MCPAP for Moms are partnerships with two critical community-based
organizations, to help facilitate linkages to resources including mental health care, support groups,
and other activities to support the wellness and mental health of pregnant and postpartum women.
MCPAP for Moms is partnering with MotherWoman and MSPP Interface Referral Service to develop
community resources and link women with perinatal supports across the state.
MotherWoman is partnering with community providers across the Commonwealth to provide

training and development around the Community-based Perinatal Support Model (CPSM), an
intervention that addresses the challenge of ensuring that mothers experiencing perinatal
depression receive the care and treatment they need. CPSM assists communities in their efforts to
effectively prevent, identify, and treat mothers with perinatal depression both within agencies and
organizations and across systems of care by addressing barriers at the maternal, provider and
system levels. MotherWoman has developed perinatal community coalitions and support groups
for mothers with children under the age of one in six communities in Massachusetts (Springfield,
Cape and the Islands, New Bedford, Lynn, Brockton, and Worcester). MotherWoman will continue
to expand this model to additional communities.
The Massachusetts School of Professional Psychology (MSPP) Interface Referral Service is working
with MCPAP for Moms to collect and categorize resources specifically related to perinatal mental
health and wellness. These resources are utilized and updated daily, and accessed by the MCPAP for
Moms Care Coordinators as they refer and coordinate mental health care for vulnerable parents.
Support group resources can be found on the MCPAP for Moms website under the For Mothers and
Families tab.
Home visiting programs.
Massachusetts home visiting programs offer voluntary, family-focused services to expecting or new
families with infants and children. Services are predominately provided in a familys home. Many
home visiting programs offer group-based services as well. Home visits are provided in a routine
and sustained manner, ranging from a weekly to a monthly basis. Typically families are eligible to
remain in home visiting programs for three to five years, although this varies by individual
program. Home visiting services are delivered by trained home visiting professionals or
55
paraprofessionals, with the goal of addressing specific issues based upon the familys eligibility for
the program. While each home visiting program has different eligibility criteria and thus delivers
different services to their participants there are many elements that are consistent across
programs. The common core elements of most home visiting programs include, but are not limited
to: addressing mother and child health, safety, and mental health; positive parenting; child
development and school readiness; and injury prevention including safe homes. These programs
also introduce parents to education and employment opportunities. The home visitor works
collaboratively with the family to set family goals, provide screenings, assessments and parenting
information, make referrals on behalf of families, and connect families to any other community-
based resources as needed. The following are some of the outcomes that home visiting programs
across the country have demonstrated:
Increased rates of teen moms staying in school and graduating
Increased access to primary care medical services
Increased child immunization rates
Improved parent-child bonding
Improved school readiness
Decreased number of low-birth weight babies
Decreased number of child abuse and neglect cases
Decreased families need for welfare, or TANF (Temporary Assistance to Needy Families)
and other social services
For home visiting resources please see the For Mothers and Families tab, Resources for Pregnant
and Postpartum Women on the MCPAP for Moms website.
MCPAP for Moms web-based resources for pediatric providers.
There are many web-based resources available to support pediatric providers, and their patients
and families. The MCPAP for Moms website provides detailed information about how MCPAP for
Moms works, FAQs, and online resources to assist providers on various issues specific to PPD
including evidence-based approaches and medication decision-making.
MCPAP for Moms website www.mcpapformoms.org.
o Provider Toolkit/MCPAP for Moms Toolkit Pediatric Providers: Provides all the
Assessment Tools, and Screening Tools and Algorithms that make up the Pediatric
Provider Toolkit. All tools are available for download.
o Provider Toolkit/MCPAP for Moms Toolkit Adult Providers: Provides additional
information about the delivery of treatment, including information about
medication and lactation, and services to parents experiencing PPD and other
mental health concerns by adult primary care providers.
o For Mothers and Families: General information pertaining to PPD as well as in-
person, online, and telephone support options for mothers and fathers.
Talking to Your Provider about Perinatal Mental Health Concerns: Provides
guidance for parents talking with providers about their mental health
concerns.
How to Find a PCP: Provides step-by-step instructions to help parents find
and choose a PCP.
56
References
1. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression
during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth
restriction. Arch Gen Psychiatry 2010;67:1012-24.
2. Britton HL, Gronwaldt V, Britton JR. Maternal postpartum behaviors and mother-infant
relationship during the first year of life. J Pediatr 2001;138:905-9.
3. Forman DR, O'Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for
postpartum depression is not sufficient to improve the developing mother-child relationship. Dev
Psychopathol 2007;19:585-602.
4. Deave T, Heron J, Evans J, Emond A. The impact of maternal depression in pregnancy on early
child development. BJOG 2008;115:1043-51.
5. Paulson JF, Keefe HA, Leiferman JA. Early parental depression and child language development.
J Child Psychol Psychiatry 2009;50:254-62.
6. Wisner KL, Sit, DY, McShea, M. Onset timing, thoughts of self-harm, and diagnoses in
postpartum women with screen-positive depression findings. JAMA Psychiatry 2013;70(5): 490-
498. doi:10.1001/jamapsychiatry.2013.87
7. Ramchandani P, Stein A, Evans J, & O'Connor TG. Paternal depression in the postnatal period
and child development: A prospective population study. The Lancet 2005;365(9478):2201-2205.
8. Carter J, Joyce, P, Roger, M, Luty, S, McKenzie, J. Genderdifferences in the presentation of
depressed outpatients: A comparison of descriptive variables. Journal of Affective Disorders
2000;61: 59-67.
9. Mott S, Schiller CE, Richards JG, OHara MW, Staurt S. Depression and anxiety among
postpartum and adoptive mothers. Arch Womens Ment Health 2011;14:335-343.
10. Senecky Y, Agassi H, Inbar D, Horesh N, Diamond G, Bergman YS, Apter A. Post-adoption
depression among adoptive mothers. Journal of Affective Disorders 2009;115:62-68.
11. Earls, M and the Committee on Psychosocial Aspects of Child and Family Health. Incorporating
recognition and management of perinatal and postpartum depression into pediatric practice.
Pediatrics 2010;126:1032.
12. Stewart AL, Dean ML, Gregorich SE, Brawarsky P, Haas JS. Race/ethnicity, SES and the health of
pregnant women. Journal of Health Psychology 2007;12(2):285300.
doi:10.1177/135910530707425
13. Cripe SM, Frederick IO, Qiu C, Williams MA. Risk of preterm delivery and hypertensive disorders
of pregnancy in relation to maternal co-morbid mood and migraine disorders during pregnancy.
Paediatr Perinat Epidemiol 2011;25:116-23.
14. Suri R, Altshuler LA, Mintz J. Depression and the decision to abort. AJ Psychiatry
2004;161:1502.
15. Flynn HA, Chermack ST. Prenatal alcohol use: the role of lifetime problems with alcohol, drugs,
depression, and violence. J Stud Alcohol Drugs 2008;69:500-9.
16. Gotlib IH, Whiffen VE, Wallace PM, Mount JH. Prospective investigation of postpartum
depression: factors involved in onset and recovery. J Abnorm Psychol 1991;100:122-32.
17. Britton JR. Infant temperament and maternal anxiety and depressed mood in the early
postpartum period. Women Health 2011;51:55-71.
18. Pilowsky DJ, Wickramaratne P, Talati A, et al. Children of depressed mothers 1 year after the
initiation of maternal treatment: findings from the STAR*D-Child Study. Am J Psychiatry 2008;
165(9): 1136-1147.
19. Foster CE, Webster MC, Weissman MM. Remission of maternal depression: relations to family
functioning and youth internalizing and externalizing symptoms. J Clin Child Adolescent Psychology
2008; 37(4): 714-724.
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20. Smith MV, Shao L, Howell H, Wang H, Poschman K, Yonkers KA. Success of mental health
referral among pregnant and postpartum women with psychiatric distress. Gen Hosp Psychiatry
2009;31:155-62.
21. Carter FA, Carter JD, Luty SE, Wilson DA, Frampton CM, Joyce PR. Screening and treatment for
depression during pregnancy: a cautionary note. Aust N Z J Psychiatry 2005;39:255-61.
22. Marcus SM, Flynn HA, Blow FC, Barry KL. Depressive symptoms among pregnant women
screened in obstetrics settings. J Womens Health (Larchmt) 2003;12:373-80.
23. Rowan P, Greisinger A, Brehm B, Smith F, McReynolds E. Outcomes from implementing
systematic antepartum depression screening in obstetrics. Archives of Women's Mental Health
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24. Chaudron L, Klein M, Remington P, Palta M, Allen C, Essex M. Prodromes, predictors and
incidence of postpartum depression. J Psychosom Obstet Gynaecol 2001;22:103-112.
25. Chaudron LH. Review of beyond the blues: A guide to understanding and treating prenatal and
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Academy of Pediatrics News Research Update Column;October 2001.
27. Chaudron L, Szilagyi PG, Campbell AT, Mounts KO, McInerny KT. Legal and ethical
considerations: Risks and benefits of postpartum depression screening at well-child visits.
Pediatrics 2007;119:123-128.
28. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J
Gen Intern Med 2001;16(9):606-613. doi:jgi01114 [pii]
29. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item
Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 1987;150:782.
30. Sheldrick, RC, Perrin, EC. Surveillance of childrens behavior and development: Practical
solutions for primary care. Journal of Developmental and Behavioral Pediatrics 2009;30:151-3.
PMID 19363367
58
Postpartum Depression Screening Algorithm for We encourage all providers to use
Pediatric Providers During Well-Child Visits the S3005 billing code that allows
the Dept of Public Health to track
screening across specialties and
regions.
Parent completes the PHQ-2, PHQ-9 or
EPDS screen during the following well child
visits and during other visits as indicated:
Within first month
If first screen for 2 month visit If subsequent
4 month visit screen for
depression 6 month visit
depression
9-12 month visit
Clinical support staff

Parent completes the Give screen to parent
explains screen PHQ-2, PHQ-9 or EPDS to complete in the
screen.
waiting room or in a
Give screen to parent to Provider/nurse tallies score.
private exam room.
complete in the waiting
room or in a private PHQ-2 3
exam room.
Administer PHQ-9 or EPDS
PHQ-9 or EPDS 10
PHQ-2 <3; PHQ-9 or EPDS<10 If positive score on
self-harm question Score suggests depression
Score does not suggest depression For all positive screens
Clinical support staff educates parent about the
importance of emotional wellness. 1. If parent is already in mental health
treatment, refer to/notify* parent's
Provide information about community provider.
resources (e.g., support groups, MCPAP for
Moms website) to support emotional wellness. 2. Give parent community resource
information (e.g., MCPAP for Moms card,
and website)
Suggests parent may be at risk of self-harm or suicide 3. Refer to/notify* parent's PCP and/or
OB/GYN for monitoring and follow-up.
Do NOT leave parent/baby in room alone until further assessment or
4. Engage natural supports* and encourage
treatment plan has been established. Immediately assess further.
parent to utilize them.
If there is a clinical question, provider calls MCPAP regional hub. For
safety concerns, refer to emergency services. Document the *Obtain parents consent
assessment and plan in medical record.
Provider steps for positive screens
Provider documents clinical plan based on screening results. Not required to include screen as part of the medical record.
If there are clinical questions (including questions about medications that may be taken during lactation), call MCPAP for Moms.
Revision: 1.15.15 Tel: 855-Mom-MCPAP (855-666-6272)
Copyright MCPAP for Moms 2015 all rights reserved. Authors: Byatt N., Biebel K., & Straus J.
59
Postpartum Depression Screening Algorithm for Pediatric
We encourage all providers to use the
Providers During Well-Child Visits (with suggested talking points) S3005 billing code that allows the Dept
of Public Health to track screening
Parent completes the PHQ-2, PHQ-9 or EPDS across specialties and regions.
screen during the following well child visits and
during other visits as indicated:
Within first month
If first screen for 2 month visit If subsequent screen
depression 4 month visit for depression
6 month visit
9-12 month visit
Clinical support staff explains screen Give screen
Emotional complications are very common during pregnancy Parent completes the PHQ- to parent to
and or after birth. 1 in 8 women experience depression, anxiety 2, PHQ-9 or EPDS screen. complete in
or frightening thoughts during this time. It is important that we Provider/nurse tallies score. the waiting
screen for depression because it is twice as common as diabetes room or in a
and it often happens for the first time during pregnancy or after private exam
birth. It can also impact you and your babys health. Dads can PHQ-2 3 room.
also experience depression or anxiety before or after the baby is
born. We will be seeing you and your baby a lot over the next Administer PHQ-9 or
few months/years and want to support you. EPDS
Give screen to parent to complete in the waiting room or in a
private exam room. PHQ-2 <3; PHQ-9 or EPDS<10 PHQ-9 or EPDS 10
Score does not suggest depression Score suggests depression

Clinical support staff educates parent about the importance of You may be having a difficult time or be depressed. What
emotional wellness: things are you most concerned about? Getting help is the
From the screen, it seems like you are doing well. Having a best thing you can do for you and your baby. It can also
baby is always challenging and every parent deserves help you cope with the stressful things in your life (give
support. Do you have any concerns that you would like to examples). You may not be able to change your situation
talk to us about? right now; you can change how you cope with it. Many
Provide information about community resources (e.g., support effective support options are available.
groups, MCPAP for Moms website) to support emotional
If positive score on For all positive
wellness.
self-harm question screens
Suggests parent may be at risk of self-harm or suicide 1. If parent is already in mental health
It sounds like you are having a lot of strong feelings. It is common for treatment, refer to/notify* parent's provider.
parents to experience these kinds of feelings. Many effective support
options are available. I would like to talk to you about how you have 2. Give parent community resource information
been feeling recently.
(e.g., MCPAP for Moms card, and website)
Do NOT leave parent/baby in room alone until further
assessment or treatment plan is established. Immediately 3. Refer to/notify* parent's PCP and/or OB/GYN
assess further:
for monitoring and follow-up.
1. In the past two weeks, how often have you thought of
hurting yourself?
2. Have you ever attempted to hurt yourself in the past? 4. Engage natural supports* and encourage
3. Have you thought about how you could harm yourself? parent to utilize them.
If concerned about the safety of parent/baby: You and your baby deserve
for you to feel well. Lets talk about ways that we can support you. *Obtain parents consent
If there is a clinical question, call MCPAP regional hub. For safety
concerns, refer to emergency services. Document in medical record.
Provider steps for positive screens
Provider documents clinical plan based on screening results. Not required to include screen as part of the medical record.
If there are clinical questions (including questions about medications that may be taken during lactation), call MCPAP for Moms.
Copyright MCPAP for Moms 2015 all rights reserved. Authors: Byatt N., Biebel K., & Straus J.
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POLITICS, IDEAS & CIVIC LIFE IN MASSACHUSETTS
Charting postpartum depression

Advocates want to identify at-risk mothers before tragedy strikes,
but universal screening is not an easy sell
GABRIELLE GURLEY Apr 14, 2015
WHENEVER SHE PICKED UP a knife, Jamie Zahlaway Belsito thought about stabbing
herself. The thought intruded so often that the mother-to-be thought it was a sign that having a
baby was a mistake.
The dark-haired, vivacious former Philips executive used to jet back and forth between Boston
and the technology companys headquarters in the Netherlands. Belsito had been a Washington
lobbyist working on business immigration reform, and an accomplished flamenco dancer.
But late in her pregnancy five years ago, Belsito got laid off. At age 35, she was at risk for
complications and had already had one miscarriage. She began avoiding touching anything
sharp. It was just horrific to even have something that was so absurd go through your brain,
Belsito says.
She had complications during labor and ended up delivering her daughter, Hadia, by emergency
caesarian section. Soon after she got home with Hadia, her husband left on one of his regular
business trips. Belsito did not know it at the time, but Hadia had dairy and soy allergies. The
infant cried, threw up all over, and did not sleep well. Belsito cried all the time, too. She sought
help from her doctor, but antidepressants did not help. I just wanted to go to sleep and never
wake up, she says of those dark times in her Beverly home.
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With growing recognition of the risks of untreated depression on women and their children,
some Bay State lawmakers, health care providers, and insurers believe that Massachusetts needs
to reorient the way the health care system handles the emotional complications of pregnancy
and childbirth. Postpartum depression is one of the most common complications of pregnancy
and the postpartum period. Whats more, the condition can be detected using a simple
questionnaire, and many women respond well to treatment. This is so minorto use a
screening tool, says Rep. Ellen Story, who co-chairs the states Special Legislative Commission
on Postpartum Depression.
But universal screening is proving to be a hard sell. Story, an Amherst Democrat, has filed
several postpartum depression screening bills over the past six years, including one to mandate
statewide screening for all women and one to mandate screening for MassHealth patients. The
proposals have gone nowhere. No one is vehemently opposed to screening, but the issue hasnt
gained enough traction to make it a priority on Beacon Hill.
Understanding postpartum depression
In the weeks after her daughters birth, Belsito knew something was seriously wrong. The
thoughts about knives had stopped, but she did not feel any better. She eventually located a
postpartum depression Meetup group at Beverly Hospital, and decided to go. No one else did.
Social workers there gave her a list of phone numbers to call. That was it, she says.
After making a couple of calls, Belsito found a therapist and went with Haida to see her once a
week. She started dancing again and her life gradually returned to normal. But when she became
pregnant again, the thoughts about knives returned. She had another emergency caesarian and a
second little girl who had trouble sleeping without her. On a summer day walking along the
Merrimack in Newburyport with her family, an ugly thought popped into her head: What if she
threw the baby into the water?
Belsito knew she needed help fast. A therapist told Belsito she could see her in six to eight
weeks. Belsito told her doctor that she might not make it that long. Instead, Belsito, who had
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moved to Topsfield, tracked down her old therapist who agreed to see the entire family. The
social worker told Belsitos husband, What she is dealing with is totally real.
Postpartum depression is a global term that encompasses the three types of emotional
complications that a woman might experience after delivery: baby blues, postpartum
depression, and postpartum psychosis. Roughly 8 to 20 percent of all women suffer from
postpartum depression following a childs birth. Health care professionals also use the term
perinatal depression to describe the condition and the period when it occurs, anytime during
pregnancy through the first year after childbirth.
There were nearly 72,000 births to Massachusetts mothers in 2013. At the urging of the state
commission, the Department of Public Health set up a screening pilot program in 2014 that
targeted more than 2,000 pregnant and postpartum, mostly low-income, patients at four
community health centers in Holyoke, Lynn, Jamaica Plain, and Worcester. The pilot program
found that, overall, about 12 percent of women who were screened had depression symptoms
ranging from mild to severe.
The program evaluated 1,059 postpartum women: 839 (79 percent) of them received a
postpartum depression questionnaire. Of the women who agreed to take the survey, 50 women
(6 percent) had symptoms that indicated mild depression. Another 48 women (6 percent) had
moderate to severe depression symptoms. The Patrick administration axed the $200,000
program during last years budget cuts.
The hormonal shifts that take place after delivery can affect some women more than others.
According to Massachusetts General Hospitals Center for Womens Mental Health, many
women experience what is commonly known as baby blues. Women cry, or get anxious or testy
after giving birth. Those symptoms usually disappear after about two weeks and a woman is able
to take care of herself and her baby.

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New mothers may experience sadness, problems with sleeping or eating, an inability to focus,
and thoughts of suicide or hurting their baby. The stress of poverty is also a risk factor
for postpartum depression: the rates are more than double for low-income women. Other social
factors can also make a woman more prone to the condition, including marital problems, being
isolated at home, having anxiety about returning to work, and depression before pregnancy.
Sen. Joan Lovely, a member of the state commission, suspects that she had postpartum
depression after the birth of her first child nearly 30 years ago. I had an anxiety condition
before I had children, says the Salem Democrat, a mother of three 20-something daughters.
After I had my first daughter, I became agoraphobic and could not leave my house for a whole
year. Because she was nursing her daughter, Lovely resisted medication and, instead, had to
undergo intensive therapy.
Postpartum depression often goes undetected. Left untreated, depression can lead to
complications, including pre-eclampsia (high blood pressure during pregnancy), premature
birth, and low birth-weight babies. After the first year, a mothers depression can lead to her
children having anxieties or being prone to disruptive behavior, according to Dr. Nancy Byatt, a
psychiatrist who is the medical director for the Massachusetts Child Psychiatry Access Project
for Moms. If a child has mental health or behavior concerns, they dont usually go away when
[that person] becomes a preteen, says Byatt.
At the opposite end of the spectrum of emotional complications is postpartum psychosis, the
most serious type of mental disorder that can occur after childbirth. Women suffering from
postpartum psychosis behave erratically and have delusions and hallucinations. The condition
affects a small minority, about one-tenth of 1 percent, of women.
Postpartum psychosis usually ends up in the headlines when a woman commits suicide after the
birth of a child or kills one or more of her children. Andrea Yates, the Texas woman who
drowned her five children in 2001, suffered from psychosis. According to news reports, Miriam
Carey, the Connecticut mother killed by police in 2013 after a car chase in Washington, DC, had
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depression with psychosis. Carey believed that President Obama had her under surveillance.
Her baby, who was in a car seat during the shooting, survived unharmed.
Underlying medical issues, such as thyroid problems, can trigger postpartum psychosis. Shauna
Kellar, an elementary school teacher turned stay-at-home mom, experienced periods of
psychosis after the birth of her older daughter in 2006. Her first postpartum experience was
horrific, complete with a stay in Berkshire Medical Centers psychiatric unit, on enough meds to
tranquilize a horse, she says. Nearly two years later, the Richmond woman says she was 100
percent better.
But Kellar nearly died as a result of a second bout of postpartum emotional complications after
the birth of her son three years later. She had abnormal thyroid levels again. Her doctors
inability to calibrate her thyroid and psychiatric medications caused major complications.
During one psychotic episode, Kellar called her mother to tell her that she planned to baptize
her son in the bathtub because Jesus was coming to save the world.
After multiple hospitalizations, two suicide attempts, and electroconvulsive therapy in a
Saratoga, New York, mental health treatment center, she came under the care of a Boston-area
psychiatrist who tried to have her committed to St. Elizabeths Medical Center in Boston. After a
judge intervened and ordered him to find a better solution, her meds got tweaked, her thyroid
returned to normal, and she recovered two weeks later.
Today Kellar is back to teaching and is writing a memoir. She plans to visit Disney World with
her husband and kids. Postpartum depression is different in each person, she says. There is
no standard treatment plan for each mom.
Most women do not want to admit that they have a problem because they fear being compared
to women like Yates or Carey. They worry that being treated for mental illness means that their
children might be taken away from them. Society is going to judge what they dont even know,
says Belsito, now a volunteer with the North Shore Postpartum Depression Task Force.
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I just wanted to go to sleep and never wake up, says Jamie Zahlaway Belsito.
Belsito says thats why its important to remove the stigma surrounding postpartum depression,
and to explain that it is very common and that most cases are mild to moderate and respond
well to treatment. If the absolute, extreme heartbreak situations of women who have hurt their
children or have hurt themselves ends up being what postpartum depression is, no mom will
ever talk about it because who wants to associate themselves with that? she asks.
The stigma surrounding mental illness and postpartum depression can be a powerful deterrent
to getting treatment. Motherhood is supposed to be one of the most idyllic periods of a womans
life. The reality is that the first year after childbirth is physically taxing and emotionally
draining. Images in the media of slim, stylish mothers cradling clean, happy babies dont jibe
with the daily grind of vomit-stained clothes, dirty diapers, and cranky infants that only sleep a
few hours at a time. The novelty of a raising a newborn quickly wears off as family and friends
return to their own busy lives, often miles away.
We have just perpetuated the myth that pregnancy is a glowing time for all women and that
having a baby is the most glorious life experience ever, says Deborah Issokson, a psychologist
in Wellesley and Pembroke who specializes in perinatal mental health. It isnt as simple as you
have your baby, you go home, and all the ladies in the neighborhood gather with their babies in
their buggies and have coffee together. Thats not how people live anymore.
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Looking for signs
The aim of screening is to identify at-risk women and help reduce stigma around postpartum
depression by handling it as a routine feature of a womans medical visit, much like testing for
hypertension and gestational diabetes. The Edinburgh Postnatal Depression Scale is one type of
questionnaire used by health care providers to identify women who may be at-risk for
postpartum depression. The survey consists of 10 questions that help judge a womans mood:
whether she has bouts of crying, has trouble sleeping, or is thinking about harming herself. A
score of 10 or higher indicates that a woman might be suffering from depression.
Treatment for postpartum depression includes talk therapy, one-on-one or in a support group,
and antidepressants (although some breastfeeding mothers prefer not to take them). If you can
get a mom or an expectant mom the help that she needs early in the pregnancy, then potentially
you can prevent postpartum depression, says Byatt.
Only a handful of states, including Illinois, New Jersey, and West Virginia, screen all mothers
for postpartum depression. Illinois legislators mandated screening more than a decade ago after
a woman suffering from postpartum depression committed suicide. Illinois law requires health
care providers to screen women, but under state regulations a provider merely has to invite
pregnant patients to complete a questionnaire; the woman is not required to complete it. Illinois
reimburses doctors for screening of both Medicaid and private patients.
Some doctors have been reluctant to screen women in part because they do not have mental
health training and arent sure what the next treatment steps ought to be. Theres a fear, too,
that a woman might fall through the cracks if a provider fails to keep tabs on her. There needs
to be a system in place, says Byatt. Doing the screen itself isnt going to change her outcome; it
needs to be followed up.
To help Bay State health care providers determine what to do about a woman who might be
depressed, the Department of Mental Health launched the Massachusetts Child Psychiatry
Access Project for Moms (MCPAP for Moms) in 2014. MCPAP for Moms provides statewide
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consultations for obstetricians, pediatricians, nurses, midwives, and others who work with
pregnant women and new mothers. The telephone resource and referral service relies on hubs at
Brigham and Womens Hospital in Boston, UMass Memorial Medical Center in Worcester, and
Baystate Medical Center in Springfield.
Psychiatrists and care coordinators offer doctors real-time consultation on issues such as drug
safety and provide information about trainings, support groups, and other local resources. In
the first six months of operation, the program handled more than 500 calls and assisted more
than 300 hundred women. The cost of the program for fiscal 2016 is $600,000.
Nationwide, the American College of Obstetricians and Gynecologists is not on board with
mandated screening. The group has advised its members that there is insufficient evidence to
support a firm recommendation for universal or postpartum screening. That view is unlikely to
shift until more states have ways to connect doctors with treatment options and more evidence
that screening is effective.
Dr. Tiffany Moore Simas, an obstetrician/gynecologist who teaches at the University of
Massachusetts Medical School, describes doctors reservations this way: What everybody has
been up in arms about is: We screen, we identify depression, and then what? says Moore Simas,
who is a member of the state postpartum commission. Is it enough to give a woman the name
and a number for a place to go? Is she going to actually engage in treatment?
Also complicating the issue is the fact that for many postpartum women, their main interaction
with the health care system is through their childs pediatrician. Pediatricians have been
reluctant to screen women because the child, not the mother, is their patient.
Some Bay State pediatricians want to shift more attention to mothers because a parents
depression can have an impact on the child. You can screen for development problems, but can
you screen for predicting mental health disorders long-term or behavioral health disorders in
[young infants]? says Dr. Michael Yogman, a pediatrician who sits on the state commission.
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The answer was clearly screening mothers for postpartum depression because maternal
depression affects the mother and child interaction.
Insurers are lukewarm on screening. The Massachusetts Association of Health Plans, which has
a seat on the state commission, has yet to take a position. Elizabeth Murphy, the associations
public policy and regulatory affairs manager, says that while screening makes sense, the decision
to screen is best left up to individual providers. With some women, there is some sensitivity
around this, Murphy says. There is also a fear by some providers that if a woman is suffering
from postpartum depressionthat she may be less likely to go to a doctors visit because she
doesnt want the doctor to see that.
Reimbursement for screening is also an issue. I have been arguing for the better part of seven
or eight years that the refusal of Medicaid to pay for postpartum depression screening was just
harmful, Yogman, the pediatrician, says. Pediatricians are asked to do so many things, and if
the insurers dont value [screening] to reimburse for it, even minimally, they are just not going
to do it. There are too many other things to do.
Behind the screen
Story has not gotten much traction on a statewide screening program, but she believes that
screening is key. Because it is prevention, it saves money, she says. If you can get somebody
in a group talking about the terrible thoughts that she is having and get her to understand that
she is not the worst mother in the world, then you may save her from a psychiatric
hospital.Story spearheaded the effort to set up a statewide postpartum commission in 2010.
The group, composed of more than 30 lawmakers, public health officials, doctors, and
advocates, examines research and works to raise awareness. The first two screening bills that
Story introduced did not advance. In January, Story re-introduced a bill that would mandate
screening for MassHealth patients and restore funding to the pilot screening program.
69
Rep. Ellen Story of Amherst is finding that mandatory screening for postpartum depression is a tough sell.
There is no statewide data currently available on who screens for postpartum depression and
who does not. Under a compromise plan after universal screening failed, state public health
officials agreed to collect data annually on available screening programs. Health care providers
must report their findings to the department early next year. To overcome the obstacles involved
in tracking information through electronic records, which had dampened the interest in
screening among some providers, state health care officials devised a special tracking code for
them to use to submit data to the department.
While state health care officials continue to mull the cost of MassHealth screening, the Joint
Committee on Health Care Finance put the statewide price tag at an estimated $101,000.
The Baker administration has adopted a wait-and-see approach. MassHealth does cover many
types of wellness screenings and views postpartum depression as an important issue, said
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Rhonda Mann, the Executive Office of Health and Human Services communications director, in
a statement. We do plan on taking a serious look at any evidence-based screening that has the
support of the public health community.
The money piece of this always gets in the way, says Lovely. We are talking about the health
of the mother and the health of her child. Doesnt that trump anything else? If a mom is
struggling,who knows if the symptoms of postpartum depression could go from mild to severe?
Photographs by Meghan Moore

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Link to watch video: http://www.wcvb.com/health/program-helping-moms-with-postpartum-

depression-get-a-fresh-start/32652994
DISTRICT II
Long Acting Reversible Contraception (LARC)

Nicholas Kulbida, MD
Albany, NY
Chair November 18, 2015
Cynthia Chazotte, MD
Bronx, NY Ms. Stephanie Williams
Vice Chair Department of District and Section Activities
Camille A. Clare, MD, MPH
The American College of Obstetricians & Gynecologists
Bronxville, NY 409 12th Street, SW
Treasurer Washington, DC 20024
Christine M. Herde, MD
Poughkeepsie, NY Dear Ms. Williams,
Secretary
Eva Chalas, MD I am pleased to nominate ACOG District IIs LARC program, under the leadership of
Mineola, NY Laura MacIsaac, MD, MPH, FACOG, for the 2016 CDC Service Recognition Award. Since
Immediate Past Chair
2013, Dr. MacIsaac and family planning experts throughout New York State have come
Ronald V. Uva, MD together to develop District IIs LARC program, as well as seek Medicaid reimbursement
Speculator, NY
Senior Advisor policy changes for providers for the provision of LARC in the postpartum period.
Donna Montalto, MPP

