AN OUNCE OF PREVENTION
Highlights from the 61st Obstetrical and Gynecological Assembly of Southern California
| OBSTETRIC HEMORRHAGE —James G. Quirk, MD, Professor and Chairman, Department of Obstetrics,
Gynecology, and Reproductive Medicine, State University of New York at Stonybrook
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| General considerations: hemorrhage leading cause of maternal mortality in United States; speaker opines
increasing frequency of cesarean delivery will make obstetric hemorrhage more significant issue in future;
causes of pregnancy-related hemorrhagic deaths—abruptio placentae, uterine rupture, uterine atony,
coagulation disorder, placenta previa, placenta accreta, and retained placenta; significant contributors—
inadequate resources and personnel, eg, home delivery, failure to prepare for obstetric hemorrhage, no
intravenous (IV) site, delay in recognition of hemorrhage, delay in treatment of hemorrhage, treatment
failures; necessity of blood transfusion in para 0 patient as frequent as para 5 patient (atony in higher parities)
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| Obstetric hemorrhage: 2% to 3% of patients having prolonged labor, operative vaginal delivery, or cesarean
delivery receive blood transfusions; definition—>500 mL blood loss during vaginal delivery and
1000 mL during cesarean delivery; occurs in at least 30% of vaginal deliveries, 20% to 25% of cesarean
deliveries; 28% of patients undergoing cesarean delivery plus total hysterectomy have blood loss of 500
to 1000 mL, 28% have blood loss of 1000 to 1500 mL, and ≈28% exceed 1500 mL; incidence of obstetric
hemorrhage—includes disorders of delivery in puerperium; cesarean delivery ≈1 in 6, ruptured uterus 1
in 11,000; uterine rupture occurs in >50% of women with surgically unscarred uteruses; obstetric lacerations
occur in 1 of 8 women; pregnant woman can lose 40% of blood volume, compared to 25% in nonpregnant
patient, before becoming hemodynamically unstable
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| Contributing factors: conditions predisposing to impaired coagulation—placental abruption, prolonged retention
of dead fetus, and amniotic fluid embolism; can lead to disseminated intravascular coagulation
(DIC), profound hypoxia, and multiple organ-system failure (recalcitrant and associated with maternal
death); contributors—trauma during labor or delivery, small maternal blood volume (small women, women
with chronic cardiovascular disease, hypertensive women, or those who bleed earlier in pregnancy), and
women with abnormal placental implantation or development, eg, ectopic, placental abruption
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| Clinical features of shock: early shock—altered mental status, tachycardia, orthostatic hypotension, oliguria,
or tachypnea; late shock—multiple organ-system failure; can be irreversible
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| Treatment: goals—maintain systolic blood pressure >90 mm/Hg, urine output >0.5 mL/kg per hour (30-
35 mL/hr), and normal mental status; eliminate source of hemorrhage; avoid overzealous volume replacement
that may contribute to pulmonary edema; management—1000-mL blood loss represents
≈15% of volume, 1001 mL to 1500 mL ≈15% to 25%; begin fluid resuscitation with crystalloid solution,
but be prepared to move quickly to transfusion; under bright lights, examine patient for source of bleeding;
rule out atony, lacerations, and retained placenta; treatment options for uterine atony—firm bimanual
compression; oxytocin infusion (40 units in 1 L of 5% dextrose in lactated Ringer’s solution [D5LR]);
intramuscular (IM) injections of carboprost (Hemabate; can be repeated); methylergonovine (Methergine)
if patient not hypertensive; bilateral uterine artery ligation; internal iliac (hypogastric) artery ligation;
hysterectomy; speaker does not consider hypogastric artery ligation first-line therapy; consult with
interventional radiologist; B-Lynch (brace suture) innovative suture technique; O’Leary suture decreases
pulse pressure and blood loss, but does not eliminate need for oxytocic agents
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| Management of hypovolemic shock: insert at least 2 large-bore IV catheters; alert blood bank; place patient
in Trendelenburg position; call for extra staff, including consultant anesthesiologist; rapidly infuse
D5LR solution while waiting for blood products; formula for transfusion of packed red blood cells (RBCs)—
patient’s weight in kg x 10; for massive blood replacement—1 unit of fresh frozen plasma after every 3rd
unit of packed RBCs; infuse only normal saline with transfusion (hemolysis with D5W can lead to renal
failure); use blood products within 4 hr; infuse at 100 mL/min; speaker opines transfusion risk overstated
when put in context of life-threatening hemorrhage
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| Improving quality of care: important to have team of well-organized skilled providers and system in
place in labor and delivery units; speaker’s institution holds simulated drills (code Noelle); caveats—
obstetric staff considering transfusing pregnant patient should notify anesthesia department; blood loss
during delivery almost always underestimated; hypotension in pregnant patient implies estimated blood
loss of >2000 mL; surgical management must be very aggressive; control source of hemorrhage; utilize
additional resources, eg, gynecologic surgeon; identify high-risk patients; maternal hemorrhage number
one cause of maternal death in New York; identify high-risk patient to prevent severe complications;
early intervention crucial for low-risk patient starting to bleed
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| CHICKEN SOUP FOR THE DEFENDANT PHYSICIAN —Richard M. Soderstrom, MD, Professor
Emeritus, University of Washington School of Medicine, Seattle
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| Standard of care: what reasonable prudent physician would foresee and would do in light of this foresight
under like circumstances (Harper and James, Law of Torts); whether requirement to have foresight too
rigid currently in question; whether negligence occurred and whether it made difference important elements
in determining medical malpractice
