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    Severe hemorrhage at delivery or during the postpartum period can occur suddenly and is a major cause of maternal morbidity and mortality in both developing and developed countries.  In spite of improved identification of maternal risk factors, the frequency of obstetric hemorrhage in the U.S. appears to be rising and peripartum blood transfusions have increased by over 90% since the mid-1990s (Callaghan, 2008 and 2010).  Timely diagnosis and treatment of obstetric hemorrhage is critical to the prevention of adverse maternal outcomes.  Implementation of a standardized obstetric hemorrhage protocol has been shown to improve patient outcomes, with early identification of significant bleeding and decreased blood product utilization (Shields, 2011; Gregory, 2009).
    The Maryland Maternal Mortality Review (MMR) Program identified obstetric hemorrhage as the leading cause of pregnancy-related death among Maryland women in 2010 and 2011.  Multiple systems issues surrounding hemorrhage evaluation and management were identified, including poor quantification of blood loss, underestimation of blood loss, delayed or inadequate replacement with blood products, and lack of a protocol for rapid response to massive hemorrhage. The MMR Program recommended that all Maryland hospitals providing obstetric care develop and implement a written protocol to respond to massive obstetric hemorrhage, including a plan to maximize accuracy in determining blood loss.  This recommendation was incorporated into the Maryland Perinatal System Standards as Standard 13.8 in November 2013.  
    The following resources are provided to assist Maryland birthing hospitals in developing an obstetric hemorrhage protocol:
    1. The California Maternal Quality Care Collaborative (CMQCC) OB Hemorrhage Toolkit is an excellent source of information, including a compendium of best practices; care guidelines; sample forms for policy and procedure, risk assessment, quantitative measurement of blood loss, and quality improvement implementation; a hospital implementation guide; and a slide set for professional education.
    2. The American College of Obstetricians and Gynecologists (ACOG) has developed a Patient Safety Checklist [LW1] - Postpartum Hemorrhage from Vaginal Delivery.
    3. ACOG’s District II Patient Safety and Quality Improvement Committee developed a resource on Management of Obstetric Hemorrhage.
    4. The ACOG District II Safe Motherhood Initiative developed a Maternal Safety Bundle for Obstetric Hemorrhage.
    Callaghan WM, MacKay AP, Berg CJ. Identification of severe maternal morbidity during delivery hospitalizations, United States, 1991-2003. Am J Obstet Gynecol 2008;199:133.e1-8.
    Callaghan WM, Kuklina EV, Berg CJ. Trends in postpartum hemorrhage: United States, 1994-2006. Am J Obstet Gynecol 2010 Apr;202(4):353 e1-6.
    Shields LE et al.  Comprehensive maternal hemorrhage protocols improve patient safety and reduce utilization of blood products.  Am J Obstet Gynecol 2011 Oct:205(4):368 e1-8.
    Gregory K, Main E, Lyndon A. Definition, early recognition and rapid response using triggers. Obstetric Hemorrhage Care Guidelines and Compendium of Best Practices. CMQCC Obstetric Hemorrhage Toolkit. 2009. Available at: https://www.cmqcc.org/resources/617. Accessed February 2014.