Albany, NY
In 2013, ACOG District II embarked on a new contraception initiative to educate ob-gyn
Executive Director providers about the safety and efficacy of long-acting reversible contraception (LARC).
Dr. MacIsaac, serving as District IIs LARC Task Force Chairperson, spearheaded the
Section Chairs:
Joanne L. Stone, MD development of this medical education project which kicked off with lobbying Medicaid
1 (Manhattan) medical plan directors to recognize the financial benefit of reimbursement for LARC
Paul H. Kastell, MD
devices in the immediate postpartum setting. These efforts resulted in New York State
2 (Brooklyn/Staten Island) becoming one of the first states to provide Medicaid reimbursement for this purpose,
increasing contraceptive options for women in the postpartum period. Other
Lisa Rosenberg, MD
3 (Queens) commercial insurers have begun to follow suit.
John J. Vullo, DO
4 (Long Island) Subsequent activities of District IIs LARC program included the development of a web-
based clinical video with patient case vignettes to test provider knowledge. This
Dhruv Agneshwar, MD
5 (Syracuse/Utica)
comprehensive video educates ob-gyn providers on:
Gil M. Farkash, MD Tools to improve their contraceptive practice

6 (Buffalo)
Currently available LARC methods
Adina H. Keller, MD Scientific evidence and clinical practice guidelines for the provision of LARC
7 (Hudson Valley)
Techniques for postpartum device insertion
Erika H. Banks, MD Barriers and solutions to reimbursement obstacles
8 (Bronx)
Lawrence M. Perl, MD And finally, because of Dr. MacIsaacs and District IIs commitment to complementary
9 (Albany)
patient education, a contraceptive options poster for office waiting rooms was also
Coral L. Surgeon, MD developed. These posters have been well-received and are continually requested across
10 (Rochester) New York State and nationally.
Dr. MacIsaac and the District II LARC Task Force are well underway in planning the
release of additional education for both patients and providers in 2016 which includes
the creation of an instructional 3-D video on postpartum LARC placement, the
THE AMERICAN CONGRESS OF OBSTETRICIANS AND GYNECOLOGISTS, DISTRICT II |

100 Great Oaks Blvd., Suite 109, Albany, NY 12203
PHONE: 518.436.3461 | FAX: 518.426.4728 | EMAIL: info@ny.acog.org | www.acogny.org
Page 2
November 17, 2015
development and statewide dissemination of postpartum LARC education for patients, as well as a billing
and coding guide as a result of ICD-10.
Through these activities, Dr. MacIsaac has demonstrated her unwavering commitment to family planning
initiatives in conjunction with the ACOG District II LARC Task Force, and District II is focused continuing its
activities in the long-term to ensure that LARC utilization increases across the state.
For the reasons mentioned above, I respectfully nominate the ACOG District II LARC program, under the
stewardship of Laura MacIsaac, MD, MPH FACOG, to receive the 2016 CDC Service Recognition Award
Sincerely,
Nicholas Kulbida, MD, FACOG

Chair, ACOG District II
NK/kz
District iv
SOUTH CAROLINA
Birth Outcomes Initiative (BOI)

ACOG District IV Chair
Thomas W Hepfer, MD
320 Knollwood Dr.
Salem, SC 29676-3909
803.212.8369
twhepfer@gmail.com
November 30, 2015

Re: CDC Service Recognition Award - South Carolina Section (District IV ACOG)
Dear Members of the Council of District Chairs:

On behalf of District IV, it is with great pleasure that I write this letter of support for the
proposal submitted by the South Carolina Section of District IV for the CDC Service Recognition Award
submitted by Dr. Scott Sullivan. The funds received would be used to support the Births Outcome
Initiative (BOI).
The BOI is a public and private partnership of stakeholders interested and involved in perinatal care
in South Carolina. The genesis of the idea originated between the officers of the South Carolina ACOG
section, and the leadership of the Department of Health and Human Services (DHHS). Since inception
of the partnership in 2011, the program boasts the following successes:
Simulation/Maternal Safety Project: Visit all 52 LDs in SC and team train delivery staff. Plan to
re-visit next year and compare outcomes.
Maternal Mortality Committee formed. The legislation required to form this committee was
introduced in 2015 and successfully passed both state houses and has been signed by the
governor. This particular committee will be chaired by Judy Burgis, MD with Scott Sullivan, MD
as Vice Chair.
South Carolina Milk Bank founded and operational.
Seven Baby Friendly hospitals now, up from zero, with two more pending.
Twelve Centering Pregnancy Centers, up from zero - PTL rates 8 %, significantly below state
averages.
Increasing educational series - 4 webinars and yearly symposium.
Continued significant reductions in both prematurity and infant mortality.
The funding from the CDC would provide the South Carolina Section with additional support in
maintaining the leadership and momentum from this very successful program that has gained
statewide attention even among the political leadership of the State. Because of the BOI, South
Carolina came very close to being accepted as a pilot state for the AIM project but lacked data
collection abilities. The additional funding may assist in the data collection as well. I enthusiastically
endorse this project as a nominee for the CDC Service Recognition Award.
Sincerely,
Thomas W Hepfer, MD
ACOG District IV Chair
Application for ACOG Council of District Chairs Service Recognition Award
Scott Sullivan MD, Judy Burgis MD
SC Section Chair and Vice-Chair
Monday, November 30, 2015
The South Carolina Section of the American Congress of Obstetricians and

Gynecologists co-founded, helps fund, and provides countless hours of volunteer effort
to the South Carolina Birth Outcomes Initiative (BOI). The BOI is a public and private
partnership of stakeholders interested and involved in perinatal care in South Carolina.
The genesis of the idea originated between the officers of the South Carolina ACOG
section, and the leadership of the Department of Health and Human Services (DHHS).
In the midst of a budgetary crisis in 2011, the Director of DHHS, Tony Keck invited all
the specialty societies to meet with him about cost containment and quality
improvement. Interestingly, the SC ACOG section was the only Society willing to meet.
In fact, the section ignored a vote of the SC Medical Association to boycott the
meetings. The Section chapter officers and other concerned OBGYNs met with DHHS
and discussed ways in which care could be improved by cooperation.
Following the meeting, Dr. Scott Sullivan (then section Vice-Chair) drafted a proposal to
reduce unindicated deliveries <39 weeks in the state. It was estimated this would save
millions of dollars in NICU and Level 2 stays which would more than offset any cost-
cutting targets that DHHS had in mind. The officers also sent a list of other dream goals
which include decreasing infant mortality, decreasing cesarean sections, providing
obstetric coverage to areas with no obstetric providers, and many others. From this
early meeting and proposal, DHHS decided that this was an exciting idea and set aside
department funds to make an official working group called the Birth Outcomes Initiative.
(Appendix A Charter Letter from August, 2011)
The first meeting of this group was seven people, five of whom where representatives of
SC ACOG. Since its founding, the membership has expanded logarithmically. A typical
monthly meeting of the BOI now has somewhere between 120-150 participants. What
started out as two administrators and five OBGYNs now includes representatives from
neonatology, midwives, nurses, insurance companies and payers, the hospital
association, lactation consultants, geneticists, charitable organizations and interested
lay persons. The response of the professional communities to this opportunity to
network and problem solve together has been rapid and overwhelming.
In addition to monthly meetings there are regular educational webinars, a yearly

symposium, simulation classes held at SC medical centers, publications, an active
website and regular press briefings. The press has been particularly interested in this
new initiative and the BOI has been featured in local and state newspapers, TV
broadcasts, speeches by politicians including SC Governor Haley, and has been
featured in as faraway places as NPR and the New York Times.
The most important question of course is what specific measurable achievements can
be attributed to the BOI. The evidence would support eight achievements thus far that
can be attributed in part to the efforts of the BOI:
Drastic reduction of elective delivery <39 weeks

15% reduction in preterm birth rate
25% reduction in infant mortality
Establishment of the first South Carolina donor milk bank
Increase in Baby Friendly designated hospitals from 0 to 7
Increase in Pregnancy Centering programs from 0 to 12
Establishment of a Maternal Mortality Review Committee
Maternal Safety Project Visiting all 52 SC LDs for simulation team training
The first goal of the BOI was the reduction and eventual elimination of non-indicated
elective deliveries <39 weeks. This was accomplished first through educational efforts.
ACOG section officers traveled to every hospital perinatal meeting over the course of a
year and attempted to obtain a voluntary pledge to support this goal and to appoint a
champion at each L&D unit to monitor the progress. This was followed by a campaign
to have the CEO of every delivering hospital verify that they were going to put in place a
hard stop for these elective deliveries. Finally, ACOG and DHHS negotiated a change
in payment strategy where purely elective deliveries <39 weeks would not receive
payment through the Medicaid system. (Appendix B, press release from 2012) The
guidelines for what was medically indicated were developed and distributed by the
Section. A system of consultation with a regional Maternal-Fetal Medicine physician in
the case of ambiguous clinical situations and for advice was also arranged by the
Section. The results have been dramatic. In the first year the instance of elective
deliveries fell by 30% and > 50% in the second. (Appendix C, table 1) Preliminary data
for 2014 may show reductions near to 80 %. (not shown) A cost analysis from SC
DHHS indicates a savings of over 6 million dollars in OB and NICU related costs from
BOI activity. (Appendix C, Table 2 and 3)
Since the founding of the BOI, the SC preterm birth rate has fallen by approximately
25%. (14.1 % to 10.8 %, MOD data) This does mirror a national trend of reduction of
preterm birth; however the South Carolina reduction has been greater than that of
national. There has been an educational outreach of the BOI and the Section to work
with practices on their utilization of 17-hydroxyprogesterone, vaginal progesterone, use
of transvaginal cervical length and appropriate referrals for cerclage and pessary
placement. Significant increases in utilization of these preventative measures have
been noted since the education started. (DHHS data, not shown) Lastly, the BOI has
sponsored a number of regional projects such as Centering of Pregnancy, which is a
prenatal care model that has shown a dramatic decrease in preterm birth among its
participants, thought largely to be due to positive behavioral changes and the reduction
of stress. The BOI has financed Centering Pregnancy Centers of Excellence in seven
locations around the state. Participant data demonstrates an 8 % preterm birth rate in
the program. (Appendix C, Table 4, courtesy of Dr. Amy Picklesheimer)
The leading causes of infant mortality in SC are similar to those elsewhere, preterm
birth, birth defects, SIDS and accidents. The BOI has been working on reducing
preterm birth as previously noted, and on SIDS reduction through patient and family
education. Promotion and protection of perinatal regionalization has been another
priority for both the BOI and SC ACOG. The section had to organize a lobbying and
legislative testimony plan to preserve the system in 2014. This system of regional
NICUs provides the best care for neonates with birth defects, and clearly reduces infant
mortality. A nearly 25% reduction in infant mortality was reported in 2014, a result that
stunned nearly everyone associated with the effort. The largest reduction was among
African-American infants, which is certainly gratifying, considering the historically high
disparity in SC. (Appendix C, Table 5)
Through discussion of the BOI Vision Team, or steering committee, breast feeding
was identified as a glaring need in the state. SC had one of the lowest breast feeding
rates in the nation. Two important projects were started, the first to provide incentives
to hospitals to achieve Baby Friendly designation, which is a recognized institutional
commitment to increase breast feeding acceptance among patients. In 18 months, SC
went from zero hospitals with this designation to 6. 2 more are pending approval. The
second project was the founding of a donor breast milk program to provide much
needed milk to premature infants. In the past, milk was imported from Texas at
exorbitant cost and significant wait time. SC ACOG and the BOI helped fund the startup
costs for this important program. As a result, breast feeding rates are rising and SC
NICUs have 24/7 access to breast milk.
South Carolina has had a historically high rate of maternal mortality, when compared to
national averages. However, there was limited data as to why, what the leading
causations might be, and how they could be decreased. SC ACOG took the lead to
establish the first Maternal Mortality Review Committee in the state. Section officers,
especially Vice-Chair, Dr. Judy Burgis lobbied DHHS and DHEC to officially recognize
and structure a committee that would represent perinatal stakeholders. Dr. Sullivan
wrote and introduced a bill to codify and permanently establish the committee as a state
function, which includes protections against liability and prosecution. A nominal amount
of funding for record retrieval and reporting was requested. This bill was passed by the
SC legislature in 2015. The committee has met on three occasions for organizational
planning and naming members. We feel that this is an important step toward identifying
maternal deaths, trends and causes, and making recommendations to reduce the
incidence of this terrible outcome.
The newest BOI/ACOG initiative is a maternal safety and team training program with
focus this year on LD units as well as reducing the first time cesarean section rate. SC
ACOG has partnered with BOI to visit every maternity unit in SC this year with the
mobile simulation unit, or Sim Coach. (Appendix C, Figure 1) This is 52 trips, which
has required a lot of hours and time on the road. The response has been overwhelming
and enthusiastic. We have encountered long lines and eager teams of providers who
want to train together and talk through common emergencies. Dr. Sullivan is
responsible for the simulation proctoring in the Low Country and Pee Dee regions. We
intend to return to the LDs in 2016-17 and look for improvements and local innovations
that have resulted from the program.
Perhaps no better illustration of the growth of BOI was seen at the November 11th, 2015
annual BOI symposium in Columbia. SC ACOG was a key sponsor of the event, and
provided the keynote speaker, and a number of breakout sessions. Attendance broke
last years record with over 350 participants from all over the state and region.
(Appendix C, Figure 2) Dr. Sullivan and Dr. Burgis were also speakers at the event.
We feel that the efforts of the SC ACOG section have been instrumental in making
positive changes in the states perinatal system and we are seeing real, measureable
results. While these accomplishments are the work of many people, across the state
and on front lines of clinical care, the SC ACOG section has provided the leadership,
the expertise, funding and the vision to get people working together in the BOI system.
The traditional silos of government, academia, private practices, nursing and pediatrics
are working together in ways they never have before. We proud of the results thus far,
and have high expectations of the coming years from our continuing efforts with the
BOI, Maternal Mortality Committee and educational efforts.
Appendix C
Table 1 (Data from Milliman, 2014)

Table 2 and 3
Table 4 (data courtesy from Dr. Pickelsheimer)
Table 5 (MOD, Peristats 2015) SC Infant Death
Figure 1 (courtesy of the author)
Beaufort Memorial Hospital, September 2015

Figure 2 (courtesy of the author)
BOI Annual Symposium, Nov 11, 2015

District iX
Reduction of Maternal Mortality in California

11/20/2015 MaternalMortality|CaliforniaMaternalQualityCareCollaborative
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Maternal Mortality
CMQCCs founding mission was to end preventable morbidity, mortality and racial disparities in
California maternity care. This section includes key definitions and data on these three inter-related
aspects of maternal outcomes.
CMQCC is contributing to the reduction ofmaternal mortality in California by conducting

Pregnancy Associated Mortality Reviews, researching primary causes of death, developing
evidence-based toolkits and implementing quality improvement initiatives across California.
These efforts are funded and completed in partnership with the Maternal, Child and Adolescent
Health Division of the California Department of Public Health. These projects have focused on
the two leading preventable causes of maternal death and severe morbidityobstetric
hemorrhage and preeclampsia. Californias rate has always been parallel to the national rate as
12% of all US births occur in the state. The national rate rose to 14-16 per 100,000 births by
2008 and has continued to rise to 18 in 2012.
The California rate began to decline in 2009 and was markedly lower in 2011 and 2012, reaching
levels similar to those in Western European countries. The timeline below illustrates key
CMQCC activities against the falling rates of maternal mortality in California.
https://www.cmqcc.org/focus-areas/maternal-mortality 1/2
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https://www.cmqcc.org/focus-areas/maternal-mortality 2/2
11/20/2015 CaliforniaandtheU.S.|CaliforniaMaternalQualityCareCollaborative
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California and the U.S.

California has seen a decline in maternal deaths since 2006 when the MMR was 16.9 maternal deaths
per 100,000 live births.The maternal mortality rate for the U.S. was 12.7 in 2007, and 22.0 in 2013.
The causes of the increase in maternal mortalityare still being examined.
Some investigators point to the recent improvements in identification of maternal deaths and
collection of maternal death data. Others point to significant changes in population characteristics of
pregnant women making them more at risk for morbidity and mortality. Lastly, most investigators
acknowledge that administrative and population characteristics changes account for only some of the
increase seen but that a significant portion of the increase may be due to clinical factors under the
control of the health care system.
The National Vital Statistics System (NVSS) will not report U.S. maternal mortality rates until all states
adopt approved data elements to capture maternal deaths on their death certificates. The rates in the
graphic below have been calculated using the CDC Wonder Database.
https://www.cmqcc.org/focus-areas/maternal-mortality/california-and-us 1/3
11/20/2015 CaliforniaandtheU.S.|CaliforniaMaternalQualityCareCollaborative
Healthy People 2020 Objective for Maternal Infant and Children's Health (MICH)
MICH-5: Reduce the rate of maternal mortality. Target: 11.4 maternal deaths per 100,000 live births.
Baseline: 12.7 maternal deaths per 100,000 live births occurred in 2007. Target setting method: 10
percent improvement. California's maternal mortality rate was 49% higher in 2006-2008 than in 1999-
2001.
In 2010, the U.S. was ranked 50th among the cohort of 59 developed countries according to a WHO
report, and in 2014, the Lancet published a study estimating the U.S. maternal mortality rate as 18.5
per 100,000 births in 2013, dropping the U.S. to 60th in the world.
CA PAMR Reports & Publications

Reports and Publications from CA-PAMR
(http://www.cdph.ca.gov/data/statistics/Pages/CaliforniaPregnancy-AssociatedMortalityReview.aspx)

https://www.cmqcc.org/focus-areas/maternal-mortality/california-and-us 2/3
11/20/2015 RacialDisparities|CaliforniaMaternalQualityCareCollaborative
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Racial Disparities
Mortality rates for African-American women are the lowest they have been since 1999. In 2011-2013,
there were 26.4 deaths among African-American women per 100,000 live births, half of what they were at
the peak in 2005-2007. Still, African-American women continue to have a three- to four-fold higher risk of
maternal mortality compared to White women. Some possible reasons for this persistent disparity
include:
African-Americans are disproportionately impacted by negative social determinants of health such

as lower wages, access to housing, unsafe environments and racism.
African-American women may have higher rates of underlying health conditions such as
hypertension, obesity, and cardiovascular disease that complicate their pregnancies.
The disparities may also reflect a disparity in health care that can be attributed to differences in
health insurance, entry to prenatal care, and access or quality of care.
Finally, the persistent disparity indicates that maternal mortality rates are decreasing proportionally
among both African-American and White women. One group is not showing a greater increase or
decline, thus the ratio remains steady.
(see Figures below).
(From California MCAH Bulletin: California Maternal Mortality Rates: A Sustained Decline in Maternal Mortality
Since 2008. May 2015)
(http://www.cdph.ca.gov/programs/mcah/Documents/MCAH%20Bulletin_MMR%20Decline_May.18.2015.pdf)
https://www.cmqcc.org/focus-areas/maternal-mortality/racial-disparities 1/3
The disparity in maternal mortality rates for African-American women compared to White women has
worsened over time, despite this recent welcome trend downward. This disparity in maternal deaths
between African-American women and women of other racial/ethnic groups is the largest disparity among
major public health mortality indicators. It is not known whether this maternal health disparity is due to
differences in health status (e.g., a higher burden of illness, injury, disability) or if it also represents a
disparity in health care that can be attributed to differences in health insurance coverage, entry to
prenatal care, access or quality of care.
Disparities in Maternal Mortality by Race/Ethnicity

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11/20/2015 AgeDisparities|CaliforniaMaternalQualityCareCollaborative
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Age Disparities


https://www.cmqcc.org/focus-areas/maternal-mortality/age-disparities 1/2
11/20/2015 Definitions|CaliforniaMaternalQualityCareCollaborative
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Definitions
Maternal Mortality Rate vs Ratio

Maternal mortality is calculated by counting deaths associated with any pregnancy outcome (livebirth,
stillbirth, ectopic, termination or miscarriage) in the numerator and using all livebirths as the
denominator. Thus, there are multiple cases in the numerator that are not present in the
denominator, indicating that the proper term would be "Maternal Mortality Ratio." However, the use
of "Maternal Mortality Rate" is so ingrained in the literature that ACOG, CDC and most current authors
continue to use "Maternal Mortality Rate," as does this website.
CDC/ACOG Definitions
Pregnancy-associated death: The death of a woman while pregnant or within 1 year of termination
of pregnancy, irrespective of cause.
Pregnancy-related death: The death of a woman while pregnant or within 1 year of termination of
pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or
aggravated by her pregnancy or its management, but not from accidental or incidental causes.
(From: Berg C, Danel I, Atrash H, Zane S, Bartlett L (Editors). Strategies to reduce pregnancy-related deaths:
from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001. NOTE:
2.9MB)
WHO/NCHS (US Death Certificate) Definitions

Uses ICD-10 codes from the Death Certificate to identify cause of death, restricted to ICD-10 codes
A34, O00-O95, O98-O99. See link for definitions of the ICD-10 pregnancy codes
Maternal deaths are defined by the World Health Organization as the death of a woman while
pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the
pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not
from accidental or incidental causes.
Late maternal deaths are defined as the deaths of a woman from direct or indirect obstetric
causes more than 42 days but less than one year after termination of pregnancy.
Pregnancy-related deaths are defined as the death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the cause of death.
https://www.cmqcc.org/focus-areas/maternal-mortality/definitions 1/3
Direct obstetric deaths: those resulting from obstetric complications of the pregnant state
(pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a
chain of events resulting from any of the above.
Indirect obstetric deaths: those resulting from previous existing disease or disease that developed
during pregnancy and which was not due to direct obstetric causes, but which was aggravated by
physiologic effects of pregnancy.
(From: Hoyert DL. Maternal mortality and related concepts. National Center for Health Statistics. Vital Health
Stat 3(33). 2007. This article is an excellent discussion of the impact of changing definitions on the Maternal
Mortality rate.)
Two Sets of Maternal Mortality Terms

Having two sets of definitions and terms can be confusing. However, each set has a unique purpose.
ICD10 Terms
Used by many nations, so they require coding conventions to be applied in a comparable

fashion.
Used to monitor trends and make comparisons.
Only cause-of-death data from death certificates can be used to identify deaths that meet ICD
definitions.
ACOG/CDC Terms
Used by individual states or cities.

Used to identify deaths for review and action.
A variety of data sources, including vital records and hospital data, can be used to identify
deaths that meet ACOG/CDC definitions.
(From: Berg C, et.al. see above)
The upshot of these competing definitions is that one has to be extraordinarily careful when
comparing Maternal Mortality rates among different time periods, among different countries or
between different papers to ensure that similar definitions are used.
Technical Definitions used by CA Department of Public Health

MATERNAL MORTALITY RATE: Death from obstetric causes <42 days postpartum, per 100,000 live
births
Numerator: Underlying cause of death on the death certificate:
ICD-10 codes A34, O00-O95, O98-O99 for 1999-present

ICD-9 codes 630-638, 640-648, 650-676 for 1979-1998
Denominator: Live Births in California per year
This is the same method as national rates calculated by National Center for Health Statistics. It is the
benchmark for Healthy People 2020 objective of 11.4 maternal deaths per 100,000 live births, and it is
used to report vital statistics and compare indicators and objectives.
PREGNANCY-RELATED MORTALITY RATE: Death from obstetric causes within one year postpartum,
per 100,000 live births
Numerator: Underlying cause of death on the death certificate:
ICD-10 codes A34, O00-O96, O98-O99 for 1999-present

Note that code O96 is specifically for deaths from any obstetric cause occurring between 42 and
365 days after delivery.
Code O97 is used to classify deaths from any direct obstetric cause which occur one year or
more after termination of the pregnancy, and is excluded from both rates.
Denominator: Live Births in California per year

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District X
2015 Perinatal Safety Initiative

Identification and trending of
MHS incidence of
Postpartum Hemorrhage,
Shoulder Dystocia
and
Birth Trauma
May 19, 2015

Table of Contents
Preface ............................................................................................................................................ 3
Introduction ...................................................................................................................................... 4
Background Information........................................................................................................... 4
Perinatal quality initiative for Postpartum Hemorrhage ........................................................... 4
Perinatal Quality initiatives for Shoulder Dystocia and Birth Trauma ..................................... 5
Appendix A - Postpartum Hemorrhage Background, details and metrics................................... 7
Appendix B - Shoulder dystocia and Birth trauma Background, details and metrics................ 14
Appendix C Resources............................................................................................................... 16
Appendix D - reVITAlize ................................................................................................................ 17
Appendix E - Hemorrhage Instruments......................................................................................... 18
Appendix F - Intrauterine Balloon ................................................................................................. 19
Appendix G - B Lynch ................................................................................................................... 21
Appendix H Slide Deck............................................................................................................... 23
2
Preface
The goal of the Military Health System (MHS) 2015 Perinatal Initiative is to introduce the concepts
and initiate a standardized MHS response to maternal and neonatal quality needs.
This Guide is designed to detail the Initiative, its corresponding evidence-base, tools and effective
strategies for monitoring and managing all requirements.
Definition of terms: It is important to understand that for the purpose of this Guide,
standardization is interpreted as adoption of the best, evidence based practices that the facilitys
resources can support.
The Guide and supporting documents are posted on the Department of Defense Patient Safety
Learning Center (PSLC) and updated as necessary.
http://health.mil/dodpatientsafety
Developed by: Partnerships for Patients Obstetrical Leadership Group
Authors: (listed in alphabetical order)
Merlin (Bardett) Faucett, Col USAF (Retired) MC former Air Force Surgeon General Consultant for
Obstetrics and Maternal Fetal Medicine.
Theresa A. Hart, RNC MS; Nurse Consultant Perinatal and Special Medical Programs, Defense Health
Agency.
Michelle L. Munroe, CNM DNP ANC Army Surgeon General Consultant for Womens Health Advanced
Practice Consultant.
Elizabeth A. Murrayxxxx, COL, ANC, Army Surgeon General Consultant for Maternal Child Nursing.
Peter E. Nielsen, COL, MC, USA, Army Surgeon General Consultant for Obstetrics/Gynecology.
Barton C. Staat, LtCol, USAF, MC, Air Force Surgeon General Consultant for Obstetrics and Maternal
Fetal Medicine.
Tracy T. Thompson, CDR MC USN Doctor of Obstetrics and Gynecology Naval Medical Center,
Portsmouth, VA.
3
Introduction
Background Information
The goal of this guide is to introduce the concepts and initiate a standardized MHS response to
maternal and neonatal quality needs. Quality initiatives are iterative processes with this 2015
Perinatal initiative running in parallel to the Partnership for Patients Transition and Sustainment
Phase.
The MHS goal is to have all metrics at NPIC averages or exceeding in the direction of improved
outcomes. The MTF rate of Postpartum hemorrhage (PPH) remains higher than the National
Perinatal Information Center (NPIC) average. For 10 years the MHS rate of Postpartum
hemorrhage has been higher than NPIC Rate of PPH with MHS 5.2%; NPIC Civilian database
average 3.3%.
The MHS has developed a dashboard to track trends. Perinatal measures on the dashboard are
postpartum hemorrhage and shoulder dystocia during a vaginal delivery of an infant greater than
2500 grams associated with birth trauma.
The focus for continuing quality improvement includes the following areas:
Maternal
Prevention, identification and treating obstetrical hemorrhage leveraging best practices

in MTFs.
Identify and correct coding/documentation to ensure accurate rates of shoulder dystocia.
Neonatal
Identify and correct coding/documentation to ensure accurate rates of birth trauma.
MHS
Ensure clinical documentation and medical record coding reflects the care delivered to
obstetrical and neonatal beneficiaries in the MTFs.
Perinatal quality initiative for Postpartum Hemorrhage

Adoption of the new definition of reVITAlize Obstetrical hemorrhage as blood loss
(regardless of mode of delivery) 1000cc or blood loss accompanied by signs and
symptoms of hypovolemia.
o Early: Cumulative blood loss of >= 1000 ml or blood loss accompanied by

signs/symptoms of hypovolemia within 24 hours following the birth
process (includes intrapartum loss).
4
o Late: Blood loss as noted above occurring greater than 24 hours after the birth
process.
o 100% review of charts identified as PPH to verify 1000cc EBL or hypovolemia

symptoms.
Active management of third stage (3rd) of labor by all providers consistent with evidence
based standards.
Standardized massive transfusion protocols for Obstetrics.
Standardization of emergency release of blood.
Standardized postpartum hemorrhage protocols for Obstetrics. (APPENDIX C details

recommendations for hemorrhage support supply).
Perinatal Quality initiatives for Shoulder Dystocia and Birth Trauma

Process measures for medical record coders and providers on birth trauma:
SIDR report has been developed to allow MTF or Service level data pull of coded data
when charts are closed.
Providers can review of infant charts with birth trauma diagnosis during hospitalization
(charts are not coded at this time) through an ESSENTRIS report. ESSENTRIS report
can then be compared the SIDR report to EMR report to verify coding is consistent
with care delivered/documented.
ESSENTRIS Newborn record (version 1.1) included Newborn Discharge note with
prompt for provider to document and describe Birth trauma.
Documentation of shoulder dystocia is standardized in the maternal delivery record

and should be coded only if documented in this note.
Diagnosis of birth trauma is now part of the discharge summary in the Newborn
record. Provider will document if birth trauma is present, the type of trauma
and its implication on the infant- length of stay, additional resources or specialty follow
up required.
Important to note:
Increased education on the identification and documentation of birth trauma will increase the
accuracy of the coding, resulting in an accurate reflection of birth trauma rate in the MHS. The
Scientific Advisory Study (SAP) began OCT 2014 (FY 2015) to review coding of birth trauma in all
5
MTFs with inpatient obstetrics to review accuracy of coding. Study completion expected May
2015.
In situ Mobile Obstetrical Emergency Simulator drills should be used to reinforce, develop and
practice team training with collaborative practice for standardized clinical identification and
treatment measures implemented.
6
Appendix A - Postpartum Hemorrhage Background, details
and metrics
Postpartum Hemorrhage
Postpartum hemorrhage remains the single most significant cause of maternal death. Worldwide
140,000 women die of PPH per year one every 4 minutes. In addition to death, 45% of serious
maternal morbidity is associated with PPH. Women die from PPH due to failure to recognize
excessive blood loss and subsequent lack of early and effective interventions.1
Causes of OB hemorrhages can be a result of: 2
Unrecognized triggers/risk factors (antepartum).
Underutilization of key medications/treatments.
Difficulty getting provider to the bedside.
Incomplete or inappropriate management.
Location of care issues involving postpartum, emergency department and PACU.
Repetitive use of the same treatment (medications or D&C)lack of a plan.
The American Congress of Obstetrics and Gynecology with additional support from the March of
Dimes, the Society for Maternal Fetal Medicine and the United Health Foundation brought
together over 80 national leaders in womens health for the reVITALize obstetric data definition
conference. As a result of the conference 49 data elements and there definition have been
finalized. Postpartum hemorrhage (early) is defined as cumulative blood loss of greater than or
equal to 1000 mls OR blood loss accompanied by sign/symptom of hypovolemia within 24 hours
following the birth process (includes intrapartum loss).
1Berg CJ, Harper MA, Atkinson SM, Bell EA, Brown HL, Hage ML, Mitra AG, Moise KJ Jr, Callaghan WM.
Preventability of pregnancy-related deaths: results of a state-wide review. Obstet Gynecol. 2005
Dec;106(6):1228-34.
Della Torre M, Kilpatrick SJ, Hibbard JU, Simonson L, Scott S, Koch A, Schy D, Geller SE. Assessing
preventability for obstetric hemorrhage. Am J Perinatol. 2011 Dec;28(10):753-60.
Joint Commission on Accreditation of Healthcare Organizations, USA. Preventing maternal death.
Sentinel Event Alert. 2010 Jan 26;(44):1-4.
2 The California Pregnancy-Associated Mortality Review, 2011; Geller SE et al. Am J
Obstet Gynecol 2004
7
Increased education and identification of postpartum hemorrhage may increase the accuracy of
this diagnosis and thereby increase the number of cases identified resulting and an increase in
the reported rate for this outcome.
The Perinatal Advisory Group (PAG) is a multidisciplinary team that collaborated to identify,
develop and implement initiatives to improve patient safety in the perinatal population. To
determine best practices, the PAG conducted a thorough review of organizational and regional
programs.
The Council on Patient Safety in Womens Health Care has 3 bundles for Womens health
available-hemorrhage, hypertensive disorders, and venous thromboembolism with the goal to
reduce variation in care processes to improve outcomes. 3 Organizations endorsing the Council
on Patient Safety in Womens Health Care are: American Association of Blood Banks
(AABB);American College of Nurse-Midwives (ACNM); American Congress of Obstetricians and
Gynecologists (ACOG); Association of Womens Health Obstetrics and Neonatal Nurses
(AWHONN);California Maternal Quality Care Collaborative (CMQCC); Centers for Disease
Control and Prevention (CDC); Society for Maternal-Fetal Medicine (SMFM); Society for Obstetric
Anesthesia and Perinatology (SOAP).
Of the 3 bundles, the Perinatal Advisory Group selected the OB Hemorrhage bundle for
implementation in the MHS. The Bundle comprises a 5-R response: Readiness; Recognition;
Respond and Report.
POST PARTUM HEMORRHAGE BUNDLE
The Bundle comprises a 5-R response: Readiness; Recognition; Respond and Report.
Readiness by identifying standardized protocols (general and massive):

Hemorrhage cart-antepartum/postpartum.
Immediate access to postpartum hemorrhage medications.
Establish an OB response team.

