• hemorrhage;
  • antepartum

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Obstetric hemorrhage is a significant cause of maternal morbidity and mortality. Early recognition and prompt intervention are keys to minimizing complications. The rate of maternal deaths in the United States has nearly doubled from 7.6 per 100,000 in 1996 to 13.3 per 100,000 annual births in 2006. However in California the rate of maternal deaths has nearly tripled from 6 per 100,000 in 1996 to 17 per 100,000 annual births in 2006. What is particularly troubling about both of these trends is the fact that the worldwide maternal mortality rate had decreased during this same time. This troubling statistic served as the impetus to develop the California Maternal Quality Care Collaborative to end preventable maternal death and injury and to promote equitable maternity care in California. Miller Children's Hospital Labor and Delivery joined a quality improvement collaborative through the California Maternal Quality Care Collaborative to develop an obstetric hemorrhage protocol.


Women in early pregnancy, before 20 weeks gestation are often triaged and treated in the main hospital emergency room when presenting for bleeding or threatened spontaneous abortion. This was true in the case of a young woman at 14 weeks gestation. Early antepartum hemorrhage (before 20 weeks gestation) can be caused by abortion/miscarriage, ectopic pregnancy, or gestational trophoblastic disease. Early diagnosis and treatment is essential and often not done urgently or with the thought of life threatening hemorrhage. Deterioration can happen suddenly, and under-estimation of blood loss and misleading maternal response can mask the need for an urgent response. The patient may maintain a normal blood pressure until sudden and catastrophic decompensation occurs. It is essential that the team in any setting knows how to respond quickly and appropriately as time is of the essence.


A well-coordinated team can mean the difference between life and death. In this case, the resident initiated the obstetric hemorrhage protocol and saved this woman's life. After the episode, the team debrief reinforced the importance of quantifiable blood loss education as well as the implementation of the obstetric hemorrhage protocol.