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| Risk management: documentation— important to document all advice given to patient; contact same-day
surgical patients by telephone following day and document conversation; when complications managed
by second facility, attempt to communicate with provider managing complication; standard of care—
applies equally between specialties; general surgeons performing laparoscopy must adhere to same standards
as gynecologists; dictation—delayed dictation or suspicion that medical record altered fertile field
for plaintiff’s attorney; American College of Obstetricians and Gynecologists (ACOG) educational/technical
bulletins—powerful tool in defending care; speaker recommends ACOG’s 2006 Compendium of Selected
Publications; dissatisfied or noncompliant patients—be aware of and pay special attention to
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| Surviving lawsuit: when served with formal declaration and summons, notify insurance carrier first, not
attorney; records from insurance carrier discoverable in some states; determine best way to communicate
with insurance carrier; do not alter or add to medical record; with disclaimer, provider may be allowed to
read from medical record if handwriting illegible; review medical record and become familiar with facts
before deposition; be readily available to take calls from insurance representative or attorney (instruct office
staff to inform you when they call); become knowledgeable about subject matter of lawsuit; educate
attorney on specific matter pertaining to lawsuit and assist in finding qualified expert witness; settlement
may be practical, does not imply malpractice or negligence
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| Preparing for deposition: review interrogatory answers; ensure medical records properly assembled; construct
story board of events pertaining to lawsuit; consider having visuals (eg, laparoscope, bipolar forceps,
trocar, at deposition); prepare updated curriculum vitae and summary of continuing medical
education credits for last 3 yr; find literature supporting your management, particularly literature around
time of event; dress professionally; exercise courtesy and good manners; make deposition practice run
for how you will conduct self at time of trial; speak up and do not use gestures; tell truth; review transcript
of deposition; understand question before answering; pause before you answer; answer only question,
do not volunteer information; do not guess, say “I don’t know or recall”; do not use hearsay
information; do not hide facts; if your attorney objects, stop talking; without objection, you are bound to
answer; be factual and straightforward; check facts against record before answering; do not look for
traps, leave that to your attorney; never argue or become hostile and angry; testify to your best memory;
give explanations in layman’s terms; discuss with your attorney whether educating opposing attorney
beneficial
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| Miscellaneous issues: endoscopy leads in surgical litigation (more than all surgical specialties combined);
make telephone “rounds” with patients undergoing outpatient procedures; poor postoperative progress
mandates office visit; emergency department providers should understand known risks of same-day surgical
procedures; chances of being sued high, but chances of prevailing good
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Educational Objectives
| The goal of this program is to educate the listener about the management of obstetric hemorrhage and the
fundamentals of handling a medical malpractice lawsuit. After hearing and assimilating this program, the
clinician will be better able to:
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 | 1. List the causes of and significant contributors to pregnancy-related hemorrhagic death.
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| 2. Discuss the guidelines for component therapy in managing obstetric hemorrhage.
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| 3. Summarize the need for having a well-organized system in place in labor and delivery units.
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| 4. Discuss steps that can be taken to reduce the risk for a medical malpractice lawsuit.
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| 5. Assist in the defense of a medical malpractice lawsuit.
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Discussed on this Program
Carboprost tromethamine [Hemabate]
Methylergonovine maleate [Methergine]
Suggested Reading
Chong YS et al: Current strategies for the prevention of postpartum haemorrhage in the third stage of labour.
Curr Opin Obstet Gynecol 16(2):143, 2004; Clauss ER et al: The fundamentals of avoiding and winning
medical malpractice suits. Otolaryngol Head Neck Surg 111(2):141, 1994; Jansen AJ et al: Postpartum
hemorrhage and transfusion of blood and blood components. Obstet Gynecol Surv 60(10):663, 2005; Mousa
HA et al: Major postpartum haemorrhage. Curr Opin Obstet Gynecol 13(6):595, 2001; Price N et al: Technical
description of the B-Lynch brace suture for treatment of massive postpartum hemorrhage and review
of published cases. Int J Fertil Womens Med 50(4):148, 2005; Sachs BP: A 38-year-old woman with fetal
loss and hysterectomy. JAMA 294(7):833, 2005; Santoso JT et al: Massive blood loss and transfusion in
obstetrics and gynecology. Obstet Gynecol Surv 60(12):827, 2005; Studdert DM et al: Defensive medicine
among high-risk specialist physicians in a volatile malpractice environment. JAMA 293(21):2609, 2005;
Teichman PG et al: Depositions: defending your care. Fam Pract Manag Jul-Aug 8(7):34, 2001.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any
significant financial relationship with the manufacturer or provider of any commercial product or service
discussed. For this issue, the faculty reported nothing to disclose.
Drs. Quirk and Soderstrom were recorded at the 61st Obstetrical and Gynecological Assembly of Southern California,
sponsored by the Obstetrical & Gynecological Assembly of Southern California, held February 24-
25, 2006, in Pasadena, California. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
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