Ensure type & screen as risk factors increase.
Ensure protocols for emergency release of blood products and massive transfusion.
Unit education of protocols with regular unit-based (in situ) drills with debriefs.
3 http://www.safehealthcareforeverywoman. org/maternal-s afety.html
8
Recognition by performing on-going and objective quantification of maternal blood loss:
Assessment of hemorrhage risk-Antepartum, on admission and throughout labor.
Active management of the third stage of labor.
Utilize reVITALize PPH definition.
o Early Cumulative blood loss of >= 1000 ml or blood loss accompanied by
signs/symptoms of hypovolemia within 24 hours following the birth process
(includes intrapartum loss).
o Late Blood loss as noted above occurring greater than 24 hours after the birth
process.
Hemorrhage risk increases intrapartum factors combined with antepartum factors.
o Chorioamnionitis.
o Prolonged Oxytocin/Pitocin >24 hours.
o Prolonged 2nd stage.
o Magnesium sulfate use.
Active management of the third stage of labor. Recommended for all vaginal births to
reduce maternal blood loss, rate of postpartum hemorrhage and prolonged 3rd stage
(more than 30 minutes)
o Administration of Oxytocin/Pitocin (add or increase Oxytocin/Pitocin in IV titration
or IM if no IV line) with shoulder delivery.
o Steady, gentle cord traction.
o Bimanual uterine massage.
Response by utilizing stage-based obstetric hemorrhage plans and checklists:

Unit-standard, stage-based obstetric hemorrhage emergency management plan.
Standardized (ACOG) Hemorrhage checklist.
Identify triggering events/roles responsibilities of team members/leader.
Notify Blood Bank to XM 2U PRBC.

Communicate the plan.
Drill, debrief and review-Implement strategies to support after action discussions with
patients, families and staff after all significant hemorrhages.
9
Escalation of response: Assess and secure the necessary resources
Surgeons: OB/GYN, Maternal-Fetal Medicine, General Surgery, Urology, Vascular,

Trauma, GYN Oncology.
Surgical support: OR teams, anesthesia.
Additional Nursing support: Know process to obtain additional products in timely fashion
(FFP, platelets, cryoprecipitate, and additional PRBC).
Notify Blood bank.
o Consider need for O-neg/uncross matched PRBC emergency release.
o Collaboration with Pathology/Blood Bank for Massive Transfusion protocol.
o Blood Products: After initial 2 units PRBC, continue to have 2 units PRBCs
available until bleeding stabilizes/stops or initiate Massive Transfusion Protocol.
o MTF with limited supply of blood products on hand should have FORMAL
process for obtaining blood in an emergency.
SAMPLE Transfusion Protocol - Transfuse in 6:6:1:1 ratio
6 units Packed Red Blood Cells

6 units Fresh Frozen Plasma
1 apheresis pack of platelets
1 x10 unit pack cryoprecipitate (cryo)
Reporting and systems learning by performing regular, in situ multidisciplinary drills

Systems learning by performing regular, in situ multidisciplinary drills
Drills.
o Or use of actual events with debrief.
o Mobile Obstetrics Emergency Simulator (MOES).
o All disciplines; include OR, ER and Clinics.
Debrief should
o Be a requirement as part of the quality improvement processes.
o Serve as Quality Assurance measure for lessons learned.
o Are not part of medical record.
10
o Include all team members to be the most effective.
Standardized postpartum hemorrhage protocols for Obstetrics (target implementation date

01APR2015) require:
Hemorrhage Instruments in place to include (*See APPENDIX E for photos)
o Long weighted speculum.*
o Vaginal side wall retractors (right angle or Deaver retractor).*

o Long instruments (needle holder, scissors, Kelly Clamps, Sponge forceps).*
o Intrauterine compression balloon with user guide.*
o Placenta Banjo curette-large 3-4cm.*
o Bright lighting.
o Bedside ultrasound.
o Lap sponges.
o Sutures for vaginal and cervical laceration repair.
o Needles/syringes/tubes for labs.
Medication
o Oxytocin/Pitocin 20 units/liter.
o Oxytocin/Pitocin 10 units/vials.
o Carboprost/Hemabate 250 mcg (needs refrigeration).
o Methylergonovine/Methergine 0.2 mg (needs refrigeration).
o Misoprostol/Cytotec 1000mcg (200 or 100mcg tabs) (delayed action onset).
Guides
o OB Hemorrhage check list of Tasks for stages 1-4.
o MTF massive transfusion protocol.
o Flow sheet.
o Procedural instruction for intrauterine balloon (detailed in Appendix F), B-Lynch
(detailed in Appendix G).
o Procedure for notification of Interventional Radiology if available.
Training completed target 01APR2015
11
Process and Training Measures:
Process measures to assist in documentation review of postpartum hemorrhage.

o SIDR report is available to allow MTF or Service level data pull of coded data when
charts are closed.
o ESSENTRIS (EMR) review of maternal charts with postpartum hemorrhage
diagnosis can be pulled as an ESSENTRIS report for providers to review
charts and documentation during the hospitalization (charts are not coded at this
time).
ESSENTRIS Postpartum hemorrhage clinical note (Version 2.0) includes
clinical note for documentation of postpartum hemorrhage outside the time
of delivery.
o Provider should document if postpartum hemorrhage occurred during the
admission on the discharge summary. Standardization of documentation will
facilitate coder identification of this diagnosis code.
Scientific Advisory Study (began OCT 2014 FY 2015) to review coding of postpartum
hemorrhage, shoulder dystocia and birth trauma in all MTFs with inpatient obstetrics to
review accuracy of coding. Preliminary data available MAR2015, final data July 2015.
Educational offering through DCO to OB and Pediatric providers along with coders to
discuss the diagnosis of postpartum hemorrhage, along with shoulder dystocia and birth
trauma. (DCO recorded for review). https://connectcol.dco.dod.mil/p9qy03utawy/
Adoption of Direct care Service wide standardized massive transfusion protocol.

Continued collaboration with professional societies in standardization of practice including
American College of Obstetrics and Gynecology, American College of Nurse Midwives,
Association of Womens Health, Obstetrics and Neonatal Nursing.
Continued use of Mobile Obstetrics Emergency Simulator (MOES) with update to
equipment and reporting of compliance. Fiscal resources will be needed for this item.
Drills or use of actual events with debrief should be interdisciplinary (horizontal and
vertical) including Obstetrics, Family Medicine, Pediatrics (Neonatology), Anesthesia,
Nursing, Medical & Administrative support personnel, OB clinics, Emergency departments
and Blood Banks/Transfusion Services.
Drills will be completed based on Service direction for the following MOES
scenarios: breech delivery, eclamptic seizures, Forceps, Vacuum, Neonatal
Resuscitation, Postpartum Hemorrhage, Prolapsed Umbilical Cord, Shoulder Dystocia,
and Non-reassuring Fetal Heart Pattern. It is anticipated that low volume scenarios of
12
Breech, Eclampsia and prolapsed cord may need to be drill scenarios, but the other
scenarios could be evaluations of actual events with debriefs.
Drills will be documented with attendance and reported to the Service level.
13
Appendix B - Shoulder dystocia and Birth trauma
Background, details and metrics
Clinical information on Shoulder Dystocia and Birth Trauma:
The MHS Goal is to mitigate the risk of maternal or neonatal injury associated with shoulder
dystocia through: (a) ANTICIPATION and prompt recognition (b) Rapid and correct execution of
appropriate maneuvers to resolve the dystocia and (c) Use of in situ clinical team drills.
Shoulder dystocia is neither predictable nor preventable obstetrical event.
Shoulder dystocia by itself does not necessarily result in maternal or infant injury.
Rates of shoulder dystocia are directly influenced by co-morbid conditions of patients that
providers do not control. Management of co-morbid conditions is part of the prenatal care
to assist in the optimal mitigation of co morbid conditions including obesity and diabetes.
Rate of neonatal birth injury with or without shoulder dystocia are the outcomes of interest
to the perinatal providers and patients rather than in incidence of shoulder dystocia alone.
Shoulder Dystocia Metrics
Two metrics are currently reported in National Perinatal Information Center NPIC for shoulder
dystocia. Be specific when discussing or documenting:
Shoulder dystocia- alone.
Vaginal delivery coded with shoulder dystocia of infant greater than 2500 grams or greater
coded with birth trauma.
Birth Trauma Metrics
The Goal - accurate identification, documentation and coding of birth trauma defined as an injury
that has at least one of the following criteria:
Increases length of stay.
Increases resources utilized.
Requires specialty follow up after discharge.
Two metrics are currently reported in National Perinatal Information Center. Be specific when
discussing or documenting birth trauma (comprehensive measure) or PSI 17 (consolidated
metrics).
Birth trauma comprehensive is based on ICD 9 code 767.
14
Patient Safety Indicator # 17 birth trauma is based on Association of Healthcare
Research and Quality (AHRQ) algorithm.
The principle goal of the perinatal care team is to mitigate the risk of maternal or neonatal injury
associated with shoulder dystocia through: (a) prompt recognition; (b) rapid and correct execution
of appropriate maneuvers to resolve the dystocia; and (c) use of in situ clinical team drills.
In addition, the accurate administrative coding of these events and the subsequent maternal and
neonatal injuries (if present) will be enhanced through (a) improved coder education/training and
(b) collaboration between coders and providers in 'real' time to ensure accuracy of coding.
Historic information on Medical Coding related to Birth Trauma:
2005 Study DoD Medical Treatment Facilities Patient Safety Indicator 17, Birth Trauma
concluded:
The percentage of agreement between the administrative data identification of birth

trauma and the medical record identification of trauma was 21.65%.
Birth trauma coding at MTFs is not of sufficient quality to allow the AHRQ birth trauma
patient safety indicator to be calculated using the SIDR data.
The birth trauma rate at MTFs for FY04 using medical records data was below the AHRQ
benchmark for birth trauma rate, indicating the quality of care for infants born at MTFs is
high.
National Perinatal Information Center data used in this guide (2014) showed over 65% of Birth
Trauma is coded in an other specified or other unspecified categories.
15
Appendix C Resources
DCO 2015 Perinatal Quality Initiative (February)
Link for provider and coder information on shoulder dystocia, birth trauma and postpartum
hemorrhage slides 39 & 41
https://connectcol.dco.dod.mil/p9qy03utawy/ recorded 29 Dec 2014
Websites:
MHS 90D Quality and Safety review (Slide 7)

o http://www.defense.gov/pubs/140930_MHS_Review_Final_Report_Main_Body.pdf
Safe Healthcare for Every Woman;

http://www.safehealthcareforeverywoman.org/hemorrhage-forms/Hemorrhage-Bundle-
07092014.pdf Accessed on 05MAY2015
16
Appendix D - reVITAlize
reVITALize Obstetric Data Definitions
The reVITALize Obstetric Data Definitions are formally endorsed by the following organizations:
American College of Nurse-Midwives.
The American College of Obstetricians and Gynecologists/The American Congress of
Obstetricians and Gynecologists.
Association of Women's Health, Obstetric and Neonatal Nurses.
Society for Maternal-Fetal Medicine.
EARLY POSTPARTUM HEMORRHAGE
Cumulative blood loss of >=1000ml or blood loss accompanied by sign/symptoms of hypovolemia

within 24 hours following the birth process (includes intrapartum loss). Signs/symptoms of
hypovolemia may include tachycardia, hypotension, tachypnea, oliguria, pallor, dizziness, or
altered mental status. Cumulative blood loss of 500-999ml alone should trigger increased
supervision and potential interventions as clinically indicated. A fall in hematocrit of >10% can be
supportive data but generally does not make the diagnosis of postpartum hemorrhage alone.
Further research is needed on blood loss for late postpartum hemorrhage
Copyright 2014 American College of Obstetricians and Gynecologists
http://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-
Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf; Accessed on 05MAY2015
17
Appendix E - Hemorrhage Instruments
Hemorrhage Instruments:
Long Instruments:
Weighted or Auvard speculum Needle Holder, Scissors (Mayo),

Kelly Clamps, Sponge Forceps
Deaver Retractor
Eastman or Right Angle retractor
Placenta Banjo Currette

(large blunt)
18
Appendix F - Intrauterine Balloon
Intrauterine Balloon:
After vaginal delivery:
1) Ensure that the bladder is empty by placing a bladder catheter

2) Fill a sterile basin with the maximum volume of sterile fluid that can be instilled, but at least
500 mL
3) Cleanse the cervix and vagina with an antiseptic solution, such as povidone iodine
4) Perform a second visual inspection of the vagina and cervix to ensure the absence of
bleeding lacerations as the source of the hemorrhage
5) Grasp the cervix with ring forceps. Use long dressing forceps to insert the balloon catheter
into the uterine cavity, ideally above the level of the internal cervical os, if identifiable.
Alternatively, the catheter can be inserted manually, similar to insertion of an intrauterine
pressure catheter
6) Ultrasound, if available, is useful to confirm correct placement in the uterine cavity (ie,
exclude extrauterine placement as might occur with uterine rupture). It is also useful to
evaluate for significant residual placental tissue, which should be removed if present
7) Avoid excessive force when placing the device, as perforation of the uterus is theoretically
possible. If resistance is encountered, catheter placement should be readjusted or the
procedure abandoned
8) If an assistant is available, the assistant can perform real-time imaging to guide balloon
placement
9) Once the correct position is confirmed, inflate the balloon with sterile fluid until slight
resistance is encountered to further instillation (this usually occurs between 250
and 300 mL) and bleeding slows down or stops. The maximum recommended
volume to be instilled depends on the specific device
19
Intrauterine balloon tamponade for control of postpartum hemorrhage; UptoDate ;Topic 4440
Version 24.0; http://www.uptodate.com/contents/intrauterine-balloon-tamponade-for-control-of-
postpartum-hemorrhage. Accessed on 05MAY2015
20
Appendix G - B Lynch
The B-Lynch suture is placed with the following steps:
1) Take bites on either side of the right edge of the hysterotomy incision. These bites are
placed approximately 3 cm from the edge of the hysterotomy incision.
2) Loop the suture around the fundus and reenter the uterus through the posterior uterine
wall.
3) Pull the suture tightly, but do not tear into the myometrium.
4) Exit the posterior wall of the uterus.
5) Loop the suture over the uterine fundus.
6) Anchor the suture in the lower uterine segment by taking bites on either side of the left
edge of the uterine hysterotomy incision.
7) Pull the two ends of the suture tight while an assistant simultaneously squeezes the uterus
to aid compression.
8) Place a surgical knot while the assistant continues to compress the uterus.
9) Close the lower uterine segment in the usual manner. B-Lynch1 advised that if there is
excessive bleeding from a specific area of the uterus (possible placenta accreta) that a
figure-of-8 stitch should be placed through that area of the uterus prior to placing the
compression suture.
OB Management; A stitch in time, B-Lynch, Hayman and Pereira Uterine Compression sutures;
December 2012 Vol. 24, No. 12 ;http://www.obgmanagement.com/home/article/a-stitch-in-time-
the-b-lynch-hayman-and-pereira-uterine-compression-
sutures/ba5101fd78f1be43ee8a6f5384f0cd80.html
21
Resource accessed 05MAY2015
22
Appendix H Slide Deck
PAG initiative 2015 v.7 2
Service POCs
Army: Air Force
COL Peter Nielsen Col Donald Lane
COL Elizabeth Murray LtCol Bart Staat
COL Michelle Munroe LtCol Theresa Clark
Maj Kristi Norcross
Navy NCR MD
CAPT William Leininger CDR Kathy Kyser
CAPT Maria Perry CDR Kim Shaughnessy
CDR Eva Domotorffy
CDR Greg Freitag
CDR Jason Layton
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31
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Council of District Chairs (CDC) Service Recognition Award
ACOG District XII Committees on Maternal Mortality and Patient Safety & Quality Improvement
November 2015
District Xii

The American Congress of
Obstetricians and Gynecologists
District XII Florida
November 23, 2015

CHAIR
Karen E. Harris, MD, MPH
Stephanie Williams
VICE CHAIR American College of Obstetricians and Gynecologists
Guy I. Benrubi, MD Dept. of District and Section Activities
409 12th Street SW
TREASURER
Shelly Holmstrom, MD
Washington DC 20024-2188
SECRETARY Dear Ms. Williams,

Cole Greves, MD
As Chair of ACOG District XII Florida, I would like to recommend ACOG District XII for the
IMMEDIATE PAST CHAIR Council of District Chairs (CDC) Service Recognition Award. In the fall of 2013, two of District
Robert W. Yelverton, MD XIIs committees-the Maternal Mortality and Patient Safety and Quality Improvement began
working with the Florida Perinatal Quality Collaborative (FPQC) on the Obstetric Hemorrhage
LIASON TO THE JUNIOR Initiative (OHI) to address pregnancy hemorrhage related mortality, which account for 15.9% of
FELLOWS pregnancy-related mortalities in Florida. The OHI included 35 pilot hospitals.
Daniel R. Christie, MD
The Pregnancy-Associated Mortality Review (PAMR) Committee in Florida has long been
recognized as a leader data gathering. However, not enough was being done to take the data to
action to reduce maternal deaths. Starting in 2013 and continuing through 2015 ACOG District
XII led an effort to address obstetrical hemorrhage related mortality. District XII fellows worked
closely with the FPQC to develop and implementation a toolkit, provide monthly webinars and
data reports as well as any technical assistance needed; including onsite consults. In addition
ACOG District XII provided trained OHI speakers to give presentations or attend educational
rounds, which provide an extensive overview of the toolkit. Lectures were tailored for the need
of the audience, whether a community hospital or an academic center. We are proud of work the
fellows on the Maternal Mortality and Patient Safety Committees did to reduce death from OB
hemorrhage in Florida.
Included with this letter of recommendation is an overview of the initiative and copies of the
toolkit, slide set, guidelines algorithm and preliminary outcomes. It is my hope that you will
strongly consider the Obstetric Hemorrhage Initiative that the ACOG District XII Committees
on Maternal Mortality and Patient Safety and Quality Improvement have been an instrumental
part of for the CDC Service Recognition Award. Please feel free to contact me if you have any
questions. Thank you in advance for your consideration.
Sincerely,
Karen E. Harris, MD, MPH

Chair
ACOG District XII Florida
6816 Southpoint Pkwy, Suite 1000, Jacksonville, FL

Main: (904) 309-6265 Fax: (904) 998-0855
info@acogdistrict12fl.org
Final Data Report

June 2015
The Obstetric Hemorrhage Initiative (OHI) was formed in order to address the issue of highly preventable morbidity and mortality
related to postpartum hemorrhage. The goals of the OHI were to: 1) Decrease short- and long-term morbidity and mortality related
to obstetric hemorrhage; and 2) Guide and support maternity care providers and hospitals in implementing successful, evidence-
based quality improvement programs for obstetric hemorrhage.
The initiative kicked off in October 2013 with a training session for OHI pilot hospitals. In collaboration with several
organizations, the FPQC provided 31 Florida and 4 North Carolina hospitals with technical assistance from an advisory team, an
implementation guide and hemorrhage management toolkit, monthly learning session webinars and collaboration with OHI
hospitals, two in-person collaborative meetings, and monthly QI data reports and score cards.
Pilot hospitals were expected to implement key elements of the OHI over 18 months, and then spend 6 months institutionalizing
the practices. Each facility implemented the key elements in the order and timing that is right for their facility and resources. The
key elements recommended to OHI hospital teams included:
1. Develop an Obstetric Hemorrhage Protocol

2. Develop a Massive Transfusion Protocol
3. Antepartum Risk Assessment
4. Active Management of the Third Stage of Labor
5. Quantification of Blood Loss
6. Construct an OB Hemorrhage Cart
7. Ensure Availability of Medications and Equipment
8. Perform Interdisciplinary Hemorrhage Drills
9. Debrief after OB Hemorrhage Events
Hospitals submitted baseline data for July September 2013 and prospective data from December 2013 April 2015. Major
findings include:
Hospitals educated 100% of their clinical staff and 71% of their obstetricians/midwives on OB hemorrhage in 2014.
The percent of participating hospitals assessing more than 75 percent of women for Risk of OB Hemorrhage increased from
11% to 75%.
The percent of hospitals not documenting Active Management of the Third Stage of Labor decreased from 45% to 13%.
Quantification of blood loss for vaginal deliveries increased from 4% of women at baseline to 62%, and QBL for cesarean
deliveries increased from 43% to 67% of women.
No significant trends in blood product transfusion or unplanned hysterectomies was identified throughout the initiative.
The overall percent of unplanned hysterectomies remained low throughout the initiative.
In summary, there was improvement across the various measures with the exception of blood transfusions. This change was
probably related to an increased awareness of the need to treat blood loss earlier in the course of a hemorrhage and may result in a
future decrease in larger replacement volumes. Detailed results are below.
FPQC Final OHI Data Report
Detailed Results
Process Measures
Hemorrhage Education
The goal for this measure was to have 100 percent of clinical staff and care providers (obstetricians and/or midwives)
receive education and training on OB hemorrhage through cognitive/didactic education within the calendar year. In
2014, 30 out of 35 hospitals reported providing training on active management of the third stage of labor; 28 hospitals
reported training on risk assessment for OB hemorrhage, quantification of blood loss, or hospital hemorrhage policies
and procedures; and 24 offered education on the hospitals massive transfusion protocol (MTP) [Figure 1].
Figure 1: Number of participating hospitals offering education and training in 2014
35
30
30
25 28 28 28
24
20
15
10
0
Education on hospital Education on hospital Training on Training on Risk Training on Active
Massive Transfusion hemorrhage policies Quantification of Blood Assessment for OB Management of the
Protocol and procedures Loss hemorrhage Third Stage of Labor
The largest discipline of team members educated was nurses, with 33 out of 35 hospitals who succeeded in training
RNs, followed by MDs, CNMs, anesthesiologists, and blood bank staff. Hospital rapid response team, lab, and
pharmacy staff were the least likely to be included in hemorrhage education and training [Figure 2].
Initiative-wide in 2014, reporting hospitals educated 100% of labor and delivery and postpartum clinical staff and
approximately 71% of delivering obstetricians and midwives on obstetric hemorrhage [Figure 3].
2|Page
Figure 2: Number of participating hospitals educating staff members in 2014

35
30 33
25
26
20
19
15 17
14
10
5 7 6 3
0
Figure 3: Ratio of physicians, midwives, and clinical staff involved in simulation drills and education in 2014
100%
100%
90% Simulation Drills
Percent achieved through 12/2014
80% Education
71%
70%
60%
48%
50%
40%
30%
19%
20% This ratio is based on the
number of OBs, Midwives,
10% and Clinical staff who have
participated in drills and the
0% average number at the
OB & Midwives Clinical Staff hospital. The ratio does not
account for staff turnover.
3|Page
Interdisciplinary Simulation Drills
The goal for this measure was that 100 percent of staff and care providers participate in at least one simulation drill
each year. Initiative-wide, 48% of labor and delivery and postpartum clinical staff and 19% of delivering obstetricians
and midwives participated in obstetric hemorrhage simulation drills in 2014 [Figure 3].
Risk Assessment for OB Hemorrhage
At baseline, 70% of hospitals were not assessing women for risk of obstetric hemorrhage. This percentage gradually
decreased, while the percent of hospitals who were assessing 75 to 100 percent of women upon admission increased
from 11% of hospitals at baseline to 75% of hospitals [Figure 4].
Figure 4: Percent of All Reporting Hospitals that assessed birthing women for risk of OB hemorrhage upon admission
and document the score in clinical records
100%
11%
90%
31%
80% 18%34% 43%49%
70% 54%
65%66%64%
74%77%70%72%78%71%76%72%75%
60%
20%29% 75 to 100% of
50% women assessed
40% 31% 1 to 74% of
70% 31%20% women assessed
30% No women
18%14%21%
20% 46%40% 12% 18%19% assessed
19%14%17%17%
13% 13%
10% 26%20%26%
18%20%15%15%
10%12% 9% 9% 10%10%10% 8%
0%
Hospitals were asked to audit 30 charts per month: 10 cesarean delivery and 20 vaginal delivery charts. Chart audit
indicated that initiative-wide, approximately 79% of women were being assessed for risk of hemorrhage upon
admission, up from 14% of women at baseline [Figure 5].
4|Page
Figure 5: Percent of charts that documented if woman was assessed for risk of OB hemorrhage upon admission by
month
100%
90%
79% 77% 77% 78% 79% 80% 79% 79%
80% 73%
70% 70%
70% 65%
Percent achieved
60% 58%
60% 55%
50% 45%
40% 35%
30%
20% 14%
10%
0%
Month
Figure 6: Percent of charts that documented if woman was assessed for risk of OB hemorrhage upon admission by
quarter
100% Mean
90%
77% 79% Max. Value
80% 74%
th
70% 64% 75 Percentile
Percent of women
60% 53% Median
50% th
25 Percentile
40% Min. Value
30%
20% 14%
10%
0%
Baseline Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015
5|Page
Active Management of the Third Stage
The recommendation for active management of the third stage of labor (AMTSL) indicated both administration of
oxytocin and fundal massage. At baseline, the percentage of hospitals who were not documenting both elements of
active management during the third stage of labor was 45 percent. This gradually decreased to 13% of hospitals who
were not documenting. The percentage of hospitals who were documenting any women increased, with a high of 69%
of hospitals achieving and documenting 75 to 100 percent of women with AMTSL, up from 34% of hospitals. At the
end of the initiative, that number was 58% [Figure 7].
Figure 7: Percent of All Reporting Hospitals that documented birthing women with Vaginal deliveries received active
management of the third stage of labor
100%
90%
26%
34%
80% 40%40%43%40%
45%50% 75 to 100% of women
53%51%
70% 61% 63%65% 59%58% received active
68% 69% 69% management
60% 31% 1 to 74% of women
21% received active
50% management
26%26%
29%34% No Active Mangement
40% Documented
24%29%39%32%
30%
24% 25%26% 28%29%
20% 45%43% 23% 19% 21%
34%34%
29%26%24%
10% 20%15%18% 15%13%13%
10% 10%10%14%13%
0%
Chart audit reveals that the number of women who received active management initiative-wide increased since the
start of the initiative from approximately 40% to 73% [Figure 8].
6|Page
Figure 8: Percent of charts that documented women with Vaginal deliveries received active management of the third
stage of labor by month
100%
90%
80% 77%
74%
70% 72% 70%
73% 71% 73%
70% 64% 62%
60% 61%
60% 52% 55% 54%
49%
50%
40% 39%
40%
30%
20%
10%
0%
Figure 9: Percent of charts that documented women with Vaginal deliveries received active management of the third
stage of labor by quarter
100% Mean
90%
Max. Value
80% 71%
73% th
66% 75 Percentile
70%
Percent of women
58% Median
60% 52%
th
50% 25 Percentile
40%
Min. Value
40%
30%
20%
10%
0%
Baseline Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015
7|Page
Quantification of Blood Loss
Recommended quantification of blood loss methods include measurement using visual percent saturation, by weight,
and by collection in graduated containers. Throughout the initiative, the percent of hospitals who were quantifying
overall increased. Hospitals gradually increased their use of all three recommended quantification methods for vaginal
births, with both measurement using weight and measurement by collection increasing to use in 71% of hospitals
[Figure 10]. While measurement using weight and collection continued to rise, measurement using percent saturation
recently declined. This may be due to new recommendations from AWHONN that do not include visual estimation
using percent saturation as a quantification method.
Figure 10: Percent of All Reporting Hospitals at which each quantification method was used for Vaginal deliveries
100%
90%
80% 71%
70% 64% 63% 66%
Percent achieved
59%
60%
Measured using weight
50% 45%
41%
40% Measured by collection
30% 23%
Measured using % saturation
20%
10% 1%
0%
December
December
Jan-14
April
May
Jan-15
April
February
March
February
March
June
August
October
July
Baseline
September
November
From chart audit, the percent of vaginal deliveries in which blood loss was quantified increased from 4 percent to
approximately 62% for all reporting hospitals [Figure 11].
For Cesarean deliveries, there has been a gradual increase in quantification methods with the greatest increase in the
use of measurement by weight [Figure 13]. Measurement by collection is still the leading method of quantification of
Cesareans (up to 82%), while measurement using percent saturation has seen the same decrease as in vaginal
deliveries.
At baseline, hospital teams were quantifying blood loss at 43% of C-section deliveries, and reached approximately
67% of C-section deliveries by the initiatives end [Figure 14].
8|Page
Figure 11: Percent of charts in which blood loss was quantified for Vaginal deliveries by month
100%
90%
80%
Percent achieved
70%
61%62%
60% 52%55%
49%47% 46%
50% 44% 45%
38%
40% 32%32%
30%
21%22%
20% 14%
8% 9%
10% 4%
0%
Figure 12: Percent of charts in which blood loss was quantified for Vaginal deliveries by quarter
100% Mean
90% Max. Value
80% th
75 Percentile
70%
Percent of women
56% Median
60%
th
50% 43% 46% 25 Percentile
40% Min. Value

