How to cite this article: Martínez-Rodríguez ÓA, Portillo-Durán J, Tamés-Reyeros JÁ, Martínez-Chéquer JC, Carranza-Lira S. Immediate response team. 59 cases with obstetric hemorrhage. Rev Med Inst Mex Seguro Soc. 2015 Mar-Apr;53(2):132-5.
Received: April 9th 2014
Accepted: July 3rd 2014
Óscar Arturo Martínez-Rodríguez,a Johana Portillo-Durán,b José Ángel Tamés-Reyeros,c Juan Carlos Martínez-Chéquer,d Sebastián Carranza-Lirae
bEspecialista en Ginecología y Obstetricia
dDirección de Educación e Investigación en Salud
eDivisión de Educación en Salud
Hospital de Ginecoobstetricia 4, Instituto Mexicano del Seguro Social, Distrito Federal, México
Communication with: Sebastián Carranza-Lira
Telephone: 01 (55) 5528 4657
Background: The lack of diagnosis as well as an appropriate medical and/or surgical treatment, due to an inefficient work team, contributes to the mortality associated to obstetric hemorrhage. The aim of this article is to analyze 59 cases in which the immediate response team (ERI) was implemented in patient with obstetric hemorrhage.
Methodology: Retrospective / prospective, observational, traverse and descriptive study in which 59 cases with obstetric hemorrhage and their attention by means of ERI.
Results: 59 patients with the diagnosis of obstetric hemorrhage were studied. The mean age of patients was 30.2 ± 6.8 years. The main reason that originated the obstetric hemorrhage, was abruption placenta followed by uterine atony. The place in which where the ERI was more frequently implemented was the expulsion room and in 93.2 % of the cases the doctor was who begin it. In 71.2 % it was not necessary to transfuse globular package. Only one surgery was carried out in 52.5 % of the cases and two in 28.8 %. The 90.1 % of women didn’t pass to intensive care unit, 8.5 % went in, and 1.7 % was transferred.
Conclusions: According to the results obtained in this study the application of ERI was in a correct, integrated and standardized way.
Keywords: Obstetrics; Hemorrhage; Emergency medical services
The main causes of maternal death are hypertensive disorders, hemorrhage, and sepsis. Uterine atony is the most common cause of postpartum hemorrhage, accounting for 80% in most studies.1 It has been reported that obstetric hemorrhage (OH) causes 28% of maternal deaths;2 in the world and in the Instituto Mexicano del Seguro Social (IMSS) it ranks second as cause of maternal mortality.3 Suboptimal management is common even in developed countries, finding that 90% of deaths associated with hemorrhage could have been prevented.4
Postpartum hemorrhage is defined as the loss of more than 500 ml of blood and severe obstetric hemorrhage is when it is greater than 1000 mL.5
OH management needs a team-led, systematic, fast, and timely procedure for medium-term morbidity and mortality to be reduced. The timeliness and quality of care in handling this situation are essential to reduce morbidity and prevent mortality.6 The reason for the high mortality associated with hemorrhage is simple, since there is delay in recognizing hypovolemia, and failure to replace the adequate volume.
Therefore, it is necessary to have case detection, to have a team ready, and to have a system of evaluation and process improvement. Bringing down OH mortality requires the rapid response team (RRT) to be comprised of a multidisciplinary team trained in proper recognition of obstetric emergency, as well as optimal time management, teamwork, and the use of different maneuvers to reduce the risk of maternal death, as well as being familiar with emergency care. OH management requires a systematic, organized, and effective protocol that can be replicated in every specific situation.7
RRT activation may occur at various sites such as the emergency department, the operating room, the delivery room, in recovery, or in inpatient.
For this activation, an effective and fast mechanism for RRT communication should be defined; it is suggested that this be by loudspeaker.
As part of the response of this team, the activities undertaken are divided by time: minute zero: RRT warning and dissemination; minute 1 to 20: resuscitation and diagnosis; minute 20 to 60: stabilization; and over 60 mins: advanced management.
This should be the general practitioner or specialist in gynecology and obstetrics; in their absence it should be the person with the most experience in handling this situation, and its functions:
Assigning attendees 1 and 2 as well as circulating staff, classifying state of shock, looking for the cause of hemorrhagic shock, beginning treatment, evacuating the bladder to measure urine output, ordering the application of blood products and drugs, and providing required information to family members or companions.
This can be a doctor, nurse, or nursing assistant, positioned at the head of the patient, who explains the procedures and establishes confidence.
If the fetus is still in utero and is more than 20 weeks old, they should keep the position of the patient shifted to the left shift and ensure the supply of oxygen. They take blood pressure and pulse, preserve the patient's temperature and monitor with pulse oximetry, tell the coordinator the state of fluid infusion and clinical signs of shock to adjust the volume to be administered, record the events on the RRT record sheet, and, if required, collaborate with the coordinator in conducting procedures.
This can be a doctor, nurse, or nursing assistant. They ensure access and functioning of two #14 or 16 venous access catheters, take blood samples in three tubes (red, purple, and gray caps), and begin the infusion of 2000 ml of crystalloid heated to 39 °C (either in microwave or with electrode in water for 2 minutes). They also perform necessary laboratory orders (hemoglobin, hematocrit, platelets, prothrombin time, partial thromboplastin time, fibrinogen, blood grouping, and cross-matching). In high complexity institutions they request D-dimer, electrolytes, pH, and blood gases. If it is severe shock, they should immediately order 2 units of red or Rh negative blood cells, using O Rh positive if that is not available. They apply fluids and medications defined by the coordinator.
