Sample approach to risk stratification and delivery preparation for PPH

Prenatal assessment and planning
Identify and prepare for patients at risk: previa/accreta, bleeding disorder, those who refuse transfusion Screen and treat for anemia (iron panel, hemoglobin electrophoresis, consider oral versus IV iron)
Low	Medium	High
≤4 previous SVD	Hgb <8 g/dL	Placenta previa
Singleton	Platelets <100,000/microL	Suspected placenta accreta
<2 prior CD	≥3 prior CD or previous myomectomy	Abruption
No previous PPH	>4 vaginal births	Coagulopathy
No known bleeding disorder	Chorioamnionitis
	Magnesium sulfate use
	Multiple gestation
	Large uterine fibroids
	EFW >4250 g
	Black race
	History of PPH
	Severe obesity (BMI >40 kg/m²)

Oxytocin preparation: 30 international units in 500 cc solution. 167 cc = 10 international units.

Low:

Type and screen on admission (if antibody positive, then will need crossmatch)
Postpartum order: Oxytocin 167 cc bolus, then 42 cc/hour for 4 hours

Medium:

Type and screen on admission
Discuss risk of PPH with patient
Postpartum orders: Oxytocin 167 cc bolus, then 42 cc/hour for 8 hours

Medium "plus" (>1 medium risk factor):

Crossmatch 2 units
Discuss risk of PPH with patient
Postpartum orders: Oxytocin 167 cc bolus, then 42 cc/hour for 8 hours

High:

Crossmatch 4 (or more) units
Discuss risk of PPH and transfusion with patient
Postpartum orders: Oxytocin 167 cc bolus, then 42 cc/hour for 24 hours
Observation on L&D postoperatively based on QBL or at least 4 hours (whichever is longer)

PPH: postpartum hemorrhage; IV: intravenous; SVD: small-vessel disease; Hgb: hemoglobin; CD: cesarean delivery; EFW: estimated fetal weight; BMI: body mass index; cc: cubic centimeter; L&D: labor and delivery; QBL: quantification of blood loss.

Courtesy of Christina Davidson, MD and Catherine Eppes, MD, MPH.

Graphic 126216 Version 6.0

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Sample approach to risk stratification and delivery preparation for PPH