29%
30%
20% 15%
10% 4%
0%
Baseline Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015
9|Page
Figure 13: Percent of All Reporting Hospitals at which each quantification methods was used for Cesarean deliveries
100%
90%
83%
80% 72%
74% 73% 75%
70% 71%
Percent achieved
64% 65%
60% 60%
57%
54%
50% 48% Measured by collection
40% Measured using weight
30% Measured using % saturation
20%
10%
0%
August
December
Jan-14
April
February
March
May
December
Jan-15
April
February
March
June
October
July
Baseline
September
November
Figure 14: Percent of charts in which blood loss was quantified for Cesarean deliveries by month
100%
90%
80%
70% 67%
Percent achieved
61% 60% 61% 61%

58% 57%
60% 53% 55% 55% 53% 54%
47% 46%
50% 43% 45% 45% 41%
40%
30%
20%
10%
0%
10 | P a g e
Figure 15: Percent of charts in which blood loss was quantified for Cesarean deliveries by quarter
100%
Mean
90%
Max. Value
80%
th
75 Percentile
70%
Percent of women
59% 57% Median

56%
60% 52%
th
50% 43% 44% 25 Percentile
Min. Value
40%
30%
20%
10%
0%
Baseline Q1 2014 Q2 2014 Q3 2014 Q4 2014 Q1 2015
Some hospital teams had trouble instituting QBL at vaginal births, while others found QBL at cesarean deliveries to be
the most challenging. A few hospitals let us know that they were delayed in implementing and/or documenting QBL
due to issues with their electronic medical records (EMR) systems. Anecdotally, the largest barrier to QBL was
physician resistance.
Hand-Off Reports
The percent of documented hand-off reports between the labor and delivery unit and the postpartum unit for all women
with greater than or equal to 1000 cc of blood loss increased from 35% at the start of the initiative to 97% at the end of
the initiative [Figure 16]. Many hospitals added this to their electronic charts and shift change handoffs procedures.
Post-Hemorrhage Debriefs
Though not all hospitals are able to submit post-hemorrhage event debriefing forms, the percent of these hemorrhages
where a post-hemorrhage event debrief was conducted (form was submitted) steadily increased. The percent of
hospitals who submitted at least one post-event debrief form where at least one hemorrhage occurred has fluctuated,
with a high of 38% in June 2014, and was 27% at the end of the initiative [Figure 17].
Figure 17 also indicates that the percent of births with a documented hemorrhage of greater than or equal to 1000 cc
blood loss increased from 1% of births to about 3% of births initiative-wide. This may indicate an increase in the
ability to recognize a major hemorrhage event through increased quantification of blood loss.
11 | P a g e
Figure 16: Percent of documented hand off reports for all women with 1000 cc blood loss or greater
100% 97%
90% 86% 85% 84%

81% 78% 80% 78% 79%
80% 73% 73%
69%
70% 63%
Percent Achieved
62%
60% 53%
50%
40% 35%
30%
20%
10%
0%
Figure 17: Post-hemorrhage debrief form submission and percent of births with documented hemorrhages of greater
than or equal to 1000 cc blood loss
Percent of Hospitals submitting at least one Post-Hemorrhage Debrief Form when at least one hemorrhage occurred
Percent of hemorrhages where a Post-Hemorrhage Debrief Form was submitted
Percent of births with a documented hemorrhage of greater than or equal to 1000 cc blood loss
40%
38%
35% 36% 36%
33% 33%
30% 31%
29%
27%
25% 25%
23%
22%
20% 21% 20% 20%
17% 18%
16% 16% 15% 16% 16%
15% 15% 14%
14% 13%
13%
10% 11%
9% 10%
8%
6%
5% 5%
3.5% 2.9% 3.6% 3.3% 3.4% 3.0%
2.5% 2.5% 2.4% 2.4% 3.5%
0.8% 1.3% 1.1% 1.8% 1.6% 1.9%
0% 0%
12 | P a g e
Outcome Measures
Blood Product Transfusion
Figure 18 shows the total units of each type of blood product transfused during birth admissions per 100 births. Cryo
was consistently the least used blood type throughout the initiative, and packed red blood cells (PRBCs) have been the
most used. The number of units of blood products used per month fluctuates, with a general trend toward increased use
of blood products [Figure 18].
The percent of women who are transfused with any blood product during birth admission shows variation, but
remained between 1% and 2% since baseline. There was no clear change or trend in these data [Figure 19].
The percent of women who were transfused with greater than 3 units of any blood product during birth admission
remained low, with the median staying generally at 0% throughout the initiative. The maximum values fluctuated, but
were on a downward trend since November 2014 [Figure 20].
Figure 18: Total units of each type of blood product transfused during birth admissions per 100 births
9
8
7
6
Units per 100 births
5 Cryo
4 Plasma/FFP
Platelets
3
PRBCs
2
1
0
13 | P a g e
Figure 19: Percent of women who were transfused with any blood product during birth admission
9%
8%
7%
6%
Percent of women
5%
4%
3%
2%
1%
0%
Figure 20: Percent of women who were transfused with > 3 units of any blood product during birth admission
4%
3%
Percent of women
2%
1%
0%
14 | P a g e
Unplanned Hysterectomies
Throughout the initiative we also collected data on hysterectomies. Figure 21 shows the number of unplanned
hysterectomies per 10,000 giving birth each month over the course of the initiative. There was no trend.
Figure 22 shows the percent of unplanned hysterectomies out of all hysterectomies each month, which fluctuated; the
percent of hysterectomies out of all hemorrhages (greater than or equal to 1000 cc blood loss), and the percent out of
all births. The overall percent of unplanned hysterectomies remained low throughout the initiative.
Figure 21: Unplanned hysterectomies per 10,000 women for All Reporting Hospitals
30
25
20
15
10
15 | P a g e
Figure 22: Percent of unplanned hysterectomies for All Reporting Hospitals
100%
92%
90% 90%
82% 83%
80% 80%
78%
75%
70% 70%
64%
60%
57% 58% Out of all
56% hysterectomies
50% 50% 50%
Out of all
44%
hemorrhages
40% 40%
Out of all births
30% 29%
20%
12%
10% 8% 7% 7% 8% 7%
6% 5% 6%
2% 3% 4% 3% 4% 4%
2% 2%
0% 0.08%0.23%0.17%0.28%0.13%0.11%0.15%0.19%0.24%
0.14%0.15%0.12%0.06%0.21%0.19%0.17%0.13%
16 | P a g e
OHI Tool Kit
FLORIDA
OBSTETRIC HEMORRHAGE INITIATIVE (OHI)
TOOL KIT
A QUALITY IMPROVEMENT INITIATIVE FOR

OBSTETRIC HEMORRHAGE MANAGEMENT
Updated
Version 10/2015
OHI Tool Kit
Suggested Citation:
Florida Perinatal Quality Collaborative (2015) Florida Obstetric Hemorrhage Initiative Toolkit: A Quality
Improvement Initiative for Obstetric Hemorrhage Management.
Acknowledgements:
The FPQC gratefully acknowledges and thanks our partner organizations, including ACOG District XII, the Florida
Chapter of AWHONN, the Florida Council of Nurse Midwives, the Florida Hospital Association, and the Florida
Department of Health.
The creation of this toolkit would not have been possible without the volunteer members of our Maternal Health
Committee, including the members of the Obstetric Hemorrhage Advisory Team listed on page three of this toolkit,
Washington Hill, MD and Karla Olson, as well as Kris-Tena Albers and Rhonda Brown from the Florida Department
of Health.
The FPQC would also like to thank the California Maternal Quality Care Collaborative, ACOG District II, and the
Illinois Department of Public Health for sharing their materials, expertise, and time to assist the FPQC in the
development of this Quality Improvement (QI) Initiative.
This toolkit has been adapted and modeled from the California Improving Healthcare Response to Obstetric
Hemorrhage Toolkit:
The California Toolkit, IMPROVING HEALTHCARE RESPONSE TO OBSTETRICAL HEMORRHAGE, was
developed through the California Maternal Quality Care Collaborative with leadership from the California
Department of Public Health, Maternal Child and Adolescent Health (CDPH-MCAH), and is available through the
California Maternal Quality Care Collaborative website: www.cmqcc.org/ob_hemorrhage.
Funding for the development of the California toolkit was provided by:
Federal Maternal & Child Health Title V block grant funding from the California Department of Public Health;
Maternal, Child and Adolescent Health Division and Stanford University.
Lyndon A, Lagrew D, Shields L, Melsop K, Bingham B, Main E (Eds). Improving Health Care Response
to Obstetric Hemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity
Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal,
Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative,
July 2010.
Dedication:
The Florida OHI Toolkit is dedicated to the individual members of the OHI Advisory Team and the OHI partners
who have provided their leadership, resources, expert feedback and time to customize the toolkit for Florida hospitals.
These efforts made it possible to launch the Florida initiative in a very short period of time with the most recently
available information.
Funding:
This QI initiative is funded in part by the Florida Department of Health with funds from the Title V Maternal and
Child Health Block Grant from the U.S. Health Resources and Services Administration.
Copyright:
2014 and 2015 Florida Perinatal Quality Collaborative. All Rights Reserved.
The material in this toolkit may be reproduced and disseminated in any media in its original format, for informational,
educational and non-commercial purposes only. Any modification or use of the materials in any derivative work is
prohibited without prior permission of the Florida Perinatal Quality Collaborative.
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Obstetric Hemorrhage Advisory Team
OB Hemorrhage Initiative Leaders FPQC Leaders and Staff
Robert Yelverton, MD, FACOG John Curran, MD

ACOG District XII (Florida) Professor of Pediatrics & Public Health, USF
Immediate Past Chair FPQC Executive Director
Karen Harris, MD, MPH, FACOG, William Sappenfield, MD, MPH

ACOG District XII (Florida) Chair Professor & Chair, Dept. Comm & Fam. Hlth
Med. Dir. Of Patient Safety and Quality, Director, USF Chiles Center
Florida Woman Care, LLC
Anthony R. Gregg, MD, FACOG Linda A. Detman, Ph.D.

Professor, University of Florida Research Associate, USF Chiles Center
Chair, Maternal Mortality Committee, FPQC Program Manager
ACOG District XII
Judette Louis, MD, MPH, FACOG Annette Phelps, ARNP, MSN

Assistant Professor Dept. of OB/GYN, USF Chiles Center
USF Medicine & Dept. of Comm. & Fam. Hlth FPQC Nursing Consultant
Bruce Breit, MD, FACOG Emily A. Bronson, MA, MPH

Womens Care Florida at Winter Park OB-GYN USF Chiles Center
Chair of Patient Safety and Quality FPQC Quality Improvement Analyst
Care Committee, ACOG District XII
Isaac Delke, MD, FACOG

Professor, UF College of Medicine-Jacksonville
Medical Director, Obstetric Services
Shands Jacksonville Medical Center
Margie Mueller Boyer, RNC, MS

Administrative Director, Florida Hospital Tampa Womens Health Pavilion
Florida Section Chair, AWHONN
Mary Kaye Collins, CNM, JD, FACNM

Treasurer, Florida Council of Nurse Midwives,
Florida Affiliate of the American College of Nurse-Midwives
Jean Miles, MD
Chief of Obstetric Anesthesia for the Memorial Healthcare System
Patient Safety Committee for the Society of Obstetric Anesthesia and Perinatology
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OHI Tool Kit
TABLE OF CONTENTS
Introduction .................................................................................................................................................................................. 4
Patient Safety Bundles ........................................................................................................................................................ 5
How to Use This Tool Kit ................................................................................................................................................. 7
2015 Toolkit Updates ......................................................................................................................................................... 7
For the Provider ........................................................................................................................................................................... 8
Postpartum Hemorrhage ........................................................................................................................................................ 9
Definition.............................................................................................................................................................................. 9
Recognition of Risk ............................................................................................................................................................. 9
Active Management of the Third Stage of Labor (AMTSL)....................................................................................... 11
Quantification of Blood Loss (QBL) ............................................................................................................................. 12
Interventions ........................................................................................................................................................................... 15
Medications ........................................................................................................................................................................ 15
Blood Product Replacement ............................................................................................................................................ 18
Surgery and Devices .......................................................................................................................................................... 20
Special Circumstances ........................................................................................................................................................... 24
The Jehovahs Witness Patient ........................................................................................................................................ 24
Placenta Accreta and Percreta ......................................................................................................................................... 26
Patients with Coagulation Defects .................................................................................................................................. 27
Emotional Support for Women Experiencing Postpartum Hemorrhage ..................................................................... 31
For the Hospital .......................................................................................................................................................................... 33
Critical Staff and Equipment ................................................................................................................................................ 34
Carts, Kits, and Trays ........................................................................................................................................................ 34
Anti-Shock Garments ....................................................................................................................................................... 34
Considerations for Small and Rural Hospitals and Birthing Facilities ........................................................................... 35
Simulation Drills..................................................................................................................................................................... 35
Debriefing ............................................................................................................................................................................... 35
Hemorrhage Documentation ............................................................................................................................................... 36
Conclusion ................................................................................................................................................................................... 38
References.................................................................................................................................................................................... 39
Appendices .................................................................................................................................................................................. 45
Appendix A: Sample Hemorrhage Policies and Procedures ........................................................................................... 46
Appendix B: FPQC OB Hemorrhage Care Guidelines Algorithm ................................................................................ 47
Appendix C: CMQCC Acute Adverse Effects of Transfusion ....................................................................................... 48
Appendix D: CMQCC Jehovahs Witness Blood Product and Technique Informed Consent/Decline ................. 49
Appendix E: CMQCC Carts, Kits and Trays Checklists.................................................................................................. 52
Appendix F: Obstetric Hemorrhage Audit Tool............................................................................................................... 54
Appendix G: FPQC OB Hemorrhage Team De-briefing Form .................................................................................... 55
Appendix H: Frequently Encountered Clinical Concerns and Responses to QBL ..................................................... 56
Appendix I: Testimonials ...................................................................................................................................................... 57
Appendix J: Tips for Quantification of Blood Loss ......................................................................................................... 58
Appendix K: OB Hemorrhage Pocket Card ...................................................................................................................... 59
Appendix L: Measurement & Deliverables Grid .............................................................................................................. 61
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OHI Tool Kit
INTRODUCTION
This document is a working draft that reflects a review of clinical, scientific and patient safety
recommendations. The information presented here should not be used as a standard of care. Rather, it is a
collection of resources that may be adapted by local institutions in order to develop standardized protocols
for obstetric hemorrhage. We acknowledge the California Maternal Quality Care Collaborative (CMQCC)
and the comprehensive work that they have completed in this area. With permission, we have reprinted,
revised and updated portions of the California toolkit to reflect contemporary practices.
Scope of the Problem

Postpartum hemorrhage (PPH) is a leading cause of pregnancy-related mortality in Florida and the remainder
of the United States.[1] While deaths due to PPH have declined in developed countries because hospitals
have easier access to blood products, the incidence of PPH has doubled in the recent decade. [2] Early
identifications and intervention are key components in the management and the ability to prevent
postpartum hemorrhage as well as to decrease related severe morbidity.
The overall goals of the Obstetric Hemorrhage Initiative Tool Kit are:
1. To decrease short- and long-term morbidity and mortality related to obstetric hemorrhage in women
who give birth in Florida
2. To guide and support maternity care providers and hospitals in implementing a multidisciplinary team
for obstetric hemorrhage prevention and management.
This toolkit will provide obstetric care providers, hospital personnel and the collaborating services with the
resources to locally develop their own obstetric hemorrhage policies and protocols.
Every US birthing facility should implement a policy to address Obstetric Hemorrhage events that is specific
to the resources and needs of the individual institution. The policy will need to address the multidisciplinary
care required for these patients because the root causes of severe maternal morbidity and mortality are often
multifactorial involving standards of care, communication, collaboration, and coordination of care.
Administration, nursing, obstetrics providers, blood bank staff, and anesthesiology are all critical partners in
the multidisciplinary team approach necessary to quality improvement. Development and implementation
of a standardized emergency response package (protocols) involving these critical partners is a key
component of the Obstetric Hemorrhage policy. The policy should also include protocols and resources to
support patients, families and staff. Ideally, there should be a reporting mechanism to identify systems
improvement opportunities that may prevent the next case of serious morbidity/mortality. For this reason,
some of the expected implementation components of the OHI initiative are related to policy and there will
be measures to determine currency in this area.
Another important element is having multi-disciplinary teams in place who know their skill sets and roles in
responding to and preventing obstetric hemorrhage. These teams need to train together and practice
together in order to maintain and gain new competencies. Because each hospital and care team has differing
resource sets, it is important to develop individualized protocols for each facility. A quality improvement
team composed of a core set of team members from the involved disciplines must review current policies
and data, determine the priorities for improvement, and develop a work plan to address their needs.
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OHI Tool Kit
This tool kit is intended to improve:

1. Readiness to address hemorrhage by implementing standardized protocols (general and massive).
2. Recognition of OB hemorrhage by performing ongoing objective quantification of actual blood loss
during and after all births.
3. Response to hemorrhage by performing regular on-site multi-professional hemorrhage drills.
4. Reporting of OB hemorrhage by standardizing definitions and consistency in coding and reporting.
PATIENT SAFETY BUNDLES

In recent years several national partners including ACOG, AWHONN, SMFM, CDC, HRSA and others
came together as the National Partnership for Maternal Safety and have worked with the Council on
Patient Safety in Womens Health to create several bundles of recommendations to improve the
outcomes and safety of pregnant women.
The first bundle to be released focused on Obstetric Hemorrhage because hemorrhage is the leading cause
of maternal mortality. It will be followed by other bundles for other high impact, high volume health
and safety issues such as hypertension.
Bundles are a collection of succinct evidence-based components that when implemented together should
have a positive impact on outcomes and safety for pregnant women. The bundles have four domains,
Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. The bundles
provide the core elements that every hospital can implement for every woman, every time. Birth facilities
are encouraged to expand on the core component by developing policies, protocols and standardized
practices that best meet local needs and are evidence based.
The Florida Perinatal Quality Collaborative includes a representative, Dr. Karen Harris, who participated in
the development of the bundles as an ACOG representative and thus helped to guide the Collaborative in
development of the Florida Obstetric Hemorrhage Toolkit. This toolkit follows the recommendations of
the bundle and offers an expanded sample protocol and guidance for the four domains. It is expected that
the local providers and birth facilities will adapt the toolkit within the evidence-based samples to have a
localized set of practice expectations that will be followed by local providers.
The Obstetric Hemorrhage Safety Bundle is shown below.
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OHI Tool Kit
HOW TO USE THIS TOOL KIT
This tool kit is intended to provide guidance and core concepts for the quality improvement team that will
include practice components and administrative components. Hospitals have an obligation to patients,
providers and others to assure patient safety and competent care, providers have an obligation to patients
and the hospital to practice in a competent, high quality manner. These obligations must be closely tied
together and supportive of the multi-disciplinary team including the immediate obstetric care team and the
extended team to include blood bank, anesthesia, rapid response teams and others. It is everyones
responsibility to maintain vigilance in having several components in place related to the recognition of
potential for hemorrhage, readiness to respond, and report on the outcomes for future improvements. This
guide offers the concepts and tools which may be adopted or adapted for local use.
This document is divided into three sections with recommendations for the providers, the hospital and
appendices with supplemental information and resources. The toolkit is arranged in a way that makes it easy
to access needed sections; however, it is recommended that all staff read the entire toolkit in order to
understand both hospital and provider aspects of obstetric hemorrhage management.
The provider section addresses standard definitions, methods for risk assessment, and methods for
management. This section is intended for use by the team of care providers (physicians, nurses, advanced
practice nurses, lab staff, pharmacy staff, etc.) and covers topics including intervention techniques and special
circumstances.
The hospital section includes requirements for preparedness, documentation and training. This section
emphasizes the importance of a team of diverse staff, well-stocked carts and available equipment, and ways
to document that policy and protocol are followed. This provides an opportunity for facilities to implement
change and improve the care provided to women.
Disclaimer
This toolkit is considered a resource. Readers are advised to adapt the guidelines and resources based on
their local facilitys level of care and patient populations served and are also advised to not rely solely on the
guidelines presented here. This toolkit is a working draft. As more recent evidence-based strategies become
available, hospitals and providers should update their guidelines and protocols accordingly; the FPQC will
also send out updates as well as revise these materials.
2015 TOOLKIT UPDATES
Obstetric Hemorrhage National Patient Safety Bundle pages 5-6

Changed Risk Assessment for Obesity to BMI > 40 kgm2 page 11
Recommendations on tranexamic acid and factor XII page 17
Recommendations on emotional support for women with postpartum hemorrhage page 31
Recommendations on anti-shock garments page 34
Considerations for small and rural hospitals page 35
CMQCC OB Hemorrhage Pocket Guide page 39
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FOR THE PROVIDER

Physicians, Nurses, Midwives, Advanced Practice Nurses, Anesthesia, Blood Bank staff, Rapid
Response Team members
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POSTPARTUM HEMORRHAGE
DEFINITION
There is no single agreed upon definition of postpartum hemorrhage. Using definitions that rely on
thresholds such as 500 mL after vaginal delivery and 1000 mL after cesarean section carry with them
inaccuracies in the estimation of absolute blood loss. Volume replacement with crystalloid together with the
movement of extravascular fluid to the intravascular space during the postpartum period results in concerns
over setting an arbitrary threshold drop in hematocrit (e.g. 10%).
Waiting for patient symptoms (e.g. dizziness) or end organ dysfunction (e.g. oliguria) may indicate a blood
loss of 10% of the total volume. Therefore, this definition is far too stringent.[19] Clinicians often
underestimate blood loss when visual cues and on the spot assessments are made. Because of these
concerns, it is recommended that clinicians use clinical "triggers, or multi-component thresholds, in an
effort to identify maternal hemorrhage status and guide the need for clinical interventions.
Proposed triggers include an absolute threshold for blood loss (e.g. 500 ml after vaginal delivery), vital
signs (e.g. >15% increase in maternal heart rate or absolute value >110), blood pressure ( 85/45), as well
as oxygen saturation (e.g. <95%).
Table 1: Triggers
PROPOSED TRIGGERS FOR BLOOD LOSS,
VITAL SIGNS AND OXYGEN SATURATION
Categorical Vaginal Cesarean Delivery
Trigger Delivery
500 1,000
Vital Sign
Trigger
Pulse >15% increase >15% increase
OR >110 bpm OR >110 bpm
BP 85/45 85/45
Oxygen <95% <95%
Saturation
RECOGNITION OF RISK
Risk assessment should be performed prenatally, on admission to labor and delivery, immediately prior to
birth, and postpartum.
When hemorrhage in the postpartum period is divided into primary ( 24 hours after delivery) and secondary
(>24 hours-12 weeks postpartum) causes the identification of risk factors may be easier to recognize. Primary
postpartum hemorrhage causes include uterine atony, retained placenta (this includes placenta
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OHI Tool Kit
accrete/percreta/increta), coagulation abnormalities, lacerations and extensions of the uterine incision,

cervical, vaginal, perineal lacerations, and uterine inversion. Secondary causes include sub involution of the
placental site, retained products of conception, infection, and inherited coagulation defects (e.g. von
Willebrand's disease).
Risk assessment is important in the establishment of any obstetric hemorrhage protocol. Because pregnancy
and the postpartum period encompass nearly a one year time span it is important that risk assessment be
performed on multiple occasions. It is suggested that this be performed at the initial prenatal visit in order
to ascertain a history of obstetric hemorrhage in a prior pregnancy (approximately 10% recurrence risk) as
well as a predisposition for bleeding such as occurs in cases of inherited coagulation defects. Next, risk
assessment performed near the end of the second trimester or early in the third trimester assists in gaining
awareness of obstetrical hemorrhage that might be encountered in cases of placenta previa (prior cesarean
section increases risk of hemorrhage and nearly 1/3 of pregnancies in the United States are delivered by
cesarean section). Finally, risk assessment applied at the time of hospitalization for delivery allows care
providers that might be mobilized in the case of obstetric hemorrhage to be alerted, medications that might
be necessary to be on hand, and blood products to be made readily available.
When risk assessment tools allow for stratification of risk, measures taken in anticipation of hemorrhage
might vary. For example in low risk cases blood might be available in the blood bank and in high risk cases
this might be on hand in the delivery room or operating room. In high risk cases, additional surgical
personnel should be on alert, whereas in medium risk cases medications should be readily available.
During the intrapartum period, induction or augmentation of labor, protracted labor or an arrest disorder
(arrest of dilation or descent), or chorioamnionitis indicate a medium risk of obstetric hemorrhage.
Assessment of low, medium and high risk factors during the antepartum and intrapartum periods should
include the items listed in the sample risk assessment table on the next page (Table 2).
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Table 2: A Sample Risk Assessment Tool

Obstetric Hemorrhage Risk Factor Evaluation
Low Medium High
No previous uterine Prior cesarean birth(s) Placenta previa

incision Prior uterine surgery Low-lying placenta
Singleton pregnancy Multiple gestation Suspected placenta
4 previous vaginal >4 previous vaginal births accreta
births Hypertension-associated conditions Hematocrit <30
No known bleeding History of previous PPH Platelets <100,000
Antepartum disorder Large uterine fibroids Active bleeding at
No history of PPH Estimated fetal weight > 4 kg admission
Morbid obesity (BMI > 40 kgm2) Known coagulopathy
Polyhydramnios Abruptio placenta
Induction or augmentation of labor

Protracted labor or arrest disorder
Intrapartum
Chorioamnionitis
Adapted from the California Toolkit to Transform Maternity Care [4],[14],[15]
ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOR (AMTSL)
The data underpinning the concept of AMTSL are continuously evolving. The Cochrane database review
that formed the basis of the CMQCC recommendations was replaced in 2011.[3] The World Health
Organization released new guidelines in 2012 for prevention and management of postpartum hemorrhage
based on a thorough analysis of the developing literature on AMTSL which significantly changed the earlier
recommendations.[6] The studies reviewed used differing combinations of AMTSL components which also
varied in dosing, timing and technique. The current research most strongly supported the use of uterotonics
in the third stage for reduction in severe blood loss, blood transfusion and the use of additional
uterotonics.[6] The recommendation for immediate cord clamping has been discontinued and the
recommendations for controlled cord traction and sustained uterine massage are weak as the techniques
require a skilled provider and the benefits are limited.[6][4]
The studies used in these recommendations compared various incarnations of AMTSL with expectant
management. Physiologic management of third stage of labor, which requires a different skill set, may be a
viable alternative for low risk women who have received no interventions that increase PPH risk and who
have been properly counseled on all the risks, benefits and the alternative of AMTSL.[4]
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Further research is still needed to assess the ideal time, dose and route of uterotonic administration in the
third stage of labor. We recommend a range of dosage from 10 to 60 units of oxytocin in 1 liter of IV fluid,
or the prepackaged dosage of the facility's choice, titrated to the fundal tone and administered at the delivery
of the baby. If there is no IV in place, 10 units of oxytocin administered IM is the recommended dosage [62-
66].
We recommend that women receive oxytocin and fundal massage. Gentle, controlled cord traction by a
skilled care provider is an optional component of active management of the third stage. Research is
continuing on the value of some of the other previously recommended components of AMTSL.
QUANTIFICATION OF BLOOD LOSS (QBL)
There is no controversy that after childbirth blood loss and clinical parameters associated with intravascular
volume depletion should be closely monitored. However, there is controversy as to whether or not efforts
should be made to quantify blood loss compared to utilization of clinical estimates.[6][4] QBL has been
reported to improve communication among physicians and nurses resulting in improved treatment
decisions.[61]
Inaccuracy of Visual Estimation

While it is common practice in obstetrics to estimate blood loss using visual cues, it is inaccurate. Research
has shown that errors include underestimation and overestimation [75]-[76]. Estimation has been shown
to be underestimated by as much as 50% [71].Other research has shown that training can initially improve
the accuracy of visual estimation but within 9 months of training completion the skills had deteriorated
[72]-[73]. Several factors were explored including specialty area and years of experience and were found to
be unrelated to the accuracy of estimation [73][75][77]. More recent data has shown that quantification of
blood loss using measures is significantly more accurate than estimation [77].
QBL Methods
While quantification remains inexact, it is more accurate than a guesstimate. See Appendix J: Tips for
Quantification of Blood Loss.
1. Weighing of blood soaked items

Quantification by weighing pads and sponges after use and subtracting dry weight of the materials;
using charts with the dry weights and weight of blood to calculate the blood loss [1 gm = 1 ml] is
strongly recommended.[78]
2. Utilization of graduated collection containers, including calibrated under-buttocks drapes.

