1. society
2. welfare
3. healthcare
4. hospital

Women & Children’s Services
Maternity Services
Guideline; Code Blue Procedure for Massive Obstetric Haemorrhage
1.
Introduction
Code Blue is initiated in cases of Major Haemorrhage associated with
 Clinical shock / Collapse
 Rapid Ongoing blood loss at/after delivery ≥1500mls as estimated total
Initiated by Delivery Suite Co-ordinator, Obstetric or Anaesthetic Registrar
 Dial 3333
 State clearly: “CODE BLUE – OBSTETRIC HAEMORRHAGE”
 State site clearly: “Delivery Suite room number or Theatre or Main Theatre or other
Site e.g. Lexden, Emergency Department”
2.
SWITCHBOARD Will Automatically Call out ALL the following in RAPID SUCCESSION
Bleep Cascade
Bleep Holder with Voiceover
No
Obstetric Registrar
Obstetric SHO
Anaesthetic Registrar
Operating Department Practitioner (ODP)
ODP Main theatre
Haematology Biomedical Scientist
Help Desk (Dispatch)
Porter
Biochemistry Biomedical Scientist
Security
Maternity Bleep Holder
Main Theatre Bleep Holder
Outreach Team
Duty Hospital Matron
244
248
400
411
202
854
207
204
557
949
722
932
247
333
Message sent out
CODE BLUE –
MAJOR OBSTETRIC
HAEMORRHAGE
“Delivery Suite Room No. or
Delivery Suite Theatre or other site”
Consultant Callout
Switchboard will also call:Consultant Obstetrician
Consultant Anaesthetist On call for Del Suite
(Out of hours this is General Consultant Anaesthetist
for theatre)
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 1 of 12
Via
Mobile,
landline
or pager
Information given as in bold above
Code Blue
Guideline No: 1.6A
3.
Clinical Management & Resuscitation
Action
Information to give
Responsibility / Role
 Patient Name
 DOB
 Hosp No
 Site
 If O Neg Blood required
 Gives contact extension 2057
 IDENTIFIES CLINICAL TEAM LEADER
o Initially obstetric or anaesthetic registrar
o Until anaesthetic consultant arrives.
 Holds Tel Ext 2057 (in Delivery Suite only)
 Other sites:
o Identifies suitable Ext
o Informs haematology & biochemistry of Ext.
 Ensures all correct bloods despatched (Page 3)
 Facilitates communication between labs and clinicians
 Maintains list of samples sent
 Keeps record of blood results
 Maintains awareness of on-going blood loss recorded on
white boards and Ensures team are aware
 Other specialty call-out
 If extra Anaesth SHO required Bleep 203 (ITU)
 If site of code blue moves calls 3333 for switchboard to inform
entire team
 Contacts recovery nurse in usual manner
 Ensures completion of ;
 Completion of WHO checklist
 Code Blue Summary sheet (Appendix Three)
 Issue stand down via switchboard
 Datix & Debrief
Nominates Scribe to record the following (Appendix Two )
 All arrivals
 All key clinical measures
 All telephone calls
 All Key operative events
 All Medication / Fluids administered / Blood / Blood products
(Concurrently on summary sheet Appendix 3)
Phone blood results to Ext 2057
If engaged try Ext 2738 / 2739.
Ongoing discussion with Consult Haematologist via 2057
regarding the woman
Phone blood results to Ext 2057
If engaged try Ext 2738 / 2739.
Portering Service Code Blue Procedure (Appendix One)
Attend Delivery Suite
Disarm Delivery Suite entry alarm system for duration and unlock
and/or man the Constable Wing doors (if out-of-hours).
Attend Delivery Suite only if requested by outreach
Contact Haematology
BMS
Ext 2088 – all times
Contact Biochemistry
BMS
Ext 4800 or Via Switchboard
CODE BLUE ORGANISER
Dedicated to CODE BLUE
(Remains throughout)
The Code Blue Organiser is:

Designated by the Delivery
Suite Co-ordinator
Critical Care Outreach
Team Member
(will attend if available)
Haematology Biomedical
Scientist (BMS
Consultant Anaesthetist /
Obstetrician
Biochemistry Biomedical
Scientist (BMS)
Porters
Maternity Bleep Holder
Security Department
Duty Hospital Matron
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 2 of 12
Code Blue
Guideline No: 1.6A
Responsibility / Role
*Clinical Team Leader
Consultant Anaesthetist
(On-going collaboration with
Cons Obstetrician)
Anaesthetic Registrar & ODP
Obstetric SHO
Obstetric Registrar
Outreach Team
Midwife
NB:
*Obstetric /Anaesthetic Reg
assumes Clinical Lead role
till arrival of Consultant
Anaesthetist
Actions
Further details









Oversee the whole
process, ensures
appropriate and timely
interventions
Initial resuscitation;
Airway
Breathing
Circulation
Monitoring
Urinary Catheter (Hourly
bag)
Bimanual Uterine
Compression
IV fluid replacement
O Neg blood IF required




