What are the steps in the "ORDER" plan for managing postpartum hemorrhage (PPH)?

Updated: Jun 27, 2018
  • Author: John R Smith, MD, FACOG, FRCSC; Chief Editor: Ronald M Ramus, MD  more...
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The following is a plan for managing massive obstetric hemorrhage, adapted from Bonner. [31] The word order is a useful mnemonic for remembering the basic outline.

  • Organization

    1. Call experienced staff (including obstetrician and anesthetist).

    2. Alert the blood bank and hematologist.

    3. Designate a nurse to record vital signs, urine output, and fluids and drugs administered.

    4. Place operating theater on standby.

  • Resuscitation

    1. Administer oxygen by mask.

    2. Place 2 large-bore (14-gauge) intravenous lines.

    3. Take blood for crossmatch of 6 U PRBCs, and obtain a CBC count, coagulation screen, urea level, creatinine value, and electrolyte status.

    4. Begin immediate rapid fluid replacement with NS or Ringer lactate solution.

    5. Transfuse with PRBCs as available and appropriate.

  • Defective blood coagulation

    1. Order coagulation screen (International Normalized Ratio, activated partial thromboplastin time) if fibrinogen, thrombin time, blood film, and D-dimer results are abnormal.

    2. Give FFP if coagulation test results are abnormal and sites are oozing.

    3. Give cryoprecipitate if abnormal coagulation test results are not corrected with FFP and bleeding continues.

    4. Give platelet concentrates if the platelet count is less than 50 X 109/L and bleeding continues.

    5. Use cryoprecipitate and platelet concentrates before surgical intervention.

  • Evaluation of response

    1. Monitor pulse, blood pressure, blood gas status, and acid-base status, and consider monitoring central venous pressure.

    2. Measure urine output using an indwelling catheter.

    3. Order regular CBC counts and coagulation tests to guide blood component therapy.

  • Remedy the cause of bleeding

    1. If antepartum, deliver the fetus and placenta.

    2. If postpartum, use oxytocin, prostaglandin, or ergonovine.

    3. Explore and empty the uterine cavity, and consider uterine packing.

    4. Examine the cervix and vagina, ligate any bleeding vessels, and repair trauma.

    5. Ligate the uterine blood supply (ie, uterine, ovarian, and/or internal iliac arteries).

    6. Consider arterial embolization.

    7. Consider hysterectomy.

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