Use of this method requires accounting for other fluids such as urine and amniotic fluid in doing
the calculation.[78]
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Transitioning from EBL to QBL

Because there has been long standing practice of estimating loss primarily from experience that does not
include formal training, there is sometimes resistance to the practice (see Appendix I: Testimonials). This
practice of estimating can present patient safety concerns. Training on the methods of quantification and
communicating the quantities is vital to success (See Appendix H: Frequently Encountered Clinical
Concerns and Responses to QBL). Just as clinicians rely on strong data in other aspects of clinical care, it
is critical that blood loss quantification play an integral role in obstetricsit is a matter of patient safety.
Clear communication is important in order to translate the message into quick action; therefore it must be
interpreted clearly. If the message is not clear the team response may be ineffective or incorrect. The use
of terms such as scant, small, minimal, moderate, heavy, or excessive bleeding are subjective and not
defined, therefore they vary from clinician to clinician. Use of specific terms and measures provides a
consistent way to share information. A clear communication provides a more accurate sense of how the
patient is fairing and provides greater opportunity for an early team response before the cascade of
hemorrhage and its sequelae can begin.[61]
Examples of effective communication related to blood loss:

Subjective Statement Objective Statement
Shes bleeding a lot She has a 1200 ml QBL
She saturated 2 pads in 1 hour She has a Stage 2 PPH
Tips for Documentation of QBL [78]

QBL is part of ongoing postpartum recovery documentation
Maintain real time, vigilant surveillance of blood loss
QBL is entered at each peripad or chux change but items may be grouped together
Ensure that blood loss is totaled and communicated to other team members at regular intervals
Document QBL at birth then ongoing QBL until the patient is stable (approximately 2 to 4
hours)
Adjust electronic medical records to perform the math, if possible.
Have formulas and/or calculators inserted into the electronic medical record (EMR) that
automatically deduct dry weights from wet weights of standard supplies such as chux and peri-
pads
Blood Loss Staging

Birthing facilities should develop and maintain protocols addressing levels of clinical involvement in care.
Obstetric hemorrhage protocols should guide all staff and clinicians involved in a hemorrhage event through
stages of management.
Several stages of obstetric hemorrhage have been defined (see Examples of OB Hemorrhage Care Guidelines
included in Appendix C: FPQC Hemorrhage Care Guidelines or CMQCC Sample Care Guidelines for
details). Generally, estimated blood loss, vital sign changes, interventions being utilized, and clinical picture
establish the transition of patients from stage 0 obstetric hemorrhage (least serious) to stage 3 (the most
serious). Please see the blood loss staging table below (Table 3).
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Table 3: Blood Loss Staging

CLINICAL
STAGE BLOOD LOSS VITAL SIGNS INTERVENTION PICTURE
Stage 0 <500 mL (VB) Stable Oxytocin utilized Normal LOC
<1000 mL (C/S)
Stage 1 >500 mL (VB) >15% change HR Additional measures, as Increased
>1000 mL (C/S) or outlined in Care bleeding
HR 110 bps or Guidelines (e.g.
BP 85/45 mm administer additional
HG uterotonic agents)
O2 sat <95%
Stage 2 500 1500 mL (VB) Continued vital Blood products Continued
1000 1500 mL (C/S) sign instability considered or initiated bleeding
Stage 3 >1500 mL Vital signs >2 units PRBC's Suspicion for
unstable transfused DIC
VB = vaginal birth, C/S = cesarean section, PRBC's = packed red blood cells
Cumulative Blood Loss

Cumulative blood loss is to be recorded in the patients chart during labor and delivery, and a handoff
report provided to postpartum staff. Cumulative blood loss should be recorded until the patient is
physiologically stable (approximately 2 24 hours).
Recommendation
Because it is clear from randomized controlled trials that visual estimates of blood loss routinely
underestimate the degree of hemorrhage and that training courses used for purposes of quantifying blood
loss after vaginal and Cesarean delivery result in more accurate accounts of blood loss, the FPQC
recommends hospitals and providers undergo training and routinely quantify blood loss during the
immediate postpartum period for purposes of diagnosing primary postpartum hemorrhage.
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INTERVENTIONS
Instituting the most appropriate interventions for postpartum hemorrhage will require an initial assessment
of possible causes. The obstetric etiologies of postpartum hemorrhage may focus on four areas: Tone,
Trauma, Tissue, and Thrombin. Following vaginal delivery, hemorrhage may be due to one of the following:
1) uterine atony 2) retained placenta/products of conception 3) lacerations. Etiologies of hemorrhage
identified at the time of cesarean section include: 1) uterine atony, 2) adherent placenta, 3) placenta
accreta/increta/percreta, 4) extension of the hysterotomy, and 5) uterine rupture. Care providers should
carefully assess for the most likely cause of the hemorrhage and initial management should be aimed at
addressing the primary etiology. For example, address uterine atony initially with medications and consider
manual extraction of the placenta or curettage using a banjo/bovine curette in cases of retained
placenta/products of conception. Surgical approaches are most appropriate in the primary management of
lacerations, and extensions of the hysterotomy.
MEDICATIONS
Utilization of oxytocin to facilitate the third stage of labor has been recommended worldwide in an effort to
reduce the risk of postpartum hemorrhage. When postpartum hemorrhage due to uterine atony is
encountered during the third stage of labor, medical interventions are appropriate. See table 4 below for
suggested uterotonic medications for postpartum hemorrhage. Although misoprostol (Cytotec) is included
in this table there is emerging controversy surrounding its utility in the face of risks to the patient especially
when high doses are utilized. Utilization of these agents may also be of benefit when postpartum hemorrhage
occurs in cases other than uterine atony. If there are no results with one agent, move to the next.
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Table 4: Uterotonic Medications
UTEROTONIC AGENTS for POSTPARTUM HEMORRHAGE

Drug Dose Route Frequency Side Effects Contraindications Storage
10-40
Usually none
units per
Nausea, vomiting,
1000 ml,
Pitocin hyponatremia (water
rate IV
(Oxytocin) Continuous intoxication) with
titrated infusion
10 units/ml prolonged IV admin.
to Hypersensitivity to
BP and HR with Room temp
uterine drug
high dose, esp. IV push
tone
Hypertension, PIH,
Heart disease.
-Q 2-4 hours
Hypersensitivity to
-If no Nausea, vomiting,
drug - CAUTION if
Methergine response after severe hypertension,
multiple does of
(Methylergoni IM (not first dose, it is esp. with rapid
0.2mg ephedrine have been
vine) given IV) unlikely that administration or in
used, may exaggerate Refrigerate
0.2mg/ml additional patients with HTN or
hypertensive Protect from
does will be preeclampsia
response w/possible light
of benefit
cerebral hemorrhage
-Q 15-90 min.
Not to exceed
Caution in women
8
Nausea, vomiting, with hepatic disease,
doses/24hrs.
Hemabate Diarrhea, Fever asthma,
IM or If no
(15-methyl (transient). Headache, hypertension, active
intra- response after
PG F2a) Chills, Shivering, cardiac or pulmonary
myometri several doses,
250mcg/ml 250mcg Hypertension, disease
al (not it is unlikely Refrigerate
Bronchospasm Hypersensitivity to
given IV) that additional
drug
doses will be
of benefit
Cytotec * Nausea, vomiting,

Per Rare known allergy
(Misoprostol) 800- diarrhea, shivering,
rectum One time to prostaglandin
100 or 200 1000mcg fever (transient),
(PR) Hypersensitivity to Room temp
mcg tablets Headache
drug
Adapted from the California Toolkit to Transform Maternity Care.[4] Updated 2015.
*Note that studies and related commentary surrounding the use of Cytotec in the management of
obstetric hemorrhage point to little or no advantage over the agents noted above the heavy black line. We
suggest the agents above the line be used primarily, and Cytotec be used in low resource settings.[16]-
[18][19]
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Coagulopathy in pregnancy is marked by increases in fibrinogen, von Willebrand factor, FVII, FVIII, and
FIX. Beginning approximately 28 weeks gestation through term, pregnancy fibrinogen is nearly double
that of a non-pregnant woman. This coupled with blood loss and subsequent transfusion can complicate
the management of obstetric hemorrhage. Most research studies have focused on trauma related
hemorrhage, much fewer studies have been done with obstetric patients. For this reason caution must be
used in applying study information to the obstetric setting. In addition to having a mass transfusion
protocol, consideration of adjunctive medications in extreme hemorrhage is recommended. Two such
adjuncts, tranexamic acid, and Factor VIIa are discussed below.
Tranexamic acid is a synthetic lysine derived medication that helps to block the breakdown of fibrin clots
by plasmin. It can have a significant effect on blood loss reduction in operative settings without significant
findings of adverse effects. Data on tranexamic acid use in post-partum hemorrhage has shown promise
but there are some remaining questions about risks and there is need for continued study before
recommending tranexamic acid for extensive use. The dosages for use vary and the standardization of
optimal dosage is not yet determined.[79] Providers are encouraged to follow the evolving literature in
order to make appropriate clinical decisions.
Factor VIIa is one of the protein factors that cause blood to clot and has been suggested as an adjunctive
medication in severe life threatening post-partum hemorrhage but there is little data to support the use.[80]
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BLOOD PRODUCT REPLACEMENT
The comments in this section regarding blood product replacement draw from the California Toolkit to
Transform Maternity Care: Improving Health Care Response to Obstetric Hemorrhage.[4]
Massive Transfusion Protocol

We recommend that every obstetrical unit have a massive transfusion protocol that is coordinated with the
blood bank and anesthesia. This protocol will often be implemented at around 4 units of blood products
transfused.
Packed Red Blood Cells

Attempts should be made to maintain the patient's hematocrit between 21 and 24%. One should anticipate
a rise in hematocrit after a single unit by about 3% in an average sized adult.[20] The number of units of
packed red blood cells to transfuse should be determined by the stage of obstetric hemorrhage and the
patient's response to therapy. When blood transfusion is considered and appropriately crossmatched blood
is unavailable from the blood bank, consideration should be given to the use of uncrossed matched O
negative blood while the blood bank continues to make efforts to complete a patient specific type and
crossmatch.
Fresh Frozen Plasma

Fresh frozen plasma consists of the acellular portion of blood. The volume of a unit of fresh frozen plasma
is approximately 250 mL. Fresh frozen plasma must be ABO compatible. Once thawed it should be
transfused immediately or maintained at 6C for up to 24 hours.[20] In the absence of a patient specific
crossmatch one can request AB negative fresh frozen plasma. This plasma is devoid of antibody against
red blood cells expressing A or B antigens. Current recommendations are to keep a high ratio of packed
red blood cells to fresh frozen plasma (e.g. 6:4 or 4:4). Fresh frozen plasma is generally initiated during
stage III obstetric hemorrhage.
Platelets
Prophylactic preoperative transfusion is rarely required when the platelet count is >100,000/uL. Major
invasive procedures (excludes vaginal delivery) generally require platelet counts of at least 40,000
50,000/uL. The threshold used for regional anesthesia is typically around 80,000/uL.[20] In the face of
massive obstetric hemorrhage, attempts should be made to keep the platelet count between 50 and
100,000/uL. A plateletphoresis unit is derived from the equivalent of six units of whole blood wherein the
platelets are pooled. A single donor unit given to an average sized patient can be expected to raise the
platelet count by 40,000 50,000/uL. Once in stage III obstetric hemorrhage, one unit of platelets should
be provided for every four or six units of packed red blood cells.
Cryoprecipitate and Fibrinogen

Cryoprecipitate is an acellular blood compound that contains at least 80 IU of factor VIII: C and 150 mg
of fibrinogen. Additionally, cryoprecipitate contains factor VIII: vW F, factor XIII (participates in fibrin
cross-linking), and fibronectin. These blood complements are in relatively low volumes of plasma (5 20
mL) when a unit of cryoprecipitate is ordered. Cryoprecipitate is typically pooled and derived from 6 to 10
donors. The volume of cryoprecipitate is indicated on the label.[20] A 10 unit pooled bag of cryoprecipitate
is expected to increase the fibrinogen level in an average sized patient by 75 mg/dL. Another useful
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approximation is to treat hypo-fibrinogenemia with one unit of cryoprecipitate for each 7 to 10 kg of body
weight.[20]
Table 5: Blood Products

BLOOD PRODUCTS
Product Considerations Advantages
Packed Red Approx. 35-40 min. is needed for Best first-line product for blood loss
Blood Cells crossmatch assuming no sample is in 1 unit = 250 mL volume, typically
(PRBC) the lab and assuming no antibodies increases Hct by 3%
present
If antibody positive, may take 1-24 hrs
for crossmatch
Tranfuse O Negative blood if you cannot
wait for crossmatching
Fresh Frozen Approx. 35-45 min to thaw for release Highly desired if >2 units PRBCs given, or
Plasma (FFP) for prolonged PT, aPTT>1.5x control
1 unit = 250 mL volume and typically
increases Fibrogen by 10mg/dL
Platelets (PLTS) Local variation in time to release (may Priority for women with platelets <50,000
need to come from regional blood bank) Single-donor Apheresis unit (=6 units of
platelet concentrates) provides 40-50k
transient increase in platelets
Cryoprecipitate Approx. 35-45 min to thaw for release Priority for women with Fibinogen levels
(CRYO) <80
10 unit pack typically raises Fibinogen 80-
100mg/dL
Caution: 10 units come from 10 different
donors, so infection risk is proportionate
Additional information regarding the use of blood products can be found in the Acute Adverse Effects
table in the Appendix C of this document.
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SURGERY AND DEVICES
The identified etiologies of the hemorrhage and the response to noninvasive interventions are the guide to
appropriate surgical intervention.
Curettage
Utilization of a banjo/bovine curettage should be considered first after a vaginal birth, especially when
obstetric hemorrhage is a result of retained products of conception. The patient should be transferred to the
operating room for the curettage and volume resuscitation. Risk factors for retained products of conception
include abnormal placenta implantation, multiple gestation, eccentric/velementous insertion of the umbilical
cord.
Strategically Placed Sutures

BLynch sutures are placed in response to uterine atony that is refractory to medical therapy. These sutures
are most commonly placed at the time of cesarean section or after vaginal delivery when medical management
of uterine atony fails. (See figure below)
B-Lynch suture. CMQCC
O'Leary stitches can be placed below an inferior lateral extension of a hysterotomy. These extensions are
identified most commonly after labors complicated by arrest disorders. Using a non-cutting needle, branches
of the uterine artery in the broad ligament are ligated by passing the needle through a clear space in the broad
ligament then through the interior. Importantly, this suture must be placed inferior to the most distal portion
of the extension. Every effort should be made to ensure the ureter is not ligated upon placement of this
suture.
Uterine artery ligation has been described but in most circumstances requires an experienced surgeon in
order to avoid worsening hemorrhage due to venous disruption in the retroperitoneal space and or improper
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ligation of the posterior branch of the uterine artery. In many centers uterine artery ligation is performed
with the assistance of a vascular surgeon or GYN oncologist.
Balloons and Embolization

Uterine artery balloon tip catheters have been employed preoperatively in cases at high risk for obstetric
hemorrhage due to placenta accreta/increta/percreta (planned hysterectomy). Their utility has been
challenged. Consensus suggests that these catheters should be placed with the guidance of experienced
interventional radiologist. Furthermore, these catheters should not be inflated prophylactically but rather in
the event of significant obstetric hemorrhage during planned hysterectomy.
The intrauterine balloon (see image below) has been used in the management of obstetric hemorrhage
following delivery of a low-lying placenta, in cases of a poorly contracting lower uterine segment, uterine
atony, the management of placenta accreta/increta/percreta, surgical implantation, and disseminated
intravascular coagulation, and as a temporary measure for patients being considered for uterine artery
embolization or hysterectomy.
Bakri Balloon. CMQCC
Uterine Artery Embolization

Arterial blood supply to the uterus is derived from four primary sources which include the right and left
uterine arteries (branches of the hypogastric arteries) as well as right and left utero-ovarian arteries. When
hysterectomy is performed successfully, adequate ligation of all four sources is required. This can be hindered
by the many anastamoses, which occur throughout the adnexae and along the lateral/outer portion of the
uterus. Aberrant vasculature is identified in cases of placenta previa, and especially cases of placenta accreta.
Thus, in cases of serious hemorrhage, isolation of the utero-ovarian arteries may be routine, but as the
operator descends into the pelvis there is routinely a requirement for more than two ligatures to achieve
adequate hemostasis.
Reduction of blood flow through the uterine arteries can be achieved by mechanical methods other than
placement of suture ligatures. Procedures provided by and interventional radiology (IR) team can be helpful
in accomplishing this goal. Placement of hypogastric balloon tip catheters when at-risk patients are identified
preoperatively can be helpful. An important aspect is to inflate the balloon tip catheters only when needed
because prophylactic inflation may result in unrecognized sources of bleeding and in inability to visualize
specific vessels needing attention once the balloon tip catheters are deflated.
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During an ongoing hemorrhage, obstetric providers will be faced with considering hysterectomy to
definitively manage hemorrhage. The option of calling an IR team may provide an opportunity to selectively
embolize the uterine arteries, additional branches of the hypogastric artery, and ovarian arteries using gel
foam, coils, or "glue" alone or in combination, thus allowing uterine preservation. It is also noted that in
some cases UAE following hysterectomy is an appropriate adjunct to mitigate further blood loss. The
material chosen for uterine artery embolization (UAE) will depend on the patients condition, anatomy and
acceptable affect. There are several major questions to consider when balancing whether or not to proceed
with hysterectomy or UAE. These include:
1) Is an IR team available within the hospital system?

2) Do obstetric providers have a detailed knowledge of the IR team and Drill together?
3) Can blood product and volume resuscitation proceed while waiting for the IR team to arrive?
4) Does the risk and benefit support UAE over hysterectomy?
There are no agreed upon professional guidelines on the use of UAE for the treatment of obstetrical
hemorrhage. Several reviews on this topic are available.[67]][[68] Overall, the literature supports UAE as a
safe and effective measure to manage both primary and secondary postpartum hemorrhage.[69][70] Critical
for any obstetric unit proposing to offer UAE as an adjunct or primary approach to address obstetric
hemorrhage is a detailed knowledge of the IR team and whether the skill needed in cases of obstetric
hemorrhage can be provided consistently. When this is not the case, hysterectomy should NOT be delayed
while considering UAE. Furthermore, drills between the obstetric care providers and the IR team that
emphasize communication and patient transfer are crucial to the success of UAE in managing obstetric
hemorrhage. It is easy to see from the figure that for UAE to supersede hysterectomy many criteria must be
met. However, once an effective practice culture is established, transarterial pelvic interventions provide a
useful service in both mitigating the need for hysterectomy and controlling pelvic hemorrhage.
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Hysterectomy
Although listed in this sequence of approaches, peripartum hysterectomy should not be delayed in the
management of obstetric hemorrhage in cases where medical management fails, bleeding has continued and
more conservative nonmedical approaches are either inappropriate to consider or have failed. For those
inexperienced with peripartum hysterectomy for obstetric hemorrhage, it is appropriate to mobilize
additional personnel that can facilitate this procedure with minimal operative morbidity. Delay in performing
a peripartum hysterectomy in response to obstetric hemorrhage can lead to maternal morbidity or mortality.
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SPECIAL CIRCUMSTANCES
THE JEHOVAHS WITNESS PATIENT
The article below is reprinted with permission from the California Maternal Quality Care Collaborative
Toolkit to Transform Maternity Care: Improving Health Care Response to Obstetric Hemorrhage.[4]
Obstetric Care for Women Who Decline Transfusions (Jehovahs Witnesses and Others)
Elliott Main, MD, Department of Obstetrics and Gynecology, California Pacific Medical Center,
Sutter Health
Background and Literature Review

Given the known rate of obstetric hemorrhage, it is very unsettling to many obstetricians and
anesthesiologists to have a patient decline a potentially life-saving treatment. Fortunately, discussions
regarding limits to intervention generally occur in advance of emergencies in pregnant women whose belief
systems preclude blood transfusion.
The goals of the interaction with the woman who is declining transfusion are the following: 1) to find
common ground to manage the birth as safely as possible; 2) to build trust or if not possible, to transfer to
a program amenable with the plans; and 3) to develop a well thought out delivery plan to minimize blood
loss and maximize decisive decisions. A large study in New York of 391 live births among Jehovahs Witness
found 2 maternal deaths from hemorrhage (512 maternal deaths per 100,000 births).[21]
With regard to goal #3, there is a broad movement in the United States to develop skills and promote the
concepts of Bloodless Surgery. While this may sound a bit utopian, there are case series of open-heart
surgeries and liver transplants without transfusions. The principles of this approach are listed below:[22]
General Principles of Bloodless Medicine Management

Employ a multidisciplinary treatment approach to blood conservation
Formulate a plan of care for avoiding/controlling blood loss
Consult promptly with senior specialist experienced in blood conservation
Promptly investigate and treat anemia
Decisive intervention, including surgery
Be prepared to modify routine practice when appropriate
Restrict blood drawing for laboratory tests
Decrease or avoid the use of anticoagulants and antiplatelet agents
Stimulate erythropoiesis
Transfer a stabilized patient, if necessary, to a major center before the patients condition deteriorates
Not all blood products are off the table. There is a wide range of acceptable blood interventions within
the Jehovahs Witness community50% will actually take some form of blood transfusions. Therefore it is
imperative to begin discussions prenatally to educate and review all possible options to be available at the
time of delivery. [23][24]
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RECOMMENDATIONS
Prenatal Care
1. Comprehensive discussion with a checklist specifying acceptable interventions[25]
2. Aggressively prevent anemia (goal: maintain HCT: 36-40%)
IronPO or IV (sucrose) (+Folate and B12)
rh-Erythropoeitin 600 units/kg SQ 1-3x per week (each dose contains 2.5ml of albumin
so is not always acceptable)
3. Line-up Consultants (consider MFM, Hematology, Anesthesiology)
Labor and Delivery
1. Early anesthesia consultation
2. Reassessment of hemorrhage risk and discussion of options (e.g. Surgery, Interventional
Radiology)
3. Review specific techniques (e.g. Options Checklist and Fibrin/Thrombin glues, rFactor VIIa
but remember that rFVIIa needs factors to work)[26]
4. Review referencesHave a Plan![27]
5. Be decisive
Postpartum
1. Maintain volume with crystaloids and blood substitutes
2. Aggressively treat anemia
IronIV (sucrose)
Rh-Erythropoeitin 600 units/kg SQ weekly (3x week); RCTs show benefit in Critical Care
units
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PLACENTA ACCRETA AND PERCRETA
The article below is used with permission from the California Maternal Quality Care Collaborative Toolkit
to Transform Maternity Care: Improving Health Care Response to Obstetric Hemorrhage[4]
Note: Consideration should be given to intraoperative consultation, and referral made to appropriate tertiary
facilities.
Placenta Accreta and Percreta: Incidence, Risks, Diagnosis, Counseling and Preparation for
Delivery
Richard Lee, MD, Los Angeles County and University of Southern California Medical Center

The rising incidence of placenta accreta is due to the rapidly rising numbers of primary and repeat cesarean
births. The most recent data in California shows that 31% of all births are by cesarean section.[28] One study
at The University of Chicago showed that between 1982 and 2002 (before the greatest rise in cesarean births)
the overall incidence of placenta accreta was 1 in every 533 deliveries.[29]
There are four types of placenta previa: 1) a complete previa occurs when the placenta completely covers the
internal os; 2) a partial previa occurs when the placenta partially covers the internal os; 3) a marginal previa
occurs when the placenta is located next to the internal os; 4) a low lying placenta occurs when the placental
margin is within two centimeters of the internal os, but not next to the internal os.
A placenta accreta occurs when there is abnormally firm attachment of placental villi to the uterine wall with
the absence of the normal intervening deciduas basalis and Nitabuchs layer. There are three variants of this
condition: 1) accreta: the placenta is attached to the myometrium; 2) increta: the placenta extends into the
myometrium; and 3) percreta: the placenta extends through the entire myometrial layer and uterine serosa.
Risk
The risk of placenta accreta is highest in patients with both prior cesarean birth and placenta previa (placenta
previa also increases with prior cesarean births). Silver, et al. reported proportionally increased risk of
placenta accreta with higher numbers of prior cesareans in women with or without placenta previa.[30]
Diagnosis
A diagnosis of accreta can be confirmed with tissue histology; however, medical imaging can be an effective
diagnostic tool. Ultrasound can detect the presence of accrete (80% sensitivity) and absence of accreta (95%
specificity).[31]-[34] Warshak et al. reported that in cases with suspicious or inconclusive ultrasonography
results, MRI accurately predicted placenta accreta with 88% sensitivity and 100% specificity.[33] While MRIs
specificity is enhanced when gadolinium is used, its effects on the fetus remain uncertain; many researchers
believe benefits of its use outweigh risks associated with mis- or undiagnosed placenta accreta.[33] A recent
Stanford study suggests that high-resolution sonography and MRI give similar results but are complimentary
when one modality is inconclusive.[34] Second trimester Maternal Serum Alpha-Fetoprotein (MSAFP) may
also be helpful. In two recent studies of patients with placenta previa, MSAFP was elevated in 45% of those
with accreta, and not in those without accreta.[35]
Counseling
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Providers caring for patients with prenatally suspected placenta accreta should counsel patients extensively
about potential risks and complications well in advance of their estimated due date. Patients with accreta are
at increased risk for hemorrhage, blood transfusion, bladder/ureteral damage, infection, need for intubation,
prolonged hospitalization, ICU admission, need for reoperation, thromboembolic events and death.[30][34]-
[36] Discussions should involve relative likelihood for hysterectomy and subsequent infertility.
Delivery Timing
In patients with strong suspicion for placenta accreta, it is strongly advised to perform the delivery before
labor begins or hemorrhaging occurs.[35] Therefore, consideration should be given to performing the
cesarean birth electively and prematurely, either after corticosteroids for fetal lung maturation or after
documentation of fetal lung maturity. The committee could not reach consensus on the recommended
gestational age for elective delivery; some tertiary referral centers recommended 32-34 weeks and others 35-
36 weeks. All agreed that patients with repeated bleeding episodes or deeper invasion (e.g. placenta percreta)
should be delivered early.
Delivery Preparations
Advance planning with anesthesia, blood bank, nursing (OB and OR) and advanced surgeons is an essential
first step. Advanced surgeons are gynecology oncologists or experienced pelvic surgeons familiar with the
operative management of complex pelvic surgeries. A Massive Transfusion Pack with 4-6 units PRBCs, FFP
and Platelets should be available. At the time of cesarean, the hysterotomy should be made away from the
location of the placenta. In all but those with focal accretas, a hysterotomy without disturbance of the
placentais strongly advised.[35] Blood salvage equipment should also be considered where available.[37]
The results of conservative surgery have been recently reviewed with many complications noted (e.g.
infection, delayed hemorrhage, reoperation requiring hysterectomy, disseminated intravascular coagulation)
and should only be considered in the most select situations.[38] Consultation with experienced surgeons (e.g.
gynecologic oncologist) or referral to appropriate facilities is required when a provider lacks appropriate
support services or surgical experience with managing placenta accreta. The use of prophylactic intravascular
balloon catheters for cesarean hysterectomy for placenta accreta is controversial as a recent large case control
study (UC Irvine/Long Beach Memorial) showed no benefit.[39] If a focal placenta accreta is found (typically
in the lower uterine segment at the delivery of a placenta previa) management options are broader and include
over-sewing, fulguration and placement of an intrauterine compression balloon (with drainage through the
cervix/vagina) for 24 hours.
PATIENTS WITH COAGULATION DEFECTS
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The article below is used with permission from the California Maternal Quality Care Collaborative Toolkit
to Transform Maternity Care: Improving Health Care Response to Obstetric Hemorrhage.[4]
Inherited Coagulation Disorders in Pregnancy

David Lagrew, MD, Saddleback Memorial Medical Center

The coagulation process is a complex biochemical chain reaction involving several pathways and proteins.
Genetic abnormalities in any of these proteins can lead to serious coagulation problems. Although relatively
rare in pregnancy, such abnormalities can lead to maternal hemorrhage events during antepartum, birth or
postpartum and can have deleterious effects on the mothers and babys health. Identifying patients with
inherited coagulation disorders and carefully planning their care is crucial for optimal outcomes. Although
postpartum hemorrhage can occur in these patients, coagulation defects are sufficiently rare that routine
screening in patients with postpartum hemorrhage will not identify a large number of these patients.[40][41]
Though incidence is low, this is an important group of individuals to identify and prepare for.[42]-[46]
The most commonly identified coagulation disorders are von Willebrands Disease (Factor VIII platelet
adhesion and coagulant deficiency), Hemophilia A (Factor VIII coagulant deficiency), Hemophilia B (Factor
IX deficiency) and Hemophilia C (Factor XI deficiency). Basic knowledge of these disorders will help to
better understand the management recommendations below. von Willebrand Disease (vWD) is the most
common hereditary coagulation abnormality described in humans with a prevalence of 1% in the general
population.[42][47][48] It occurs less frequently as an acquired disorder (acquired von Willebrand Syndrome)
manifested by the presence of auto-antibodies. Von Willebrand Disease is caused by a deficiency of the
plasma protein that controls platelet adhesion (VIII:vWF) and decreased activity of the protein that stabilizes
blood coagulation (VIII:C). The disorder can cause mucous membrane and skin bleeding symptoms,
bleeding with vaginal birth, surgical events or other hemostatic challenges. Women of child-bearing age may
be disproportionately symptomatic compared with other age groups.
Several types of vWD have been described.[49] Type 1 individuals make up 60-80% of all vWD cases and
have a quantitative defect (heterozygous for the defective gene) but may not have clearly impaired clotting
function. Decreased levels of vWF are detected in these patients (10-45% of normal, i.e., 10-45 IU). Most
patients lead nearly normal lives without significant bleeding episodes. Patients may experience bleeding
following surgery (including dental procedures), noticeable easy bruising or menorrhagia (heavy periods).
Type 2 vWD patients (20-30% of all vWD cases) have a qualitative defect and the tendency to bleed varies
between individuals. Individuals with Types I and II are usually mildly affected by the disorder and pass on
the trait in an autosomal dominant fashion.
Type III vWD is the most severe form; it is autosomal recessive and severely affected individuals are
homozygous for the defective gene. Patients have severe mucosal bleeding, no detectable vWF antigen, and
may have sufficiently low factor VIII. They can have occasional hemarthoses (joint bleeding) as in cases of
mild hemophilia. Most vWD diagnoses are in women with a positive family history or menorrhagia. Blood
testing for vWF activity provides confirmation of diagnosis.
Hemophilia A (Factor VIII coagulant deficiency) is a blood clotting disorder caused by a mutation of the
factor VIII gene, which leads to Factor VIII deficiency. Inheritance is X-linked recessive; hence, males are
affected while females are carriers or very rarely display a mild phenotype. It is the most common hemophilia,
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occurring in 1 in 5000 males. Women can, on rare occasion, exhibit a homozygous state if both parents carry
the disorder. More frequently, carriers show atypical performance of Lyonization of the X chromosome
(random inactivation of the X chromosome). Usually women have 50% activity but if inactivation of the
normal gene occurs in greater frequency, lower levels can be seen.[50] Of note, Factor VIII activity usually
increases during pregnancy. [51]
Hemophilia B (Factor IX deficiency) is a blood clotting disorder caused by a mutation of the Factor IX gene,
also carried on the X-chromosome. It is the least common form of hemophilia (sometimes called Christmas
Disease, after the first afflicted patient), occurring in about 1:30,000 males and very rarely in females.
Diagnosis can be made by measuring levels of IX activity in the blood, which does not usually change during
pregnancy.
Hemophilia C (Factor XI deficiency) is a rare condition in the general population (less than 1:100,000) but
more common in Ashkenazi Jewish patients, and it can occur in both males and females.[52] Up to 8% of
these individuals are carriers (autosomal recessive) of the gene, which is located on Chromosome 4.
Treatment is usually not necessary because patients have approximately 20-60% factor XI activity; however,
they should be closely followed since the postpartum hemorrhage rate is 20%.
Diagnosis in pregnancy of any of these coagulation disorders may be difficult due to the variability of clotting
factor activity caused by hormonal changes of pregnancy.[53] When a patient with an inherited coagulation
disorder delivers, one must be concerned about extrauterine bleeding and hematomas and the effect of the
disorder on the fetus. Cesarean section is rarely recommended.[54] Autoimmune acquisition of these
disorders has been described and therefore may occur despite the lack of familial history.
RECOMMENDATIONS
1. Review family, surgical and pregnancy history for possible clinical symptoms of excessive bleeding
following surgery (including dental procedures), noticeable easy bruising, joint hemorrhage or
menorrhagia (heavy periods).
2. Request the following laboratory screening tests for patients with suspected disorders:[49][50]
von Willebrand Disorder: Measurement of Ristocetin Co-Factor Activity and von
Willebrand Antigen (VIII:Ag) activity
Hemophilia A: Measurement of Factor VIII activity (Factor VIII:C assay)
Hemophilia B: Measurement of Factor IX activity (If Factor VIII:C is normal)
Hemophilia C: Measurement of Factor XI activity
Other tests performed for patients with bleeding problems: complete blood count
(especially platelet counts), APTT (activated partial thromboplastin time), prothrombin
time, thrombin time and fibrinogen level. Note that patients with von Willebrand disease
typically display normal prothrombin time and variable prolongation of partial
thromboplastin.
3. Affected patients or carriers, or patients with suspected history should consult with a hematologist
who has specific interest and knowledge of coagulation disorders.
4. Obtain perinatal consultation for planning and coordination of antepartum and intrapartum
management.
5. Refer patients for genetic counseling regarding possible testing and evaluation of the fetus and
newborn.
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6. Develop intrapartum and postpartum management plans well in advance of the anticipated date of
birth so specific medications and blood components are available at the time of delivery and given in
consultation with a hemotologist:
von Willebrand Disorder: Mild forms can be treated with desmopressin acetate (DDAVP)
but more severe forms require vWF and VIII factor replacement.[46] DDAVP challenge
testing can identify whether patients will respond to this medication.
Hemophilia A/B: Concentrates of clotting factor VIII (for hemophilia A) or clotting factor
IX (for hemophilia B) are slowly dripped in or injected into a vein. Consider DDAVP
adjunctive therapy.
Hemophilia C: FFP is the first product used to treat patients with hemophilia C. The main
advantage of FFP is its availability. Disadvantages of its use include the large volumes
required, the potential for transmission of infective agents and the possibility of allergic
reactions.
Factor XI activity: Factor XI concentrates provide the best source for factor XI
replacement.
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EMOTIONAL SUPPORT FOR WOMEN EXPERIENCING POSTPARTUM HEMORRHAGE