This may be the nursing assistant or other institutional staff trained for this function. They deliver to the assistant 2 the first 500 ml crystalloid at the temperature it is at, and start the heating of the remaining liquid. They properly identify the tubes and verify that they arrive promptly to the laboratory. They maintain contact with the RRT coordinator to ensure timely and accurate information on the patient’s condition for family members. They recruit more staff if needed. They collaborate with the coordinator in carrying out procedures if required.
The aim of this study was to analyze 59 cases where the RRT was implemented in patients with OH.
An observational, retrospective/prospective, transversal, and descriptive study was conducted during the period from June 6, 2011 to January 29, 2014 at the UMAE Hospital de Ginecoobstetricia No. 4 “Dr. Luis Castelazo Ayala” of the IMSS. 59 women who had OH and were attended by RRT were included. OH was considered any hemorrhagic event related to pregnancy at any time during pregnancy. The information was obtained from the database of the evening shift UMAE coordinator. The age of patients, the cause of OH, the RRT site of origin, who initiated the RRT, treatment performed, and transfusion volume were analyzed. The project was approved by the Local Health Research Ethics Committee of this UMAE, with registration number R-2012-3606-31.
59 patients with a diagnosis of OH were found. The mean age was 30.2 ± 6.8 years. OH causes that triggered the RRT were varied; predominantly normal-insert abruptio placenta (NIAP) (33.9%) and uterine atony (23.7%) (Table I). The site where RRT most frequently originated was the delivery room (33.9%), followed by the floor (27.1%) (Table II). In 93.2% (n = 56) of cases, the doctor was who initiated the RRT, the nurse in 3.3% (n = 2) and both in 3.3% (n = 2), mainly by paging in 98.3% of cases (n = 58) and only 1.7% (n = 1) by telephone.
|Table I Etiological diagnoses in a group of patients with obstetric hemorrhage|
|Caesarean section due to preeclampsia||5.1||3|
|Table II Site where IRT originated|
In 71.2% (n = 42) it was not necessary to transfuse the packet of red blood cells (Table III). Surgery was performed in 52.5% of cases, and two surgeries in 28.8% (Table IV). 90.1% of women (n = 53) did not go to the intensive care unit (ICU), 8.5% (n = 5) did enter the ICU, and 1.7% (n = 1) were transferred.
|Table III Volume transfused|
|Table IV Number of surgeries performed|
|Number of surgeries||%||n|
The procedures most frequently used for the resolution of the OH were: Caesarean 40.7% (n = 24), caesarean plus hypogastric ligation 15.3% (n = 9), vaginal delivery plus uterine massage 13.6% (n = 8) and vaginal delivery plus hypogastric ligation 10.2% (n = 6) (Table V).
|Table V Form of resolution of obstetric hemorrhage|
|Caesarean section plus hypogastric ligation||15.3||9|
|Vaginal delivery plus hypogastric ligation||10.2||6|
|Caesarean section plus total abdominal hysterectomy||3.4||3|
|Uterine curettage plus hypogastric ligation||3.4||2|
|Uterine curettage plus uterine dearterialisation||3.4||2|
|Caesarean section plus abdominal total hysterectomy plus hypogastric ligation||1.7||1|
|Vaginal delivery plus hypogastric ligature plus total abdominal hysterectomy||1.7||1|
There were surgical complications in 5.1% (n = 3) consisting of: hypogastric vein injury, iliac vein injury, and median sacral artery injury. Four of the five patients who went to the ICU were more than 30 years old. There was no difference between ≤ 30 and > 30 years regarding the diagnostics. We found that patient age did not influence the type of operative resolution of the OH event.
Every day 1,500 women die from complications of pregnancy and childbirth, mostly in developing countries and most of which could have been avoided. The incidence of maternal deaths has an uneven worldwide distribution that reflects the gap between rich and poor. In Mexico OH was the second leading cause of maternal mortality in 2011.3 Massive OH is the largest contributor to maternal morbidity and mortality. The clinical management of pregnant women should be integrated with the knowledge and skills to manage massive OH to timely and properly initiate treatment to preserve the life of the patient. Early resuscitation and reversal of coagulopathy are critical while definitive measures are being taken to stop the bleeding. Surgical measures used to prevent peripartum hemorrhage are, among others: the use of compression sutures, uterine balloon tamponade, uterine and hypogastric artery ligation, and others.8 Education in management protocols and adherence to these guidelines are important in reducing maternal deaths related to OH.6
Among the strategies designed by IMSS to abate OH mortality is the creation of a multidisciplinary system called RRT9 whose correct and complete application can reduce mortality. This study showed that in most cases a favorable outcome in patient intervention was obtained. In this study the main cause of RRT activation was normal-insert abruptio placenta, unlike other studies in which it was uterine atony.
The RRT is a program whose main objective in the UMAE is OH resolution. According to the data obtained from this study, their application was successful, correct, and integrated.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.