Postpartum Hemorrhage Management for the out of hospital midwife

Atul Gawande’s beautiful book The Checklist Manifesto easily applies to all of us out of hospital midwives. Check that link out–it’s the audio format because I know you are driving several hours per day between carpool and pick-ups and drop-offs and client visits and the grocery store and the gym. And back to the grocery store for whatever you forgot on the first trip.

Why does this book matter to us?  Why do these ideas matter to us? I can hear your midwife brains roaring about how we intuit our way through our practice–even obstetric emergencies–and we do it better and more efficiently than an entire team of OBs, neonatologists, and resuscitation teams designed just for, well, obstetric emergencies and resuscitation. You’re right, we carry a lot of the capacity of the combined powers of these teams in our personhood. We do so out of necessity. Because we are fortunate to spend most of our time in observation, but we are trained for the times where we must act and resolve obstetric emergencies in the out of hospital setting. ALSO is a training course originally designed for family practice docs to learn to manage obstetric emergencies through the use of team work and checklists in the form of mnemonics. I took this course way back and was the only midwife present with about 200 residents and practicing physicians. It was a terrifying 3 days and I learned the management of obstetric emergencies in hospitals–then adapted what I had learned to the out of hospital setting for use in my own practice. To say it has served me well over the years is an extreme understatement. So I was thrilled to see that I could re-up my certification this year at the end of a recent midwifery conference. I am happy to say the course is now extraordinarily well adapted to my learning style and actual practice. I highly recommend it or attending Expect the Unexpected, BEST, or one of the other specific courses designed for managing obstetric emergencies.

When it comes to emergencies, there have been many studies (many! Pubmed search “safety checklist and get reading!) that we should pay attention to. Studies show that outlining steps, having someone in charge of reading the steps, and making sure they are followed really matters when it comes to outcomes.

Who is your team?  In the space of an out of hospital obstetric emergency, every adult human in the room and building is a part of your team.

I’ll be posting additional sheets like this one—they are from our practice and not universally perfect.  Take it and make it your own, let it inspire you to have clear easy to read information for every kind of emergency you drill for.  Use it, adapt it, make it work for you.

This sheet is a simple tool to help you navigate through a postpartum hemorrhage–a common maternal morbidity in high resource countries that is trending upward. By acting promptly, hitting each step, and using your best skills along the way you greatly improve the chances that you will stop it long before it causes the need for a transfer. And for that rare mom that will require the entire run of our storehouse and hospital support to boot, by completing these tasks and documenting them you can help ensure a smooth transfer of services.

Please note this is designed for states where midwives have access to legend drugs and carry them as a regular tool in their birth kit. It does not address the use of herbs or other measures employed in states where medications are not available for use or low resource settings. I would love to hear what you are doing in those places–let us know in the comments below!

Click Here for the PDF

new-piktochart_26245788 (1)


Author: Midwifery

Jodilyn is a licensed midwife (WA, TN) and certified professional midwife. Recently relocated to Memphis, TN, and passionate about the intersection of social justice and perinatal healthcare. She owned Essential Birth & Family Center in South Seattle's Seward Park neighborhood. She is co-founder of South Seattle Women's Health Foundation, an organization dedicated to providing midwifery-led maternity care in a collaborative community-based setting and to increasing capacity within the community to support healthy birth and breastfeeding practices.