Experiencing a stressful event such as a PPH has both physical and emotional impacts. Women having a
significant hemorrhage may experience transient hypotensive episodes, pituitary ischemia or infarction,
cortisol levels may elevate, and other consequences. This physical and emotional stress has the potential to
negatively impact the woman and her family in multiple ways, including breastfeeding, bonding and long
term emotional health. Consider a referral to psychiatric, psychosocial, and social support services for
women who experience obstetric hemorrhage.
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FOR THE HOSPITAL

Physicians, Nurses, Midwives, Advanced Practice Nurses, Anesthesia, Blood Bank staff, Rapid
Response Team Members
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CRITICAL STAFF AND EQUIPMENT

Success of a maternal hemorrhage initiative is dependent on the right leadership and a multidisciplinary team.
Nurse and physician leaders will assist in defining the problem, making the case for change, setting goals and
identifying local resources.
It is important to identify the clinical services involved in a response to maternal hemorrhage. These may
include but are not limited to obstetrics, anesthesia, surgery, pediatrics, blood bank, critical care medicine,
and interventional radiology. The development of a massive transfusion protocol in collaboration with the
blood bank is particularly important in these cases and improves response while decreasing cost.[7]
All level of providers should participate in development of policies, simulation drills, and debriefs, including
nurses, physicians, midlevel providers and ancillary staff.
Additionally, consistent with State and Federal Guidelines as well as the Joint Commission Statement
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care, hospitals are
expected to be able to meet the needs of Limited English Proficient (LEP) patients as well as those with
other disabilities (e.g. hearing impaired and speech impaired).
CARTS, KITS, AND TRAYS
Postpartum hemorrhage (PPH) is a commonly encountered obstetrical emergency on labor and delivery
units. Although medical management is often successful in treating PPH, if there is a lack of response, the
obstetrician may have to proceed to surgical measures. For an efficient response to the emergency, the
obstetrician should have rapid access to surgical instruments and tools designed to treat PPH. Equipment
and instruments compiled on an obstetrical hemorrhage cart is designed to treat vaginal/cervical
lacerations and perform uterine tamponade or uterine/ovarian artery ligation. In short, the cart would have
all the instruments necessary to treat PPH before hysterectomy is considered. A list of recommended
instruments is included in Appendix E. Each institution should engage their providers, obtain feedback on
the components of the hemorrhage cart and adapt this list based on their own local resources.
ANTI-SHOCK GARMENTS
The World Health Organization has offered recommendations for non-pneumatic anti-shock garments
(NASG) to their recommendations for prevention and treatment of post-partum hemorrhage, primarily in
low resource settings to gain time to reach definitive treatment. Limited studies have been conducted in
the resourced obstetric settings. There remains a need for further research regarding use and mechanisms
of action in pregnancy and post-partum.
Consideration should be given to use of NASG in the face of obstetric hemorrhage when transport of the
patient is necessary to achieve definitive treatment.
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CONSIDERATIONS FOR SMALL AND RURAL HOSPITALS AND BIRTHING FACILITIES

A primary focus of any patient safety initiative is preparedness. The OHI Committee identifies hospitals
and other obstetric care facilities that are at particular risk for a hemorrhage emergency:
1) Low volume delivery service
2) Resource poor setting
3) Geographically isolated
We call special attention to facilities with these challenges and urge not only routine drills but hard wiring
a formal plan for hemorrhage assessment, identification of a transfer/transport plan, relationship building
with regional center capable of managing hemorrhage and early transfer of care.
SIMULATION DRILLS
Importance of Simulation
Simulation has been used to support training in high stress situations that would be unsafe to rehearse in
clinical practice. It offers the opportunity for learning from error without causing harm to the patient,
provides for competence acquisition, and the development of clinical reasoning skills.[8]-[10] In obstetrics,
simulation has been demonstrated to improve short term response to obstetric emergencies and improved
long term recollection.[9][11]-[13]
Medical simulation drills of obstetrical hemorrhage cases can assess system weaknesses and strengths, test
policies and procedures for coping with hemorrhage and improve teamwork and communication skills of
staff members. Drills that include all disciplines (obstetrics, anesthesia, pediatrics and nursing) can be
especially effective in improving team training and communication.
In order to improve success, these simulations should include members of all of the clinical services that are
required in the management of an obstetric hemorrhage, represent situations that are as similar to real life
as possible and include a debriefing post event.
RECOMMENDATION
All hospitals adopt regularly scheduled simulation drills for practicing response to obstetric hemorrhage.
Optimal implementation would require that these drills occur onsite with members of all relevant disciplines
available. These drills should occur during different shifts. Unscheduled drills may also provide additional
information about preparedness. Ideally these should take place on at least an annual basis.[13]
Sample simulations can be found in the CMQCC Toolkit.
DEBRIEFING
Debriefing is a process of information exchange and feedback conducted after an event and is designed to
improve teamwork skills and outcomes.[58] Following an obstetric hemorrhage or any major obstetric event,
conducting a debriefing will provide the team with the opportunity to decompress while identifying areas for
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improvement. Simulation participants benefit from the immediate feedback provided during debriefings,
increasing learner engagement and enhancing retention of information.[59] Debriefing is a crucial element
of the simulation process and results in a higher level of staff preparedness and confidence, contributing to
optimal outcomes when emergencies arise.[60]
Led by a facilitator who outlines the debriefing process and assists as a resource to ensure the objectives are
met, the participants debrief themselves.[57] The debriefing room should be comfortable, private and away
from interruptions and provide the opportunity for all participants to be seen and heard.[57] Effective
debriefs allow the participants to look upon the process as a learning opportunity and not a punitive one.
The debrief begins with the facilitator providing a recap of the situation, background and key events that
occurred. Through a thorough and accurate reconstruction of the events, analysis of why the event occurred,
what worked, and what did not work, discussions ensue of lessons learned and what should be done
differently in the future.[58]
The basis for a debrief, whether it is impromptu or planned, is to answer the following questions: What did
we do well? What did not go so well? What can we improve upon in the future? A simple checklist can be
created with the following questions to help aid the process for both the facilitator and the participants: [58]
What did we do well?
As a team, assess how the following played a role in the performance of the team:
o Team Leadership
o Situational Awareness
o Mutual Support
o Communication
Did we have the equipment and resources necessary?
Lessons Learned?
Goals for Improvement?
What can we do differently?
Debriefing forms for hemorrhage drills and actual PPH emergencies should be developed in conjunction
with the risk management office or other department involved with quality analysis such as root cause
analyses. The forms should include information such as: the number and type of providers and staff
participating; the procedures used; the equipment used; the materials used; the environment; the management
and the problems identified through the process. A sample debrief form is available in Appendix G.
HEMORRHAGE DOCUMENTATION
As with other aspects of health care, obstetric hemorrhage prevention and management requires precise and
thorough documentation. It is ideal if all departments utilize the same or similar documents for the same
care and that communication between departments and levels of care is ongoing and comprehensive. The
obstetrical hemorrhage risk assessment tool used in labor and delivery for admission should be similar, if not
identical to that used in the physician and midwifery offices. The recovery room documents for cesarean
section should contain the same assessment for hemorrhage information as that for the recovery of the
vaginal delivery.
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CONCLUSION
The Florida OHI toolkit is intended to provide guidance to hospitals and obstetric providers in the
development of individualized policies and protocols related to obstetric hemorrhage. It is not to be
construed as a standard of care; rather it is a collection of resources that may be adapted by local
institutions in order to develop standardized protocols for obstetric hemorrhage. The toolkit will be
updated as additional resources become available.
Other resources and references are also available online at the California Maternal Quality Care
Collaborative website as cited in the references and appendices. Additionally, ACOG, CDC, HRSA,
AWHONN, SMFM, and the American Blood Bank Association, in conjunction with other partners, are
working to develop a bundle of care for future distribution.
If you have any questions related to the content or use of this toolkit, please contact the FPQC.
Contact:
Florida Perinatal Quality Collaborative
Lawton and Rhea Chiles Center for Health Mothers and Babies
University of South Florida College of Public Health
3111 East Fletcher Avenue
Tampa, FL 33613-4660
Phone: (813) 974-9654
Fax: (813) 974-8889
E-mail: fpqc@health.usf.edu
Website: fpqc.org
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importance. British Medical Journal, 1(5537), 398-400.
[77] Al Kadri et al. (2011) Visual estimation versus gravimetric measurement of postpartum
blood loss: a prospective cohort study. Arch of Gynecol Obstet, 283. 1207-1213.
[78] Association of Womens Health, Obsetric, and Neonatal Nurses (2014) Quantification of
Blood Loss: AWHONN Practice Brief Number 1 JOGNN, 00, 13; 2014. DOI: 10.1111/1552-
6909.12519
[79] Ducloy-Bouthors et al, Medical Advances in the Treatment of Post-partum Hemorrhage,
Anesthesia and Analgesia, November 2014, Volume 119, Number 5
[80] Colis and Collins, Haemostatic management of obstetric haemorrhage, Anaesthesia 2015, 70
(Supplement 1), 78-86
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APPENDICES
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APPENDIX A: SAMPLE HEMORRHAGE POLICIES AND PROCEDURES
See: Example Hospital Hemorrhage Protocols
CMQCC Obstetric Hemorrhage Care Guidelines: Sample Policy and Procedure

From the California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care
POLICY INDEX: O Page 1 of X

POLICY TITLE: Obstetric Hemorrhage Care Guidelines
DEPARTMENT AND USERS DISTRIBUTION:
Maternal Child Health, Labor and Delivery, Emergency Department, Operating Room,
Blood Bank, Intensive Care Unit, Post-Anesthesia Care Unit(s)
Original Date of Issue: ___________________________
Reviewed
Date
Revised
Date
PURPOSE
The purpose of this protocol is to provide guidelines for the optimal response of the multidisciplinary team
in the event of obstetric hemorrhage. This protocol will also aid in recognizing patients at risk for
hemorrhage and identifying stages of hemorrhage and primary treatment goals.
POLICY STATEMENTS
Optimal response to obstetric hemorrhage requires the coordination of effort of team members from
multiple disciplines and departments.
Obstetric unit, anesthesia department, blood bank, operating room, and other appropriate services
work together to identify necessary system supports and processes for mounting an efficient and
coordinated response to obstetric hemorrhage.
Obstetric physicians, obstetric RNs, certified nurse midwives, anesthesiologists, and other
appropriately qualified clinicians are authorized to mobilize the team to respond to an obstetric
hemorrhage.
The OB hemorrhage critical pack/cart are always kept stocked, not expired, and available for an
emergency in all areas of the hospital where women are treated for OB hemorrhage. Note: the
assignments for stocking and checking the cart need to be clearly delineated by each hospital. For
example: medications will be kept together in an emergency packet in the pharmacy cart on the unit;
the emergency medication packet will be maintained by pharmacy; the adult resuscitation cart or a
separate resuscitation cart will be designed with an OB hemorrhage supply component.
The Obstetric (OB) Hemorrhage general and massive policies and procedures will be updated at
least every three years.
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Pre Admission
Identify patients with special consideration: Placenta previa/accreta, Bleeding disorder, or those who decline
blood products
APPENDIX B: Follow appropriate workups, planning, preparing of resources, counseling and notification Verify Type &
Screen on
FPQC CARE Time of Admission
prenatal record; if
positive antibody
Screen All Admissions for hemorrhage risk: Low Risk, Medium Risk and High Risk screen on
GUIDELINES Low Risk: Hold blood Medium Risk: Type & Screen, Review Hemorrhage Protocol,
High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage Protocol
prenatal or
current labs
ALGORITHM (except low level
anti-D from
STAGE 0- ALL BIRTHS Rhogam), Type &
Active management of 3rd stage of labor Crossmatch 2
Oxytocin IV infusion or 10 Units IM Units PBRCs
Vigorous fundal massage for 15 seconds minimum
Ongoing Evaluation:
Quantification of blood loss, vital signs, LOC
Cumulative Blood Loss NO

>500ml Vag or >1000ml C/S Standard Postpartum
YES 15% Vital Sign change -or-HR110, Management
BP 85/45, O2 Sat <95%, Fundal Massage
Clinical Sx (ex. LOC change)
STAGE 1
Activate Hemorrhage Protocol
Notify- OB, Charge RN, anesthesia Increase IV rate (LR); Increase Oxytocin. Repeat fundal massage.
personnel Methergine 0.2 mg IM (if not hypertensive) Onset of action 3-5 minutes. If unresponsive, repeat or next drug
Order Type & Crossmatch 2 Units If hypertensive, Hemabate 250 mcg IM (caution with asthmatics), Onset of action 5 minutes
PRBCs if not already done Insert indwelling foley catheter; Keep Warm; Administer O2 to maintain Sat >95%
VS, O2 Sats q 5 min, Measure blood loss q 5 to 15 min (weigh bloody materials)
Inspect all vaginal walls, cervix, uterine cavity, and rule out retained POC, laceration or hematoma
Start 2nd IV line (16-18 gauge)
Draw and Send blood for CBC, PT,PTT and fibrinogen
Continued heavy bleeding

Cumulative Blood Loss NO Increased Postpartum
QBL 500-1500 ml- VB Surveillance
YES EBL 1000-1500 ml- C/S Hand off report of cumulative BL
STAGE 2 Vaginal Birth:

Notify rapid response team and OR team Bimanual Fundal Massage
OB at beside if not already there Retained POC: Dilation and Curettage
Give meds: Hemabate 250 mcg IM, Onset of action Lower segment/Implantation site/Atony: Intrauterine Balloon insertion
5 minutes, May repeat every 15-90 minutes, max Laceration/Hematoma: Packing, Repair as Required
dose 2mg Consider IR (if available & adequate experience)
Continue QB Cesarean Birth:
Notify blood bank and ascertain blood product Continued Atony: B-Lynch Suture/Intrauterine Balloon
availability Continued Hemorrhage: Uterine Artery Ligation
Transfuse 2 Units PRBCs per clinical signs

Do not wait for lab values, Consider thawing 2 Units FFP
Cumulative Blood Loss>1500 ml NO Increased Postpartum

2 Units PRBCs Given Surveillance
YES Vital Signs Unstable Hand off report of
documentation of
cumulative blood loss
STAGE 3
To OR (if not there);
Activate Massive Hemorrhage Protocol
Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts
6:4:1 or 4:4:1
Conservative Surgery
Unresponsive Coagulopathy: After 10 B-Lynch Suture/Intrauterine Balloon
Units PBRCs and full coagulation factor Uterine Artery Ligation / Hypogastric Ligation (experienced
replacement, may consider rFactor VIIa HEMORRHAGE CONTINUES
surgeon only)
Consider IR (if available & adequate experience
Definitive Surgery
HEMORRHAGE CONTROLLED Consider ICU Care Hysterectomy
Increased Postpartum Surveillance
Hand off report of cumulative blood loss
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APPENDIX C: CMQCC ACUTE ADVERSE EFFECTS OF TRANSFUSION
BLOOD PRODUCT REPLACEMENT: OBSTETRIC HEMORRHAGE, From Holli Mason, MD
Acute Adverse Effects of Transfusion

(Onset within minutes or hours)
Type of Reaction Incidence Usual Cause Signs or Symptoms
Hemolysis-Immunologic 1:25,000 Red cell incompatibility, Fever, chills, renal failure, DIC,
(Acute Hemolytic usually ABO pain, hypotension, tachychardia,
transfusion anxiety, hemoglobinemia,
reaction) hemoglobinuria, cardiac arrest.
Hemolysis-Physical or Unknown Overheating, freezing, Asymptomatic hemoglobinuria,
Chemical addition of hemolytic drugs or rarely DIC, renal failure,
solutions. hypotension
Febrile Nonhemolytic 0.5-1.5% Recipient antibodies to Fever, chills
donor leukocytes; or
preformed cytokines in
blood product
Anaphylaxis 1:20,000- IGA deficient recipient with Respiratory obstruction and
47,000 antibodies to IgA in donor cardiovascular collapse,
plasma; antibodies to other angioedema, anxiety, chills,
plasma proteins, WBCs and agitation.
platelets.
Urticarial 1-3% Antibody to donor plasma Pruritis and hives

proteins
Transfusion Related Reported DONOR antibody to Respiratory distress, pulmonary
Acute Lung Injury (TRALI, 0.001%, recipient leukocytes or edema and hypoxemia with
Noncardiogenic 0.02%, patient antibody to donor normal wedge pressures. White
Pulmonary Edema) 0.34% specific HLA or granulocytes out on CXR
Congestive Heart Failure Unknown Volume overload Respiratory distress
Septic Complication 1:1000- Bacterial contamination Usually gram negative sepsis

7:1000 when the transfusion is red cells,
gram positive cocci are most
common in platelet transfusion
Hypothermia Unknown Rapid infusion of cold blood Chills without fever
Hyperkalemia Unknown RAPID infusion of stored red Cardiac dysfunction (usually

cell problematic only in infants or
those with compromised renal
function)
Hypocalcemia Unknown RAPID AND MASSIVE Cardiac dysfunction (usually
transfusion of stored blood problematic only in patients with
Prophylactic SEVERE hepatic insufficiency or
administration of Calcium neonatal massive exchange
is not recommended. transfusion)
Lyndon A, Lagrew D, Shields L, Melsop K, Bingham B, Main E (Eds). Improving Health Care Response to Obstetric Hemorrhage. (California Maternal
Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health;
Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, July 2010.
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APPENDIX D: CMQCC JEHOVAHS WITNESS BLOOD PRODUCT AND TECHNIQUE

INFORMED CONSENT/DECLINE
My signature below indicates that I request no blood derivatives other than the ones which I have
designated in this consent be administered to me during this hospitalization. My attending
physician,_____________________M.D. has reviewed and fully explained to me, the risks and
benefits of the following blood products and methods for alternative non-blood medical management
and blood conservation available to me. My attending physician_____________________M.D. has
also fully explained to me the potential risks associated by not authorizing blood and / or nonblood
management during this hospitalization.
ACCEPT DO NOT ACCEPT

COMPONENTS OF HUMAN BLOOD
Red Blood Cells ________ ________
Fresh Frozen Plasma ________ ________
Platelets ________ ________
Cryoprecipitate ________ ________
Albumin ________ ________
Plasma Protein Fraction ________ ________
INTRAVENOUS FLUIDS WHICH ARE NOT COMPONENTS OF HUMAN BLOOD

Hetastarch ________ ________
Balanced Salt Solutions ________ ________
MEDICATIONS WHICH CONTAIN A FRACTION OF HUMAN BLOOD

Rhogam ________ ________
Erythropoeitin ________ _______
Human Immunoglobulin ________ ________
Tisseel ________ ________
TECHNIQUES FOR BLOOD CONSERVATION / PROCESSING

Hemodilution ________ ________
Cell Saver ________ ________
Autologous Banked Blood ________ ________
Cardiopulmonary Bypass ________ ________
Chest Drainage Autotransfusion ________ ________
Plasmapheresis ________ ________
Hemodialysis ________ ________
Other_____ ________ ________
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PLEASE CIRCLE WHICH ONE APPLIES

I do (do not) have a durable power of attorney.
I accept (do not accept) this consent as an addendum to my durable power of attorney.
I fully understand the options available to me and hereby release the hospital, its personnel, the attending
physician and any other person participating in my care from any responsibility whatsoever for unfavorable
reactions or any untoward results due to my decision not to permit the use of blood or its derivatives. The
possible risks and consequences of such refusal on my part have been fully explained to me by my
attending physician. I fully understand such risks and consequences may occur as a result of my decision.
DATE:______________ TIME:_______________
SIGNATURE:__________________________________
(patient/parent/guardian/conservator)
RELATIONSHIP:_______________________________
WITNESS:_____________________________________
Tool: Jehovah's Witness Consent Form and Management Checklist from:

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SPECIFIC CHECKLIST FOR MANAGEMENT OF PREGNANT WOMEN WHO DECLINE TRANSFUSIONS
Prenatal Care
checklist specifying acceptable interventions
-40%)
PO or IV (sucrose) with Folate and B12 as needed
-Erythropoeitin 600units/kg SQ 1-3x per weekly as needed
(most preparations have 2.5ml of albumin so may be refused by some
Jehovahs Witnesses)
-up Consultants (consider MFM, Hematology, Anesthesiology)
Labor and Delivery
(e.g. Surgery, Interventional Radiology)
rFactor VIIabut remember that rFVIIa needs factors to work)

Have a Plan!!
Postpartum
stitutes
IV (sucrose)
-Erythropoeitin 600units/kg SQ weekly (3x week)
RCTs show benefit in Critical Care units
For more information, please review: www.CMQCC.org section on OB Hemorrhage/Jehovahs

Witness
Tool: Specific Checklist for Managment of Pregnant Women who Decline Transfusions from:
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APPENDIX E: CMQCC CARTS, KITS AND TRAYS CHECKLISTS
Tool: OB Hemorrhage Carts, Kits, Trays-Recommended Instruments, Supplies
RECOMMENDATION
Labor and delivery units construct a sterile tray that provides rapid access to instruments used
to surgically treat PPH. Hysterectomy trays are separately available.
OB Hemorrhage Cart: Recommended Instruments

Set of vaginal retractors (long right angle); long weighted speculum
Sponge forceps (minimum: 2)
Sutures (for cervical laceration repair and B-Lynch)
Vaginal Packs
Uterine balloon
Banjo curettes, several sizes
Long needle holder
Uterine forceps
Bright task light on wheels; behind ultrasound machine
Diagrams depicting various procedures (e.g. B-Lynch, uterine artery ligation, Balloon
placement)
OB Hemorrhage Medication Kit: Available in L&D and Postpartum Floor

PYXIS/refrigerator
Pitocin 20 units per liter NS 1 bag
Hemabate 250 mcg/ml 1 ampule
Cytotec 200mg tablets 5 tabs
Methergine 0.2 mg/ml 1 ampule
OB Hemorrhage Tray: Available on Postpartum Floor

IV start kit
18 gauge angiocath
1 liter bag lactated Ringers
IV tubing
Sterile Speculum
Urinary catheter kit with urimeter
Flash light
Lubricating Jelly
Assorted sizes sterile gloves
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Labor and Delivery Emergency Hysterectomy Tray: Available in L&D OR Suite
4 Towel Clips, Backhaus (perforating) 5 6 Forceps, Heaney, Curved, 8 1/4"

1/4" NH, Mayo Hegar, 8"
4 Mosquito, Curved, 5" 4 Sponge Stick, 9 1/2"
2 Clamp, Mixter 9" 1 Scissor, Jorgensen, Curved, 9"

2 Clamp, tonsil 1 Scissors, bandage 7"
2 Clamp, Allis, Extra long 10" 1 Scissors, curved dissecting, Metzenbaum
2 Clamp, Allis 6" 1 Scissors, Mayo, curved
2 Clamp, Babcock 8" 1 Scissors, sharp/blunt, Straight, 5 1/2'
2 Clamp, Babcock 6 1/4" 1 Scissors, Curved Metzenbaum 12"
2 Clamp, Lahey 6" 1 Scissors, Mayo Straight 11"
2 Clamp, Heaney-Rezak, Straight, 8" 1 Scissors, Mayo Curved 11"
8 Kelly, Curved 5 3/4"

2 Kelly, Straight 5 3/4" 1 Knife Handle #3
8 Pean Curved, 6 1/4" 1 Knife Handle #4
1 Knife Handle #3, Long
2 Forceps, Debakey, 9 1/2"
1 Forceps, Tissue with teeth 9 3/4" 1 Retractor, Kelly, large
1 Forceps, Russian 8" 1 Retractor, Deaver, Large, 3" x 12"
1 Forceps, Smooth 8" 1 Retractor, Deaver, Medium
1 Forceps, Ferris Smith 2 Retractor, Med/large Richardson
2 Forceps with Teeth, 6 " 1 Retractor, Balfour Blades
1 Forceps, Russian 6" 2 Retractor, Goulet, 7 1/2"
2 Forceps, Adson with Teeth
1 Forceps, Tissue, Smooth, 7" 1 Suction, Yankauer Tip
1 Suction, Pool Tip
2 Kocher, Straight, 8"
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APPENDIX F: OBSTETRIC HEMORRHAGE AUDIT TOOL

Please audit 20 vaginal delivery and 10 Cesarean delivery charts each month.
MR#_________________________
Risk Assessment
(Numerator= # charts with risk assessment documented / Denominator= Total Number of audited charts)
Documented in chart Yes No
Active Management of Labor
(Numerator= # charts with both oxytocin and fundal massage documented / Denominator= Total Number of
audited charts)
Oxytocin IV/IM Fundal Massage
Oxytocin administered at delivery of: baby OR placenta
Cumulative Blood Loss and Quantitative Measurement
(Numerator= Not measured; Estimated with Visual Cues Only; Measured using one or more of the three
recommended formal measurements / Denominator= Total Number of audited charts [please audit 10 Vaginal
and 10 Cesarean)
Vaginal Delivery Cesarean Section
Measurement NOT recorded in chart
EBL Visual Estimation of Blood Loss (includes mixed methods)
QBL Quantification of Blood Loss (only used quantification methods)
If QBL, Select all that apply:
Formally measured by % saturation with the use of pictures to determine blood volume
Formally measured by weighing
Formally measured by collection

Adapted the California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care
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APPENDIX G: FPQC OB HEMORRHAGE TEAM DE-BRIEFING FORM

Adapted the California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care
Topic: The de-brief form provides an opportunity for maternity service teams to review then document sequence of events, successes
and barriers to a swift and coordinated response to obstetric hemorrhage.
Goal: De-brief completed in 100% of all obstetric hemorrhages that progress to Stage 2 or 3. All de-briefs have at least Primary RN,
and Primary MD who participates in the de-briefing session.
Instructions: Complete as soon as possible, but no later than 24 hours after any Stage 2 or 3 hemorrhages. During de-brief, obtain
input from participants (all or as many as possible). Attach additional pages with notes as needed.
(Stage 2 or 3 hemorrhages are defined as bleeding that continues after administration of IV or IM Oxytocin, vigorous fundal massage, emptied
bladder and Methergine 0.2 mg IM)
___________________________________________________________________________________________________________
Were the following medications, procedures or blood products used? (Check if yes, check all that apply)
Medications
High dose misoprostol (800-1000 mcg) Post-hemorrhage, the patient required
Carboprost tromethamine (Hemobate (Check if yes, check all that apply)
Blood Volume/Options Intubation Central Line
Invasive hemodynamic monitoring Pressors Arterial Line
Blood warmer Admission to ICU Admission to higher acuity unit
Rapid fluid infuser (level one machine) (e.g., PACU)
Blood cell salvage machine (cell saver) Volume of blood lost: _____ mls
Factor VIIa (non-standard treatment) Method of Blood Loss Measurement (Check all that
Procedures apply)
Intrauterine balloons Visually Estimated Only
B-Lynch suture Formal Estimate using Posters/Pictures
Uterine artery ligation Formal Measure by weight
Uterine artery embolization Formal Measure by volume collection
Non-pneumatic Anti-shock Garments (NASG; non- Blood Product Transfusion Ratios - Active
standard Hemorrhage Treatment and Resuscitation Period
treatment) (~the first 4-6 hours PP)
COMMENTS about medications, procedures, or blood Units of PRBCs: ______________ Units of FFP:
products: ______________
Units of Platelets: _____________ Units of Cryo:
_____________
Who participated in the debrief? (check all that apply)
Primary MD/DO/CNM Blood bank staff
Primary RN Pharmacy
Other RNs Lab team
Anesthesia Rapid Response team
Thinking about how the obstetric hemorrhage was managed