Clinical Assessment
Oxygen 10-15 litres/min
Get resuscitation trolley
2-3 large 14-16 gauge IV
Cannulae
 Anaesthetist to consider
Haemoccue® and need for
arterial blood gases
NB see Appendix 4



Keep patient warm
Obstetric SHO
NB:
*Blood Samples as for all
cases of major haemorrhage
Ensure communication with
entire multidisciplinary team
IV Crystalloids / Colloid
Blood/ blood products
(see summary next page)
CVP line as required
 Fluid Warmer (Hotline®)
 Bair Hugger®
Consider Rapid infuser
Level 1® from Main Theatre
Take *Correct Blood Samples and label bottles at bedside
 FBC and Full Clotting Studies (including Fibrinogen)
 Group & Crossmatch request x 6 units
 Electrolytes, Creatinine and LFT’s
 Baseline blood gases,
 Label Samples and complete forms using the Information
on Patient ID Band – (if ID labels used, ensure correct
patient details to match with Patient ID band)
Obstetric Registrar &
Obstetric Consultant











Theatre scrub Practitioner

Patient’s Name
DOB & Hosp No
Date & Time
Personally hands blood samples to Porter
Organise repeat blood samples as instructed
 Manage according to
Ongoing resuscitation
guideline for major
Identify & control cause of
obstetric haemorrhage
bleeding
(No 1.6).
Oxytocic therapy
 Consider EUA,
Assess & move to theatre
Uterine balloon or
Discuss with multidisciplinary
packing, suturing,
team using WHO checklist
laparotomy
Maintain regular update of
patient’s clinical status
If not already in attendance scrub practitioner will attend to
scrub for the appropriate procedure
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 3 of 12
Code Blue
Guideline No: 1.6A
4.
Flowchart - Provision of Blood & Blood Products in Massive Obstetric Haemorrhage
First Wave
-
6 units of pre-cross matched blood if available
Or 2 units of O Rh Neg blood IF immediately needed (from main blood bank)
And/or 6 units of group compatible (type specific) blood released by
Haematology BMS on receipt of blood sample for cross match
Commence thawing 4 units (1000mls) FFP as soon as blood group known
Consultant Obstetrician & Anaesthetist
- To discuss clinical status & blood results involving Cons Haematologist if coagulopathy
Decision for Surgery / Laparotomy
Request second wave response from Haematology
Second Wave
- 6 units of group compatible blood
- 4 Units (1000mls) FFP as soon as available
- Send full blood count (FBC), and clotting samples
Consultant Obstetrician, Anaesthetist, Haematologist
IF still bleeding - request third wave response from haematology lab; repeat blood samples
Third Wave
- 6 units of group compatible blood and 1 unit of platelets.
- (Only 1 unit of Platelets stored in Transfusion - further units obtained from Brentwood)
- Send FBC and clotting sample (and U&Es, Creatinine and LFTs to Biochemistry)
- FFP if not already issued with second wave
Consultants – Obstetrician, Anaesthetist, Haematologist
Discuss clinical status & all blood results
- IF still bleeding request fourth wave response from Haematology Lab
Fourth Wave
- Further blood will be issued in batches of 6 units
- Further Transfusion of FFP / platelets and cryoprecipitate beyond this stage should be
guided by lab results, aiming for:
- PT and APTT <1.5 control with FFP (PT/APTT <14sec /44sec)
- Platelet count up to 100 with platelet transfusion/s
- Fibrinogen >1.0 g/l with cryoprecipitate
-
Once haemorrhage controlled and patient clinically stable
Acknowledge total estimated blood loss & record in healthcare records & anaesthetic record
Sign out WHO checklist, team debrief & discuss need for transfer to CCU and on-going care
Code blue Organiser issues stand-down call via switchboard
Switchboard will ensure all personnel are informed of stand-down via bleep cascade
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 4 of 12
Code Blue
Guideline No: 1.6A
5.
Monitoring Compliance
The Maternity Services will prospectively audit all cases of CODE BLUE to monitor compliance
with this guideline.
Tools will include:



