● General considerations
∘ Team-based closed-loop communication
∘ Assurance of enough team members
∘ Support and communication with family
∘ Code sheet and assigned scribe to record times, events & medications
● Assurance of equipment and supplies
∘ Hemorrhage cart with appropriate equipment
∘ Uterotonics
∘ Uterine balloons and filling equipment
∘ Retractors- abdominal, vaginal and self-retaining, as needed
∘ Large packing sponges
∘ Long instruments
∘ Cystoscope and tower
∘ Cesarean hysterectomy tray
∘ Ultrasound
∘ D&C equipment (possibly including manual vacuum aspiration (MVAC))
● Monitoring of blood loss
∘ Quantitative drapes
∘ Qualitative assessments
∘ Scale and weights of blood-soaked items
∘ “Call out” and check back of total EBL at regular intervals
● Maternal hemodynamic support and anesthesia/pain control
∘ Massive transfusion and maternal care as appropriate
∘ Provision of anesthesia for maternal comfort
∘ Avoidance of hypothermia
∘ Antibiotics, re-dosed as appropriate for procedure type and after 1500-2000 cc estimated blood loss or 4 h of operative time2
● Optimization of physical environment:
∘ Appropriate positioning of patient in stirrups
∘ Optimization of lighting
■ OR lights
■ Headlamps
■ Task lighting
■ Lighted specula
● Full anatomic evaluation and systematic treatment
∘ Evaluation of sources of vaginal bleeding working from distal to proximal
∘ Evaluation for retained products
■ Bedside ultrasound
■ Manual exploration
∘ Evaluation and assist abdominally (if not already open)
■ Evaluation of pelvis in systematic manner
■ Evaluation of non-pelvic organs if shock out of proportion to vaginal/abdominal bleeding