Identify what went well (Check if yes, describe) Identify opportunities for improvement: nonhuman
Communication went well factors (Check if yes, describe)
Teamwork went well Delay in blood products availability
Leadership went well Equipment issues
Decision-making went well Medications issues
Assessing the situation went well Inadequate support (in-unit or other areas of the
Other hospital)
Briefly describe: Delays in transporting the patient (within the
hospital or to another facility)
Other
Briefly describe:
Identify opportunities for improvement: human factors
(Check if yes, describe)
Communication needed improvement
Teamwork needed improvement
Leadership needed improvement
Decision-making needed improvement
Assessing needed improvement
Other
Briefly describe:
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APPENDIX H: FREQUENTLY ENCOUNTERED CLINICAL CONCERNS AND RESPONSES

TO QBL
Adapted from Bingham, D. & Main, E. [74] and AWHONN Slides from Council on Patient Safety in Womens Health Care QBL Safety Action Series
Presentation 8/28/14.
Issue AWHONN Response

Providers believe that their patients are unique; Distribute key peer-reviewed literature related to
thus, the research does not apply to their specific the measurement of blood loss to every nurse and
group of patients. physician.
Many physicians and nurses have only performed The lack of experience indicates that there is a
EBL. They are not familiar with how to QBL. need for more education tactics with QBL details.
The providers are concerned, on the basis of their Track the number of births quantified and their
training and experience, that if they begin relationship to early recognition of PPH. Report
quantifying blood loss they will have higher blood facts and QBL trends to the physicians and nurses.
loss levels which might reflect negatively on their
practices, putting their reputations in jeopardy.
QBL is only needed for cases where a Measurement of cumulative blood loss is the goal.
hemorrhage is identified. Often it is too late when we recognize that the
woman has lost too much blood. Perform regular
quantification in non- emergency situations to
prepare the team for the actual PPH event.
QBL is not exact and therefore it is not worth The goal is not a perfect, precise number. There
doing. may be some discrepancies from mixing with
amniotic fluid, urine, irrigant, etc. and this can be
measured to some degree. It is more accurate to
do some measurements than to rely solely on
visual estimates.
There was fluid already in the canister, just Since irrigation is usually done after the major
estimating, we forgot it and so its just an bleeding is controlled, it may be best to connect to
estimate. another canister BEFORE irrigating to capture
this fluid separately. With continued use,
documenting the measures at birth and then
ongoing becomes routine practice and there is less
forgetting to document.
With QBL, it is now my responsibility to get it Shared responsibility and accountability is critical
right. I used to be in charge and still want the to quality patient outcomes. A shared team
responsibility. awareness is needed. It is no one persons
responsibility. It is a TEAM responsibility.
QBL takes a lot of time doesnt it? Teams that do QBL report that it becomes routine
and takes very little additional time. Have QBL
nurse and physician experts showcase do-ability of
QBL and describe how they successfully
performed QBL.
Its going to slow down OR room turnover. Have scales and dry item lists readily available in
every OR. Develop quick methods for
totaling/calculating in EMR. Think of the time
that will be saved by avoiding a hemorrhage event.
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APPENDIX I: TESTIMONIALS
WHY DO QUANTIFICATION OF BLOOD LOSS IN OBSTETRICS?
When I was practicing in Ohio, a quality improvement project was initiated for reduction of obstetric hemorrhage.
I was skeptical about some of the components and somewhat taken aback to having anesthesiologists or nurses
telling me what the blood loss amount was. I had been estimating blood loss for years without any problems and
did not see the value for the added time and attention that it would take. That is, until the consistent measurements
indicated that estimation was not as safe for my patients as measured quantification.
Over time, I learned from the literature that estimations were often as much as 50% inaccurate, usually
underestimating the true loss. I have heard from nurses, that on day two the hematocrit is sometimes low and the
patient symptomatic when estimations are used and quantifications ignored. This has made a believer out of me
and now, I consistently want to have quantified measurement of blood loss for vaginal and caesarean deliveries.
Quantification is not a perfect measurement but is more accurate than guessing . . .
We have the evidence that early recognition of significant blood loss and early intervention is safer for our patients.
We need to get over the old thinking that we are not good at our jobs if there is blood loss and move to the
evidence based model that says we are best at our work if we recognize and respond appropriately.
Judette Louis, MD, MPH
Assistant Professor, College Of Medicine Obstetrics & Gynecology Assistant Professor, Morsani
College of Medicine and College of Public Health
When it comes to obstetric hemorrhage, denial and delay in recognition can equal maternal death. The uterus can
bleed 500-800 cc/minute and within 5 minutes of unrecognized hemorrhage a patient can suffer loss of an entire
blood volume along with valuable clotting factors. Signs of hypotension are often masked in healthy patients due to
increases in cardiac output and vasoconstriction. Quantification of blood loss in the operating room and labor and
delivery room is vital to providing early intervention in recognition and treatment of obstetric hemorrhage. As
medical providers, we need to join together in accurately measuring blood loss as part of the multidisciplinary
approach to obstetric hemorrhage. By putting the ego aside and letting go of estimates, we can move towards
evidenced based quantification of blood loss to help providers overcome the denial and delay in treatment of
maternal hemorrhage.
Jean Miles, MD
Regional Director Obstetrical Anesthesia Services, Memorial Healthcare System Director
Obstetrical Anesthesia, Memorial Regional Hospital Sheridan Healthcorp Hollywood, FL
When implementing any new initiative among nursing staff it is essential to understand the why behind the
purpose of implementing the new process/procedure. QBL allows us to have a more accurate clinical picture of
blood loss so we can proactively manage our patients rather than reactively manage their symptoms after they are
already occurring. Even the most experienced clinicians can have a difference of opinion when it comes to
subjective assessment. QBL is the closest we can come to objectively assessing the blood loss post-delivery so we
can improve clinical outcomes for our patients.
Marie Sakowski, MSN, RNC
Nurse Manager, Perinatal, Labor and Delivery, Womens Health Pavilion, Florida Hospital Tampa
AWHONN recommends measuring blood loss for every woman who gives births in order to reduce denial that
leads to delays in women receiving lifesaving treatments. Measuring blood loss makes an un-reliable subjective
process much more reliable.
Debra Bingham, DrPH, RN
AWHONN Vice President of Nursing Research, Education, and Practice
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APPENDIX J: TIPS FOR QUANTIFICATION OF BLOOD LOSS
Every birth needs to have quantification of blood loss (QBL). Careful planning and training are important to
successful implementation of QBL.
Because there is always concern about the mixing of other fluids into the blood loss, the following information is
offered to assist in decision making. Average amounts of amniotic fluid have been estimated at 700 ml for normal,
300 ml for oligohydramnios, and 1400 ml for polyhydramnios.[61] It is important to make note of fluids contained
in the collection container at the time of infant delivery and continue to measure until the patient is stable, usually 2
to 4 hours postpartum. If there is amniotic fluid collected in the drape or container, this fluid should not be
included in the blood loss calculation. Since the majority of blood loss occurs after the delivery of placenta, an
establishment of baseline measure of other fluids should occur before delivery of the placenta.[4] The use of a
calibrated drape, which has an error rate of less than 15% is recommended for vaginal deliveries.[73] For Caesarean
Sections, a two part collection method is recommended, changing to a second container after the infant is delivered
or noting the collection amount at the time of delivery.
Methods of QBL:
Weight
Use scales to weigh all blood-saturated items (e.g., laps, chux, cloth pads, peripads) and clots.
Standardize products used for deliveries and determine their dry weights.
Create a laminated list of dry weights of items used during birth that may become blood soaked. Attach to
every scale.
Converting Grams to Milliliters: Calculate the gram weight and convert to milliliters. Grams (a unit of
mass) converted to Milliliters (a unit of volume): One gram = One milliliter
Direct Measurement
Graduated suction canisters
Under-buttocks and OR drapes with calibrated pouches.
Quantification Tips:
Measure amount of fluids after birth of the infant. The majority of the bleeding is after the placenta is
delivered.
Keep track of any extra fluids added e.g. irrigants, urine, feces.
Pre-determine the dry weights of items regularly used and have these weights readily available
A practical way of measuring blood in laps is to weigh them in groups of 5.
Adjust electronic medical records to document and perform the math if possible
Need ready access to measuring devices such as scales, suction canisters, etc.
QBL at Cesarean Deliveries:

Between delivery of infant and placenta, the OB suctions the drape of amniotic fluid; scrub staff directs
circulator to change suction tubing to second canister. Circulator records volume in second canister before
irrigation is used (or amount of irrigation to subtract).
Bloody lap sponges passed off scrub table by staff, circulator weights bloody sponges, and numbers are
recorded.
Train staff to account for other large sources of blood loss, if indicated.
Adapted from AWHONN Practice Brief, Quantification of Blood Loss, May 2014
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APPENDIX K: OB HEMORRHAGE POCKET CARD
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Reproduced with permission from CMQCC. For a full-size version, download the OB Hemorrhage Toolkit v 2.0 from CMQCC.org
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APPENDIX L: MEASUREMENT & DELIVERABLES GRID
OB Hemorrhage Multi-Hospital Collaborative
Aim 1: Reduce the number of massive hemorrhages and the number of major complications from massive hemorrhage, including
transfusions and hysterectomies, for all birthing women in participating hospitals by 50% by December 31, 2014.
Aim 2: All collaborative participants develop and implement a multidisciplinary team response to every massive obstetric hemorrhage by
December 31, 2014.
Purpose of the Measurement Grid: The measurement grid outlines the measures to be collected over the 18-24 month life of the OB
Hemorrhage multi-hospital collaborative. The grid includes the specific parameters for each measure, what data to collect, and how to submit
data on the deliverables. Hospital teams may determine their data collection methods.
Process Measures
Identify progress over time in changes to processes of care that affect outcome measures. Measuring the results of these process changes will
show if the changes are leading to an improved, safer system.
Measure Deliverable Specifics Data Collection Plan Data Submission/Calculation
1. General General Department Policy is reviewed and Create or revise a written At baseline and annually:
Department updated and includes (but is not limited to the general hemorrhage policy Submission of general department
Hemorrhage Policy following elements): and protocol hemorrhage policy and procedure
and Procedure is Identify roles and multi-disciplinary team Date of most recent review and
reviewed and updated responders for stage 1, 2, and 3 update
hemorrhages
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Determine and implement the most

desirable method for maintaining
accessibility to the needed OB hemorrhage
supplies (Hemorrhage Kit/Cart)
2. Massive Massive Transfusion Protocol is reviewed and Create or revise a written At baseline and annually:
Transfusion Protocol updated and includes (but is not limited to) the massive transfusion policy Submission of massive transfusion
and Procedure is following elements: and protocol protocol
reviewed and updated Coordination of response with Blood Bank Date of most recent review and
update
3. Cognitive/ didactic Cognitive/Didactic education includes, but is not Track the number of Monthly
education and Skills limited to, Grand Rounds, Flip Charts existing MDs and non-MD
education conducted clinical staff who receive # of existing MD and # of non-MD
with/provided to didactic/cognitive and clinical staff who received
>80% of existing RN skills education cognitive/didactic education on
and MD staff and an Skills education includes, but is not limited to: hemorrhage policies and
ongoing education intrauterine balloons, B-Lynch suturing, Track the number of new procedures each month
plan is developed for quantitative measurement of blood loss hires who receive Denominator: # of existing MDs
100% of incoming education on hemorrhage and # of non-MD clinical staff in
(new hire/new join) policies and procedures. pool of possible responders
staff
Are 100% of new hires receiving
cognitive/didactic and skills education
on hemorrhage policies and
procedures? Y/N
4. Create drills Have 100% of staff run at least one multi- Track the number of Monthly
tailored to your disciplinary (i.e., doctors and nurses) drill per clinicians and staff
hospital P&Ps and YEAR to identify system and process involved in drills. Submit drill debrief forms to
responder roles improvement opportunities. Complete drill debrief edunn2@health.usf.edu
After each drill complete a drill debrief form. forms. These forms will be
used to track number of # of MD and non-MD clinicians
drills. involved in drills/mo over total #
clinicians
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5. Percent of women Utilizing an evidence-based risk scoring tool, all Use audit tool to audit 20 Monthly
assessed for risk of women admitted for birth will be assessed for randomly selected charts
obstetric hemorrhage risk of obstetric hemorrhage and the score per month. Numerator: # of women
on admission documented in clinical record so that the risk is 10 vaginal and 10 c- assessed for risk of OB
considered in the patient care plan for labor and section. hemorrhage at admission each
delivery. month
Note whether the risk Denominator: 20
score was included in the
patient care plan for L&D.
6. Percent of women In order to be considered Active Management, Use audit tool to audit 20 Monthly
receiving Active must include two 2 components: randomly selected charts
Management of the Oxytocin (IV or IM) at delivery of the per month. Numerator: # of women who
Third Stage of Labor baby received active management of
Fundal Massage for 15 seconds Note: the third stage (both oxytocin
minimum Administration of oxytocin and fundal massage)
Optional: at delivery of: Denominator: 20
Gentle cord traction - Baby
- Placenta
7a. Quantitative Quantification and documentation of blood loss Use audit tool to audit 20 Monthly
measurement of blood is performed (during and after all births until randomly selected charts
loss is documented immediate recovery status changes to routine per month. Numerators:
DURING vaginal postpartum care and woman is physiologically 10 vaginal and 10 c- Not measured
deliveries stable) using 1 or more of the 3 preferred section. Estimated with visual cues
methods: only
1. Formally estimate blood loss by Measured using % saturation
7b. Quantitative recording percent (%) saturation of Measured using weight
measurement of blood blood soaked items with the use of Measured by collection
loss is documented visual cues such as pictures/posters to
DURING cesarean determine blood volume equivalence of Denominator: 20
deliveries saturated/blood soaked pads, chux, etc.
2. Formally measure blood loss by
weighing blood soaked pads/chux, etc.
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3. Formally measure blood loss by

collecting blood in graduated
measurement containers.
8. Documented hand Handoff report assessing cumulative blood loss Track # of reports. Monthly
off report assessing between L&D and postpartum staff in 100% of
for cumulative blood cases involving blood loss of 1000 cc or greater Numerator: # of reports
loss, between labor
and delivery and These reports are to assure that continued Denominator: # of hemorrhages that
postpartum medical vigilance is maintained for progression of blood advanced beyond 1000 cc / Stage 2 or
and nursing staff for loss and appropriate actions taken as needed. 3 hemorrhages
all women with 1000
cc blood loss or
greater.
9. Frequency of Stage 2 or Stage 3 hemorrhages are defined as Track all hemorrhages Monthly
debrief sessions hemorrhages that continues requiring beyond 1000 cc / stage 2
involving MD and additional interventions, treatments, or or 3. Numerator: # of debrief forms
non-MD staff that took procedures after the patient received IV or IM submitted to FPQC
place for a Oxytocin, vigorous fundal massage, and either Track the number of MDs
hemorrhage that IM Methergine or PR Misoprostol. and non-MD staff who Denominator: # of hemorrhages that
advanced beyond participated in debriefings advanced beyond 1000 cc / Stage 2 or
1000 cc /beyond Stage 2 and 3 interventions are outlined in the on debrief forms. 3 hemorrhages (hemorrhages that
stage 2 or 3 CMQCC OB hemorrhage checklist. required interventions, treatments,
See Obstetric Hemorrhage procedures outlined in stage 2 or 3 of
Recommendation: Completion of debrief is Team DeBriefing Form or the CMQCC OB hemorrhage checklist)
encouraged to occur immediately after the any form that captures the each month
patient is stabilized e.g. when she goes to the elements contained on this
recovery area, but no later than 24 hours after form.
event. Email scan of debriefing to
RN who took care of patient leads debriefing the FPQC
and fills out form
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10. Percent of women Blood Transfusion: data from internal source Track the number of Baseline
(who gave birth 20 such as blood bank data, patient charts, women transfused with any
0/7 weeks gestation) medical records, Electronic Medical Record blood product during the Monthly
who were transfused (EMR), etc. birth admission.
Numerator: # of women (who gave
with any blood
birth 20 0/7 weeks gestation) who
product during the If available: Blood loss data recorded in
were transfused with any blood
birth admission patient record or delivery log. Track the number of
product during the birth admission
women who gave birth (20
each month.
ICD-9 Procedure Code for transfusions: 99.0 0/7 weeks gestation) each
month
Denominator: Total # of births (20
CPT Code: 36430: Transfusion, blood or blood
0/7 weeks gestation) each month
components
Note that these codes do not typically identify

transfusions accurately. We recommend
obtaining data from the Blood Bank when
possible.
Cross check against patient charts as needed.
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11. Total units of each Work with your blood bank to identify units Track the number of units Baseline
type of blood product transfused per month during birth admission of each type of blood
(PRBCs, Platelets, of each type: product per birth Monthly
Plasma/FFP, Cryo) PRBCs admission.
Numerator: Total units of each type
transfused during Platelets of blood product (PRBCs, Platelets,
birth admissions per Plasma/FFP Debrief Form: For women Plasma/FFP, Cryo) transfused during
total births Cryo who experience Stage 2 or 3 birth admissions each month.
hemorrhage, identify units of # Units of PRBCs
Accounting records can also be an accurate PRBCs, Platelets, # Units of platelets
source for these data Plasma/FFP, Cryo (for each # Units of plasma/FFP
woman) on the Debrief Form # Units of Cryo
Cross check data obtained from blood bank Denominator: Total # of births (20
and/or accounting with chart reviews Track the number of
women who gave birth (20
0/7 weeks gestation) each
month
12. Percent of women See above Track the number of Baseline

(who gave birth 20 women who were
0/7 weeks gestation) transfused with 5 units Monthly
who were transfused PRBCs during the birth
Numerator: Number of women (who
with 5 units PRBCs admission.
gave birth 20 0/7 weeks gestation)
during the birth
who were transfused with 5 units
admission
PRBCs each month.
Denominator: Total Number of

Births (20 0/7 weeks gestation)
each month.
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13. Rate of Peripartum hysterectomies are stratified by: Peripartum Hysterectomy: Baseline
peripartum Women with Placenta Previa and/or Data Collection from
hysterectomies in Placenta Accreta/Percreta internal source such as Monthly
women (who gave Women without Placenta Previa and/or EMR, medical records, or
Numerator: Number of peripartum
birth 20 0/7 weeks Placenta Accreta/Percreta other method determined
hysterectomies (performed during
gestation) per 1000 by each site
birth admission) in women who gave
births Women who had a hysterectomy and placenta
birth 20 0/7 weeks gestation each
(hysterectomy previa and/or accreta/percreta are reported ICD-9 Procedure Codes
month.
performed during separately from women who had a 68.3 Subtotal abdominal
# hysterectomies with
birth admission) hysterectomy and NO placenta hysterectomy
Placenta
stratified by risk of previa/accreta/percreta. This measure 68.39 Other and
previa/accreta/percreta
Placenta Previa includes both planned and emergent unspecified subtotal
# hysterectomies without
and/or Placenta hysterectomies. abdominal hysterectomy
Accreta/percreta
68.4 Total abdominal
Denominator: Total Number of
hysterectomy
Births (20 0/7 weeks gestation)
68.49 Other and
each month.
unspecified total abdominal
hysterectomy
Annotation for each hysterectomy:
- indication for hysterectomy
CPT Codes
- # of prior c-secs
59525 Cesarean
- # of days post-delivery
Hysterectomy
58150 Hysterectomy
Total/Partial (Use Post-
Partum or with Vaginal)
59160 D&C after delivery
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14. Percent of women Note: FFP, RBC or plt 10pack=1 unit Track the number of Baseline
(who gave birth 20 women transfused with >3
0/7 weeks gestation) Blood Transfusion: data from internal source units of any blood product Monthly
who were transfused such as blood bank data, patient charts, during the birth admission.
Numerator: # of women (who gave
with >3 units of any medical records, Electronic Medical Record
birth 20 0/7 weeks gestation) who
blood product during (EMR), etc.
were transfused with >3 units of any
the birth admission Track the number of
blood product during the birth
If available: Blood loss data recorded in women who gave birth (20
admission each month.
patient record or delivery log. 0/7 weeks gestation) each
month
Denominator: Total # of births (20
ICD-9 Procedure Code for transfusions: 99.0
CPT Code: 36430: Transfusion, blood or blood

components
Note that these codes do not typically identify

transfusions accurately. We recommend
obtaining data from the Blood Bank when
possible.
Cross check against patient charts as needed.
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FPQC OHI Slide Set November 2013
OHI Slide Set Instructions

You may delete this slide before presenting
There are three OHI slide set modules: Florida Perinatal Quality Collaborative
Module 1: Maternal Mortality and Obstetric Hemorrhage
Module 2: The Florida OHI Toolkit
Module 3: Hospital Level Implementation Plan of the OHI
Please use the FPQC template for any slide you use
Florida Obstetric Hemorrhage
Please do not use the FPQC or CMQCC logo if you
modify a slide or add a slide to the presentation.
Initiative (OHI):
Speaker Notes are provided with this slide set in the notes Quality Improvement in Obstetric
section. Hemorrhage Management
Please provide us feedback and recommendations for
Insert here your name, credentials, affiliations and date
improving the slide set Version 11/2013
Course Objectives Mission Statement of the OHI
Decrease short- and long-term morbidity and mortality

Describe the issue of maternal mortality and related to obstetric hemorrhage in women who give
hemorrhage in the state of Florida birth in Florida
Describe the Florida Obstetric Hemorrhage Initiative Guide and support maternity care providers and
(OHI) Toolkit hospitals in implementing successful, evidence-based
quality improvement programs for obstetric
Describe the FPQC OHI Care Guidelines hemorrhage
Discuss the OHI hospital implementation plan
3 4
1
Annual Postpartum Hemorrhage Rates, United States,

1994-2006
Annual rates of postpartum hemorrhage caused by

atony, by mode of delivery, and by induction status
Florida Pregnancy Associated Mortality
(United States, 19942006) Review FL PAMR
Hemorrhage is one of the top two causes of maternal

mortality from 1999 to 2010 (15% of deaths) in Florida
Causes:
Uterine atony/postpartum bleeding
Placenta accreta, percreta or increta
Retained placenta
Ruptured ectopic pregnancy
7 8
2
Overview: 1999-2010 Florida Pregnancy-Related Mortality Ratios

Pregnancy-Related Mortality (PRMR) Florida 1999-2010
Findings
PAMR screening committee selected 756

pregnancy-associated deaths for investigation
during 1999-2010
Identified 470 (62%) deaths as pregnancy-

related
9 10
Number of Pregnancy-Related Deaths by Hemorrhage-Related Deaths

Cause, Florida 1999-2010 (N=470) Florida 1999-2010
Hemorrhage by Cause
Other 23
Ectopic
25
(35%) (32%)
Hemorrhage 8
7
(N=71) 8 Atony
Retained
Placenta (11%)
(10%) Accreta
11
(11%) 12
3
Hemorrhage-Related Deaths Hemorrhage-Related Deaths

Florida 1999-2010 Florida 1999-2010
Hemorrhage pre-delivery through 42 days post-delivery
Undelivered
Abortion 4%
8-42 days 6%
6%
1-7 days Fetal Outcomes Live Birth

24% Ectopic
Before Delivery 52%
42%
32%
<1 day
Hemorrhage
28% Stillbirth
(N=71) 6%
13 14
Peri/Post partum Hemorrhage Pregnancy-Related Peri/Postpartum Hemorrhage Mortality Ratios

Deaths by Hospital Characteristic, Florida, 2006-2011 by Hospital Characteristic, Florida, 2006-2011
15 16
4
Local Hospital Data Questions or Comments

Insert your hospital-specific information on
hemorrhage here
17 For more information about FPQC, please visit: http://health.usf.edu/publichealth/chiles/fpqc 18
Disclaimer
The OHI Toolkit is a resource and not a standard of

care.
FPQC will provide research updates
Hospitals should individualize their protocols based

on an assessment of their own resources
20
5
Florida OHI Hospitals

IMPROVE READINESS
13% of hospitals do not perform drills
32% of hospitals do not have access to all procedure Implement standardized protocols
options (e.g. B-lynch suture, etc) Hemorrhage Cart
33% of hospitals do not have a written general Procedural Instructions (balloons, stitches)
hemorrhage policy Partnership with the blood bank
35% do not have a massive transfusion protocol Regular unit-based drills (with debriefs)
42% do not utilize techniques to quantify blood loss for Ensure rapid availability of medications
both vaginal and cesarean births Special case resources (previa, Jehovahs Witness)
60% DO NOT perform debriefs after events Unit Education to protocols
21 22
Prevention/Learning IMPROVE RECOGNITION
Active Management of the 3rd Stage

Establish a culture of Post-event Debrief/Huddle On-going assessment of hemorrhage risk
Review of all serious cases for systems issues Prenatally
Mini RCA format On Admission
Prior to delivery
Postpartum
Early Warning Tools for vital signs and symptoms
Quantitative CUMMULATIVE blood loss assessment
23 23 24
6
IMPROVE RESPONSE Issues with Hemorrhage Response
Perform regular
hemorrhage drills
Unit-standard OB Denial
Hemorrhage Protocol
Delay
with checklists
Lack of practice with rare occurrences
Massive transfusion
protocols Imperfect estimation/quantification of blood loss
Poor utilization of blood products
Insufficient communication
25 26
Key Elements of the OHI

IMPROVE REPORTING
1. Develop an Obstetric Hemorrhage Protocol
2. Develop a Massive Transfusion Protocol
Improve reporting of OB hemorrhage by 3. Antepartum Risk Assessment
standardizing definitions and consistency in coding and 4. Active Management of the Third Stage of Labor
reporting.
5. Quantification of Blood Loss
This is accomplished by standardizing our definitions,
following protocols, quantifying blood loss, practicing our 6. Construct an OB Hemorrhage Cart
responses, and consistent coding and reporting. 7. Ensure Availability of Medications and Equipment
8. Perform Interdisciplinary Hemorrhage Drills
27 9. Debrief after OB Hemorrhage Events 28
7
Why a Protocol for Obstetric Hemorrhage?
Now a complex series of steps that involve

1. Develop an Obstetric Hemorrhage Policy many staff members and departments
Communications!
PPH seems to always happens at night or
weekends(when people may be tired or there
are less resources)
We can improve
30
Core Elements of any Protocol

Develop an effective written document for responding to
maternal hemorrhage
Rapid response to hemorrhage emergency
Coordination among
physicians
nurses
anesthesiologists
blood bank 2. Massive Transfusion Protocol
Complete set of prewritten orders to instantly execute
Escalation through stages
31
8
Lessons from Combat in Iraq Whole blood is good for OB hemorrhage

After 2u PRBCs, start FFP
Massive transfusion protocol: 1:1 ratio FFP/RBC
6 RBC + 4 FFP + 1Plt pack (Stanford+)
4 RBC + 4 FFP, plts and cryo on request (CPMC)--think ahead!
Keep up!
Two Stages: Resuscitation and Treatment

Pending use Resuscitation, transfuse per clinical signs
of photos
purchased for DIC treatment, transfuse per lab parameters
CMQCC use Lowest losses ever
from hemorrhage Supportive measures are critical
Key: increased Warm patient (Bair Hugger, fluid warmer)
FFP:RBC ratio 33
34
Correct metabolic acidosis
Recommendations:
Massive Transfusion Protocol
Every OB unit needs one!

Coordinated with Blood Bank, Anesthesia, and
ER/ICU
Ability to deliver large volumes of RBCs and
coagulation products
Principle: Whole blood out = whole blood in
Guidelines for coagulation product usage 3. Antepartum Risk Assessment
36
35
9
Risk Assessment Ongoing Hemorrhage Risk Assessment

Low Medium High
No previous Prior cesarean birth(s) Placenta previa

uterine incision Prior uterine surgery Low-lying placenta
Risk factor identification Singleton Multiple gestation Suspected placenta
pregnancy >4 previous vaginal births accreta
A prewritten order set for admission to L&D 4 previous Hypertension-associated Hematocrit <30
vaginal births Conditions Platelets <100,000
includes risk scoring for obstetric hemorrhage Antepartum
No known History of previous PPH Active bleeding at
bleeding disorder Large uterine fibroids admission
Definition checklist No history of Estimated fetal weight greater Known
PPH than 4 kg coagulopathy
Risk assessment can also occur intrapartum Morbid obesity (BMI > 35 kgm2) Abruptio Placenta
Polyhydramnios
Induction or augmentation of
labor
Protracted labor or arrest
Intrapartum disorder
38 Chorioamnionitis
37 38
38
Active Management of the Third

Stage
4. Active Management of the Third Stage
Oxytocin (10u) IV or IM with delivery of infant
of Labor
or placenta
Vigorous fundal massage (at least 15 sec) after
placenta delivery
Controlled cord traction

is an optional component
Click to edit Master title style to be applied by a skilled
care provider
40
#
10
Quantification
EBL method used most Accurate QBL prompts

often is visual estimation the Nurse on critical
5. Quantification of Blood Loss Visual estimation is actions such as mobilizing
unreliable and inaccurate the team
Underestimated as much Critical decisions are made
as 50 % of time Institute based on QBL
most accurate methods: QBL leads to earlier
Quantification of Blood interventions & improved
Loss outcomes
References: Gabel et al 2013; Lyndon et al 2010; Bingham et al 2012 42
Recommended Methods for Ongoing

Quantitative Measurement of Blood Loss Methods to Estimate Blood Loss
Quantifying blood loss
1. Formally estimate blood loss by recording percent
by weighing
(%) saturation of blood soaked items with the use Establish dry weights of
of visual cues such as pictures/posters to determine common items
blood volume equivalence of saturated/blood Standardize use of pads
Build weighing of pads
soaked pads, chux, etc.
into routine practice
2. Formally measure blood loss by weighing blood Develop worksheet for
soaked pads/chux. (1 gram = 1 ml) calculations
3. Formally measure blood loss by collecting blood in

graduated measurement containers.
43 With kind permission of Bev VanderWal, CNS
44 44
11
Methods to Estimate Blood Loss Methods to Estimate Blood Loss

Develop Training Tools: Visual aids displayed in Labor & Delivery
Quantifying blood loss by measuring and/or Postpartum areas are guides for more accurate visual
Use graduated collection containers (C/S and vaginal estimation (visual aids can be displayed discreetly for clinicians)
deliveries)
Account for other fluids (amniotic fluid, urine, irrigation)
With kind permission of Bev VanderWal, CNS

With kind permission of Bev VanderWal, CNS
45 46
Recommendations Recommendations
Teach clot size using posters showing known blood quantities on Many centers will customize their approach to quantification
common materials or compared to common volumes (e.g a Coke using a combination of approaches for different settings
can=350ml) Vaginal deliveries
Weigh wet materials (with known dry weight); this can be done by Cesarean sections
gathering a group of pads and weighing them all together Minimal loss
Measure what can be suctioned at CS (less irrigation+AF) Greater than usual loss
Use calibrated under-buttock drapes (at vaginal birth, note the Massive loss
volume of amniotic fluid, urine and stool after birth but before the The process is intentionala formal effort!
placenta)
No more vague Guesstimates
What we dont know: How to estimate the blood loss that we
dont see (i.e. intra-abdominal) Continues and is cumulative
47 48
12
Who should determine QBL?

Anesthesia is at the head of the table and often does
not see it all
OBs arent looking at the suction bottles or at the
collective sponges
No one is doing it in a standardized manner
obstetricians need help! Collaboratively!
We should be able to answer:
How much blood is in the suction bottle (after amniotic
fluid)?
How much blood is on sponges?
How much blood is on the floor/on the table? 6. Construct an Obstetric Hemorrhage Cart
In a big case, hourly and cumulatively
49
Hemorrhage Carts, Kits and Trays

Checklist of medications and procedures 7. Assure Availability of Medications and
Diagrams depicting various procedures
Equipment
B-Lynch
Uterine artery ligation
Balloon placement
Set of vaginal retractors
Sponge Forceps
B-Lynch sutures
Vaginal Packs
Uterine Balloons
Banjo curettes
Uterine forceps
Long needle holder 51
13
OB Hemorrhage Medication Kit

Cook Bakri Intrauterine Balloon
PYXIS/refrigerator
There are now several balloons, but the most available
in the US is the Cook Bakri Balloon
Pitocin 20 units per liter NS 1 bag
Specificallydesigned for this purpose
Hemabate 250 mcg/ml 1 ampule
Double lumen (for drainage from above)
Methergine 0.2 mg/ml 2 ampule
Silicone (non-latex)
Cytotec* 200mg tablets 5 tabs
Uterine contour shape
Good filling capacity (saline)
Inexpensive
*There is no strong evidence that misoprostol is useful as primary or Easy to use

adjunctive therapy of postpartum hemorrhage in addition to standard
injectable uterotonics.
53 54
Successful Applications of the Intrauterine Intrauterine Balloon

Balloon
Low-tech, fast, inexpensive, easy to utilize on any L&D
Low-lying placental implantation site, esp with placenta Unit
previa Least morbidity of any next step
Poorly contracting lower uterine segment
Can be used as Tamponade Test to temporize,
Uterine atony determine needs and mobilize other resources
Placenta accreta / percreta
There is some user learning
Cervical implantation
How much to fill? (150-500ml is a big range).
DIC at term or after 2nd trimester loss
usually 250-300ml is sufficient unless the uterus is
In combination with Compression Suture at hysterotomy
(Sandwich technique) very floppy
Vaginal sidewall lacerations There can be hour-glassing of the balloon thru the
55
cervix into the vagina. 56
14
B-Lynch Compression Suture B-Lynch Suture completed

Belt and Suspenders
57 58
Photo courtesy of Elliott Main, MD-CPMC
B-Lynch Suture
Every Obstetrician should know how to do this

(diagrams are in each OR)
Quick (<2 minutes) and easy!
Ideal at time of Cesarean birth for atony
Can be combined with an intrauterine balloon for
8. Perform Hemorrhage Drills
Sandwich technique
59
15
Importance of Drills / Simulations Simulation Drills

Safety and QI Leader: Paul Preston, MD
Hospitals should run drills at different times of the day
to ensure that appropriate hemorrhage team members
Medicine is the last high-risk industry that expects are available at all times.
people to perform perfectly in complex, rare All members of the health care team should participate,
emergencies but does not support them with high- including nurses, physicians and ancillary staff, as
quality training and practice throughout their careers. appropriate.
Debriefings should occur after every drill and after
every actual OB hemorrhage emergency.
Certain individual and team skills require regular
This allows for continuous quality improvement
practice that cannot ethically occur in routine care.
61 62
Debriefs
After major OB hemorrhage event or simulation drill,
provides opportunity to:
Decompress
Discover areas for improvement
Benefit from immediate feedback
9. Debrief after OB Hemorrhage Event Enhances retention of information

Increases learner engagement
Leads to higher staff confidence
Is a learning opportunity, not punitive

64
16
Debriefing
Led by facilitator (primary RN and primary MD)
Includes:
Recap of the situation OB HEMORRHAGE STAGES
Key events that occurred
What worked
What did not work
E.g. communication, lack of necessary equipment
Discussion of what can be done differently
Completion of a debrief form

65 66
OB Hemorrhage Checklist
Obstetric Hemorrhage Care Summary:

STAGE 0
Every woman in labor/giving birth

Focuses on
risk assessment
active management of the third stage
67
68
17
Recommendations
Vital Signs are Often Ignored
Concept of Triggers
Labor and Delivery Policies include specific vital sign
Triggers identify patients that need more attention and blood loss triggers
(from on-call physician, in-house physician, or rapid identify when to call for Physician attendance and
response team (RRT)) evaluation
Prevent such patients from being ignored identify when to call the Rapid Response Team
Independent of diagnosis, useful for all OB The Hemorrhage Protocol/Guideline should have
emergencies specific thresholds that identify when to call-in more
Used in many areas of hospital medicine staff and move along a series of interventions
Do not wait for lab results before acting
69 70
Maternal Alerts (Triggers)
Systolic BP, mmHg <90 or >160

Diastolic BP, mmHg >100 STAGE 1
Heart rate; <50 or >120
beats per min Blood Loss > 500 ml vaginal or > 1000 ml C/S
Respiratory rate; <10 or >30 VS changes/triggers by >15% or
Breaths per min HR >110,
Oxygen saturation, % <95 BP <85/45,
Room air, sea level O2 sat < 95%
Oliguria; <30
mL/hr for 2 hours Activate OB Hemorrhage Protocol and Checklist
71 72
18
Draft 1.2

STAGE 2
Continues bleeding with total QBL under 1500 ml
OB back to bedside (if not already there)
Patient to OR (vaginal birth)
Extra help 2nd OB, Rapid Response Team
Escalating treatment
Sequentially advancing through

Medication
Mobilize Blood Bank
Procedures
Keep ahead with volume and blood products
73 74
73
73
Draft 1.2
Steadily Moving Up the Protocol
If there has been little/no response to Methergine, do

not give the second dose but MOVE ON to the
prostaglandin second medication.
Second medication - Hemabate
If Hemabate has had little/no effect, move on to non-
pharmacologic methods
Little value in giving both hemabate and misoprostol,
as the mechanism of action is the same
75 75 76
75
19
Who should determine QBL?

STAGE 3
Total QBL over 1500 or >2 units
VS unstable
Suspicion of DIC
Massive Transfusion protocol

Invasive surgical approaches for control of
bleeding
77 78
Examples of OB Hemorrhage Care

Guidelines
FPQCs
OB Hemorrhage
Care Algorithm
Available in CMQCC toolkit 79 80
20
FPQC Obstetric Hemorrhage Guidelines Algorithm FPQC Obstetric Hemorrhage Guidelines Algorithm
Pre Admission Verify Type &

STAGE 0 - ALL BIRTHS Ongoing Cumulative Blood
Identify patients with special consideration: Screen on
Active Management of Evaluation: Loss
Placenta previa/accreta, Bleeding disorder, or those prenatal record;
3rd stage of labor Quantification of >500ml Vag or
who decline blood products if positive
Oxytocin IV infusion or blood loss, vital >1000ml CS
Follow appropriate workups, planning, preparing of antibody screen
10 Units IM signs, LOC 15% Vital Sign change
resources, counseling and notification on prenatal or
Vigorous fundal -or-HR110,
current labs
massage for 15 seconds BP 85/45, O2 Sat
(except low level
anti-D from <95%,
Time of Low Risk: Hold blood
Rhogam), Type & Clinical Sx (ex. LOC
Admission Medium Risk: Type & Standard
Crossmatch 2 NO change)
Screen All Screen, Review Postpartum
Hemorrhage Protocol, Units PBRCs Management
Admissions for
hemorrhage risk: High Risk: Type & Fundal Massage YES
Low Risk, Medium Crossmatch 2 Units PRBCs;
Risk and High Risk Review Hemorrhage
Protocol
Lyndon et al 2010; ACOG 2006; Berkowitz and Bernstein 2012;
Lyndon et al 2010; ACOG 2006; Berkowitz and Bernstein 2012; Shields et al 2011
Shields et al 2011 81 82
STAGE 1 STAGE 2
Activate Hemorrhage Protocol Notify rapid response team and OR team
Notify- OB, Charge RN, anesthesia personnel OB at beside if not already there
Order Type & Crossmatch 2 Units PRBCs if not already done Give meds: Hemabate 250 mcg IM, Onset of action 5 minutes, May repeat every 15-90
minutes, max dose 2mg
Continue QBL. Notify blood bank and ascertain blood product availability
Increase IV rate (LR); Increase Oxytocin. Repeat fundal massage.
Methergine 0.2 mg IM (if not hypertensive) Onset of action 3-5 minutes. If unresponsive, repeat or
Vaginal Birth: Transfuse 2 Units
next drug Bimanual Fundal Massage
If hypertensive, Hemabate 250 mcg IM (caution with asthmatics), Onset of action 5 minutes PRBCs per
Retained POC: Dilation and Curettage
Insert indwelling foley catheter; Keep Warm; Administer O2 to maintain Sat >95% Lower segment/Implantation site/Atony: Intrauterine Balloon insertion clinical signs
VS, O2 Sats q 5 min, Measure blood loss q 5 to 15 min (weigh bloody materials) Laceration/Hematoma: Packing, Repair as Required Do not wait for
Inspect all vag walls, cervix, uterine cavity, and rule out retained POC, laceration or hematoma Consider IR (if available & adequate experience) lab values,
Start 2nd IV line (16-18 gauge) Cesarean Birth:
Continued Atony: B-Lynch Suture/Intrauterine Balloon Consider thawing
Draw and Send blood for CBC, PT,PTT and fibrinogen
Continued Hemorrhage: Uterine Artery Ligation 2 Units FFP
Continued heavy bleeding Increased Postpartum Cumulative Blood

NO Increased Postpartum NO
Cumulative Blood Loss Surveillance Surveillance Loss>1500 ml
QBL 500-1500 ml- VB
QBL 1000-1500 ml- C/S Hand off report of documentation of 2 Units PRBCs
YES YES
cumulative blood loss Given
83
Vital Signs Unstable
Lyndon et al 2010; ACOG 2006; Berkowitz and Bernstein 2012; Shields et al 2011 84
21
STAGE 3
To OR (if not there); Consider additional OB assistance or RRT We Can Make a Difference
Activate Massive Hemorrhage Protocol
Mobilize Massive Hemorrhage Team TRANSFUSE AGGRESSIVELY RBC:FFP:Plts -
>6:4:1 or 4:4:1 Systems Approach to
Unresponsive Coagulopathy: After 10 Units PBRCs and full coagulation factor
replacement, may consider rFactor VIIa Obstetric Hemorrhage
Conservative Surgery
B-Lynch Suture/Intrauterine Balloon Organize your unit and your response
Uterine Artery Ligation / Hypogastric Ligation (experienced surgeon only)
Recognize Denial and Delay
Consider IR (if available & adequate experience
Get help
HEMORRHAGE CONTROLLED
HEMORRHAGE CONTINUES Get exposure to perform thorough exams and
identify the source of bleeding
Consider ICU Care Definitive Surgery Do not get behind
Increased Postpartum Surveillance Hysterectomy
Hand off report of cumulative blood Process Is Most Important!
loss 85 86
Systems Approach to OB Hemorrhage Can we lower the frequency and

morbidity/mortality of OB Hemorrhage?
Department: OB Hemorrhage Protocol with stages
Lower the incidence:
Hospital: Massive Transfusion Protocol
Reduce the cesarean birth rate (both primary and repeat)
Summary Flow algorithm: graphic or tabular Reduce chorioamnionitis
Nursing checklist by stages Fewer multiple gestations
Documentation forms: OB Hemorrhage Report Reduce long inductions of labor
Worksheets to assist with assessment of blood loss Reduce long second stages
Hemorrhage cart/kit Respond rapidly to OB hemorrhage:
Instruction cards for new procedures in cart or OR Use the new techniques and respond in an organized, well-
executed, timely fashion
Drills Keep a small hemorrhage from evolving into a massive
hemorrhage
87 88
22
Questions or Comments
For more information about FPQC, please visit: http://health.usf.edu/publichealth/chiles/fpqc 89
OHI Aims Maternal Mortality Advisory Board

Reduce the number of massive hemorrhages Hemorrhage Experts:
and the number of major complications from Robert Yelverton, MD, FACOG, ACOG District XII Chair
massive hemorrhage, including transfusions and Karen Harris, MD, MPH, FACOG, ACOG District XII Vice-
Chair
hysterectomies, for all birthing women in Anthony R. Gregg, MD, FACOG, District XII Chair of the
Maternal Mortality Committee
participating hospitals by 50% by December 31, Judette Louis, MD, MPH, FACOG, Assistant Professor Dept. of
2014 OB/GYN, University of South Florida
Bruce Breit, MD, FACOG, Chair of District XII Committee on
All collaborative participants develop and Patient Safety and Quality
Isaac Delke, MD, FACOG, Medical Director, Obstetric Services,
implement a multidisciplinary team response to University of Florida College of Medicine - Jacksonville
every massive obstetric hemorrhage by Margie Mueller Boyer, RNC, MS, Florida Section Chair,
AWHONN
December 31, 2014 Mary Kaye Collins, CNM, JD, FACNM, Florida Affiliate of the
American College of Nurse-Midwives
91 92
23
Maternal Mortality Advisory Board Rapid Cycle Learning
FPQC Leaders & Staff: MAP-IT

John Curran, MD, FPQC Executive Director Mobilize
William Sappenfield, MD, MPH, Director, USF Chiles Center Assess
Linda A. Detman, Ph.D., FPQC Program Manager
Plan
Annette Phelps, ARNP, MSN, FPQC Nurse Consultant
Implement
Emily A. Dunn, MA, MPH, Quality Improvement Analyst
Track
Heidi Curran, MBA, Marketing and Communications Officer
Source: Guidry, M., et. al. Healthy people in healthy communities: A community planning guide using healthy people 2010.
Washington, D.C. U.S. Dept. of Health and Human Services. The Office of Disease Prevention and Health Promotion.
94
Expectations of MD and Nurse Expectations of Hospital

Leaders Administrators
Lead the hospitals OHI quality improvement efforts Connect the goals of the Collaborative to a strategic
Perform baseline assessment initiative in their hospital
Attend the in-person meetings and monthly phone calls Serve as sponsor for the team
Share information with the Collaborative Provide the resources to support their team, including time
to devote to this effort and active senior leadership
Perform tests of change that lead to process
involvement as appropriate
improvements in the organization
Spread successes across the entire hospital system where
suitable
95 96
24
Expectations of the FPQC Expectations of Participating

Collaborative Hospitals
Coordinate experts and other support resources Identify an implementation team to include local and
Provide content oversight and process management travel components and a physician champion
Provide a mechanism for sites to report project data Develop and implement policies adhering to the
Provide analytic support evidence-based strategies for management of obstetric
hemorrhage
Provide effective communication strategies
Participate on phone calls and webinars and share their
Communicate progress and deliverables to stakeholders
challenges and successes to provide for joint learning
Evaluate and report OHI activities and impact and practice improvements
97 98
Collaborative Timeline Collaborative Activities

Tasks Target Completion Date
Establish baseline data August 2013 December 2013
Initial in-person meeting of alpha In-Person Meetings
October 2013
cohort
Monthly Conference calls with alpha Representatives will participate in an initial in-person
cohort to report progress and
additional training opportunities as
November 2013 June 2015 meeting
need indicates
All hospitals attempt will attempt to
Share material for core elements and guideline/protocol
January 2014
have initiated their plans examples, training on change management, and clinical
Mid-project in-person meeting of
alpha cohort
Spring 2014
practice elements.
Optimization and sustainability phase
of the alpha cohort implementation December 2014 June 2015 A second face-to-face meeting to review data and share
reached
Technical assistance for alpha cohort August 2013 June 2015
successes and ideas for project improvement.
Project Monitoring and Evaluation Ongoing
99 100
25
Pre-Implementation Phase
Collaborative Activities
October 2013
Action Periods
Establishment of Hospital QI Leadership that leads the
Between meetings, hospitals will work toward rollout of the initiative within their hospital
improvement.
Will receive ongoing technical assistance: expert
consultation, site visits, training, and data review as Sign data use agreement and CEO commitment forms
needed.
Ongoing communication will occur.
Each hospital will report progress and additional Send representatives to FPQC October 30th OHI Kick
training opportunities as needed Off
Shared improvement efforts internally and externally
with other participating hospitals.
Submit data for quality improvement reports
101 102
Assess and Plan Change

Mobilize QI Team - November 2013 December 2013
Hospital QI Leadership recruits hospital QI team and Baseline data collected and process survey completed
convenes meeting to establish the following: by hospital QI team
Change strategy that addresses:
Hospital Policy
Scheduling Guidelines Convene department meetings to secure buy-in
Physician and Nurse Leadership
Rollout timeline and deadlines Amend hospital hemorrhage policies
Identification of barriers to success
Finalize work plan
Clinical education needs Conduct clinical staff education
Data collection process
Set launch date Monthly conference call to report progress and discuss
Hospital QI Team meetings needs
103 104
26
Initiative Launch January 2014 Implementation- February 2014
Conduct clinical staff education
Submit data for the prior month

announce initiative and begin collecting
data Monthly conference call and training as needed
105 106
Track Progress- April and Beyond Core Measures

Use this grid to guide the creation of your hospitals work plan.
Attend annual FPQC Conference on Perinatal Quality
in Tampa
PROCESS MEASURES
Attend mid-project in-person meeting of alpha cohort

(Spring 2014)
Report data monthly
107 108
27
1. General Department Hemorrhage Policy and 2. Massive Transfusion Protocol and Procedure
Procedure is reviewed and updated is reviewed and updated
DELIVERABLE SPECIFICS DATA COLLECTION PLAN DELIVERABLE SPECIFICS DATA COLLECTION PLAN
General Department Policy is Create or revise a written general Massive Transfusion Protocol is Create or revise a massive
reviewed and updated and includes hemorrhage policy and protocol reviewed and updated within 1 transfusion protocol
(but is not limited to the following year and includes (but is not
elements): limited to) the following
Identify roles and multi- DATA SUBMISSION/ DATA SUBMISSION/
elements:
disciplinary team responders for CALCULATION CALCULATION
At baseline and annually: Coordination of response At baseline and annually:
stage 1, 2, and 3 hemorrhages
with Blood Bank
Determine and implement the Submission of general Submission of massive
most desirable method for department hemorrhage transfusion protocol
maintaining accessibility to the policy and procedure Date of most recent review
needed OB hemorrhage supplies Date of most recent review and update
(Hemorrhage Kit/Cart) and update 109 110
3. Cognitive/didactic education and skills education conducted

with/provided to >80% of existing RN and MD staff and an
ongoing education plan is developed for 100% of incoming (new
hire/new join) staff
DELIVERABLE SPECIFICS DATA COLLECTION PLAN

Cognitive/Didactic education includes, Track the number of existing MDs
but is not limited to, Grand Rounds, and non-MD clinical staff who Debrief
Flip Charts
Skills education includes, but is not
receive didactic/cognitive and skills
education
Form
limited to: intrauterine balloons, B- Track the number of new hires who
Lynch suturing, quantitative receive education on hemorrhage
measurement of blood loss
OHI Toolkit
policies and procedures.
DATA SUBMISSION/ CALCULATION

# of existing MD and # of non-MD clinical staff who received training and
education on hemorrhage policies and procedures each month
Denominator: # of existing MDs and # of non-MD clinical staff in pool of
possible responders 111
28
4. Create drills tailored to your hospital policies and procedures

and responder roles

Run one multi-disciplinary Track number of drills
(i.e., doctors and nurses) drill Complete drill debrief forms
per month for four Audit Tool
consecutive months (two on DATA SUBMISSION/
night/evening shift and two CALCULATION
on day shift) to identify system Monthly OHI Toolkit
and process improvement
Submit drill debrief forms
opportunities. After each drill
complete a drill debrief form. # of MD and non-MD
clinicians involved in drill
debriefs/mo over total #
clinicians 113
5. Percent of women assessed for risk of obstetric hemorrhage 6. Percent of women receiving Active Management of the
on admission Third Stage of Labor
DELIVERABLE SPECIFICS DATA COLLECTION PLAN DELIVERABLE SPECIFICS DATA COLLECTION PLAN
Utilizing an evidence-based risk Use audit tool to audit 20 In order to be considered Active Use audit tool to audit 20
scoring tool, all women admitted randomly selected charts per Management, must include two 2 randomly selected charts
for birth will be assessed for risk month. components: (vaginal deliveries) per month.
of obstetric hemorrhage and the 10 vaginal and 10 c-section. Oxytocin (IV or IM) at delivery of
score documented in clinical the baby
Note whether the risk score
record so that the risk is Fundal Massage for 15 seconds
was included in the patient minimum
considered in the patient care care plan for L&D.
plan for labor and delivery.
Numerator: # of women who received active management of the
Numerator: # of women assessed for risk of OB hemorrhage at
third stage (both oxytocin and fundal massage)
admission each month
Denominator: 20
Denominator: 20 115 116
29
7. Quantitative measurement of blood loss is documented

Sample Audit Tool
DURING vaginal deliveries , cesarean deliveries
Risk Assessment DATA COLLECTION PLAN
(Numerator= # women with risk assessment documented /
DELIVERABLE
Use sample audit tool to audit 20
Denominator= Total Number of audited charts) SPECIFICS randomly selected charts per month.
Documented in chart Yes No Quantification and
10 vaginal and 10 c-section.
documentation of blood
loss is performed (during DATA SUBMISSION/
Active Management of Labor and after all births until CALCULATION
(Numerator= # charts with both oxytocin and fundal massage immediate recovery status
Numerators:
documented / Denominator= Total Number of audited charts) changes to routine
Not measured
Oxytocin IV/IM Fundal Massage postpartum care and
Estimated with visual cues only
Cord Traction (if performed at your facility) woman is physiologically
Measured using % saturation
stable) using one or more
Oxytocin administered at delivery of: baby -OR- placenta Measured using weight
of the three preferred
methods Measured by collection
117 118
Denominator: 20
Sample Audit Tool 8. Documented hand off report assessing for cumulative blood
loss, between labor and delivery and postpartum medical and
Cumulative Blood Loss and Quantitative Measurement
nursing staff for all women with 1000 cc blood loss or greater.
(Numerator= Not measured; Estimated with Visual Cues Only; Measured
using one or more of the three recommended formal measurements / DELIVERABLE SPECIFICS DATA COLLECTION PLAN
Denominator= Total Number of audited charts [please audit 10 Vaginal and Track number of reports
10 Cesarean) Handoff report assessing
Vaginal Delivery Cesarean Section cumulative blood loss between
L&D and postpartum staff in
DATA SUBMISSION/
100% of cases involving blood
Measurement NOT recorded in chart CALCULATION
loss of 1000 cc or greater
Estimated with Visual Cues ONLY (if this is selected do not go further) Monthly
These reports are to assure that
continued vigilance is Numerator: # of reports
Select all that apply:
maintained for progression of Denominator: # of
Formally measured by % saturation
blood loss and appropriate hemorrhages that advanced
Formally measured by weighing beyond 1000 cc
actions taken as needed.
Formally measured by collection
119 120
30
122
9. Frequency of debrief sessions involving MD and non-

MD staff that took place for a hemorrhage that
advanced beyond 1000 cc /beyond stage 2 or 3 OUTCOME MEASURES
Stage 2 or Stage 3 hemorrhages Track all hemorrhages beyond 1000 cc /
stage 2 or 3.
are defined as hemorrhages that
Complete Debriefing form.
continue requiring additional
Track the number of MDs and non-MD
interventions, treatments, or staff who participated in debriefings
procedures after the patient
received IV or IM Oxytocin,
vigorous fundal massage, and DATA SUBMISSION/ CALCULATION
either IM Methergine or PR Numerator: # of debrief forms submitted
Misoprostol. to FPQC
Denominator: # of hemorrhages that
advanced beyond 1000 cc / Stage 2 or 3
hemorrhages
(please follow along with handout)
121 122
10. Percent of women (who gave birth 20 0/7) 11. Total units of each type of blood product
who were transfused with any blood product transfused during birth admissions per total births
during the birth admission
DELIVERABLE SPECIFICS DELIVERABLE SPECIFICS
Blood transfusion data from internal source such as blood bank data, Work with your blood bank, accounting, charts, to identify units
patient charts, medical records, electronic medical record, etc. transfused per month during birth admission of each type: PRBCs,
DATA COLLECTION PLAN Platelets, Plasma/FFP, Cryo
Track the # of women transfused with any blood product during DATA COLLECTION PLAN
birth admission Track the number of units of each type of blood product per birth admission.
DATA SUBMISSION/ CALCULATION For women who experience Stage 2 or 3 hemorrhage, identify units of PRBCs,
Baseline: January December 2013 Platelets, Plasma/FFP, Cryo (for each woman) on the Debrief Form
Monthly DATA SUBMISSION/ CALCULATION
Numerator: # of women (who gave birth 20 0/7 weeks) who were Numerator: Total units of each type of blood product transfused during birth
transfused with any blood product during the birth admission each admissions each month: # Units of PRBCs // # Units of platelets // # Units of
month. plasma/FFP // # Units of Cryo
Denominator: Total # of births (20 0/7 weeks gestation) each month
Denominator: Total # of births (20 0/7 weeks) each month 123 124
31
12. Percent of women (who gave birth 20 0/7) 13. Rate of peripartum hysterectomies in women
who were transfused with 5 units PRBCs during per 1000 births (hysterectomy performed during
the birth admission birth admission) stratified by placenta previa
DELIVERABLE SPECIFICS and/or placenta accreta/percreta
Work with your blood bank, accounting, charts, to identify units DELIVERABLE SPECIFICS
transfused per month during birth admission of type: PRBCs Women who had a hysterectomy and placenta previa and/or accreta/ percreta
are reported separately from women who had a hysterectomy and NO placenta
DATA COLLECTION PLAN
Track the number of women who were transfused with 5 units
DATA COLLECTION PLAN
PRBCs during the birth admission.
Data Collection from internal source such as EMR, medical records, or other
DATA SUBMISSION/ CALCULATION method determined by each site
Numerator: Number of women (who gave birth 20 0/7 weeks DATA SUBMISSION/ CALCULATION
gestation) who were transfused with 5 units PRBCs each month. Numerator: Number of peripartum hysterectomies (performed during
Denominator: Total Number of Births (20 0/7 weeks gestation) birth admission) in women who gave birth 20 0/7 weeks by
each month. # hysterectomies with Placenta previa/accreta/percreta
125 126
# hysterectomies without previa/accreta/percreta
Submitting Data Qualtrics Tips
One designated user to enter data.
Communicate - Avoid duplication and confusion
Some questions are required
Avoid the back button on browser
Save and Continue option

Return later by revisiting the same link from the same
computer and browser
127 128
32
Potential Challenges for OHI Benefits of Hospital Participation

Implementation
Improved patient safety and risk management
Requires buy-in from hospital Improved staff skills related to assessment and
administrators, physician and nurse management of obstetric hemorrhage
champions Improved health outcomes related to obstetric morbidity
Fears of aggressive management and mortality
Resource-related concerns Improved tools and resources for obstetric management
with expert technical assistance
Apprehension towards feasibility of
implementing clinical changes Improved development of the hospitals quality
improvement infrastructure
129 130
129 130
Questions or Comments
For more information, please visit:
http://health.usf.edu/publichealth/chiles/fpqc/ohi
Contact:
Emily Dunn Annette Phelps
Quality Improvement Analyst FPQC Clinical Consultant
edunn2@health.usf.edu annettephelps.ap@gmail.com
131 For more information about FPQC, please visit: http://health.usf.edu/publichealth/chiles/fpqc 132
33

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*Winning Projects

Massachusetts Child Psychiatry Access Project For Moms

Dear Ms. Williams and Fellow CDC Chairs,

Patricia Miller, MD, FACOG

HOW MCPAP FOR MOMS WORKS

WHO CAN CALL

HOW WE HELP PROVIDERS

HOW WE HELP PREGNANT AND POSTPARTUM WOMEN AND THEIR FAMILIES

FACTS AND FIGURES

SUPPORTING DOCUMENTS AND RESOURCES (please see accompanying Appendix)

RESEARCH BUILDING ON MCPAP FOR MOMS

Marketing and outreach materials

MCPAP for Moms builds on the successful

MCPAP for Moms promotes

Our goal is to improve outcomes for babies,

Provider Resources Family Resources MCPAP Educational Services

MCPAP4MOM_Moms_Brochure_6pg_Final.indd 1 6/4/15 7:31 AM

One in eight women report experiencing

You Are Not Alone

LIMITED TO NO SYMPTOMS MILD SYMPTOMS MODERATE SYMPTOMS SEVERE SYMPTOMS

Limited or no symptoms of depression Severe symptoms of depression

Assessing Thoughts of Harming Baby

Suggests not at risk of harming baby Suggests at risk of harming baby

Risk Factors for Postpartum Depression1

Other Considerations During Clinical Assessment

How to Talk about Perinatal Depression with Moms1

The EPDS should be administered during:

Woman completes the EPDS. Staff tallies

The EPDS should be administered during: The clinical

Score 10 Positive score on question 10

Name: ______________________________ Address: ___________________________

Your Date of Birth: ____________________ ___________________________

Babys Date of Birth: ___________________ Phone: _________________________

Here is an example, already completed.

I have felt happy:

In the past 7 days:

Administered/Reviewed by ________________________________ Date ______________________________

2. All the items must be completed.

Bipolar Disorder Screen

Screen for bipolar disorder1

If yes to questions 1 and/or 2

The screen suggests the Continue screen for bipolar disorder1

Refer to the Recommended Steps

Recommended Steps before Beginning Antidepressant Medication Algorithm

Counsel patient about antidepressant use:

Is patient currently taking an antidepressant?

Does patient have a history of taking an

First line treatment (SSRIs)

Second line treatment

Promoting Maternal Mental Health During and

Nancy Byatt, DO, MBA, FAPM

MCPAP For Moms

With respect to the following presentation, there

1 in 8 women suffer from perinatal depression

Perinatal depression is twice as common as

Two-thirds of perinatal depression begins before birth

Perinatal depression effects mom, child & family

Poor health care

Low birth weight

Perinatal depression is under-diagnosed and

Women do not Unprepared providers,

How can I help Ms. Y?

The perinatal period is ideal for the detection and

Name: ____ Address: _

Your Date of Birth: _______

Babys Date of Birth: _ Phone: _______

Administered/Reviewed by __ Date