6.
Use of DATIX electronic incident reporting forms and subsequent review.
Review of healthcare records and documentation.
Monthly statistics collated using the RCOG Maternity Dashboard,
o Information is gathered and reported to the Delivery Suite Forum
References – Further reading
Centre for Maternal and Child Enquiries (CMACE) 2011 Saving Mothers Lives: Reviewing
maternal deaths to make motherhood safer: 2006-2008 Wiley-Blackwell
Royal College of obstetricians and Gynaecologists, Setting Standards to improve women’s
health, Green -Top Guideline No 52
Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and
Gynaecologists, Royal College of Paediatrics and Child Health (2007). Safer Childbirth: Minimum
Standards for the Organisation and Delivery of Care in Labour, London: RCOG
…………………………..
Dr Gavin Campbell
Consultant Haematologist
…………………………..
Dr Liam McLoughlin
Lead Consultant Anaesthetist
…………………………..
Dymphna Sexton-Bradshaw
Associate Director of Women,
Children's & Sexual Health Division
/ Head of Midwifery
……………………………….
Aban Kadva
Consultant Obstetrician
Lead Delivery Suite
--------------------------------------Anne Regan
Lead Pharmacist
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 5 of 12
Code Blue
Guideline No: 1.6A
Version
Author (s)
Date
Circulation
One
Jo Osborne
2003
Multidisciplinary
forum
Two
Jo Osborne
Consultant Obstetrician
Comments
2004
Reviewed and
revised
2009
Reviewed and
revised
Consultant Obstetrician
Aban Kadva
Consultant Obstetrician
Three
Jo Osborne
Consultant Obstetrician
Julie Hinchcliffe
Senior Midwife / Risk Management
Four
Aban Kadva
2011
Gaynor Clayson
Consultant Obstetrician
Constable Theatre Sister
Julie Hinchcliffe
David Cottrell
Senior Midwife / Risk Management
Acknowledgement to V Aston Midwife
for her contribution to Appendix 4
Logistics & Safety
Manager
Reviewed and
revised
Susan Turner
Blood Transfusion
Practitioner
Five
Aban Kadva
2012
Gaynor Clayson
Consultant Obstetrician
Constable Theatre Sister
Julie Hinchcliffe
David Cottrell
Senior Midwife / Risk Management
Logistics & Safety
Manager
Reviewed and
revised
Susan Turner
Blood Transfusion
Practitioner
Jo Osborne
Clinical Lead for obstetrics
Obstetric
Anaesthetists
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 6 of 12
Code Blue
Guideline No: 1.6A
Appendix One
Operating Procedures For Portering for Code Blue
Introduction
Dispatcher
Facilities
Coordinator
Second Porter
This procedure is to ensure that the Portering team respond to the CODE BLUE
To enable medical staff to make sure that there is no break down in
communication in getting units of blood or specimens to their destination. The
location would be DS (Delivery Suite)
On receiving the CODE BLUE Call over the emergency bleep, the dispatcher is to
contact the Facilities Coordinator via radio giving him/her the location to report to,
On doing this the dispatcher must then call one of the porters to report to the
Haematology lab awaiting further instructions.
Once the Facilities Coordinator has been given the location he/she is to proceed
directly to that location and report to the Doctor/Nurse in charge awaiting further
instructions. If he/she are required to take/collect anything to the laboratory
he/she must be in contact with the porter located at the laboratory via radio and
agree to meet half way between the laboratory and the location of the CODE
BLUE If the second porter needs to deliver blood or blood products to the
department, the Facilities co-ordinator should make their way to the Haematology
laboratory in readiness for the next delivery.
When being instructed by the Dispatcher, Proceed directly to the laboratory and
await instructions, the laboratory will receive instructions and will know if any
blood products are required at the location of the CODE BLUE - If the porter is
required to deliver blood or blood products, he must alert the Facilities
Coordinator via radio that he/she is on his way to the location of the CODE BLUE
and inform him/her what he/she is bringing. The porter taking the blood or blood
products must deliver them directly to the clinical staff dealing with the CODE
BLUE
Stand Down
Once being told to stand down (this can only come from the Doctor/Nurse in
charge) then the Facilities Coordinator will confirm with the Doctor/Nurse in
charge that the second porter is clear to stand down. Then the Facilities
Coordinator is to contact the dispatcher and to inform him/her that the
CODE BLUE is completed.
Emergency
Numbers
Portering Facilities Co-ordinator: 07500 826210
Porters Emergency Bleep: 207
Helpdesk: 7676
Porters Dispatch: 2983
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 7 of 12
Code Blue
Guideline No: 1.6A
OBSTETRIC SCRIBE SHEET
Appendix Two
OBSTETRIC INCIDENT:
DATE:
LOCATION:
PATIENT NAME
HOSPITAL NUMBER
SCRIBE/S
Time
Name
Signature
Initial
Name
Signature
Initial
Event (including arrival of personnel)
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 8 of 12
Initial
Code Blue
Guideline No: 1.6A
Time
Event (including arrival of personnel)
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 9 of 12
Initial
Code Blue
Guideline No: 1.6A
SUMMARY SHEET
Appendix Three
(To be completed by Code Blue Organiser & Scribe)
CODE BLUE at Site:
Time:_
_Date:
___
Woman’s Name:............................................ D.O.B:............................ Unit No:..............................................
Staff Called
Obstetric Registrar
Obstetric SHO
Anaesthetic Registrar
ODP (Operating Department Practitioner)
Porter
Theatre Scrub Nurse
Outreach Team
Maternity Bleep Holder
Consultant Obstetrician
* Consultant Anaesthetist
CLINICAL TEAM LEADER
Time of Arrival
Name
Additional Staff (Designation, Name)
Time Called
Time of Arrival
Record of Therapy given during Code Blue Procedure
Transfusion
Red Blood Cells
Fresh Frozen Plasma
Platelets
Cryoprecipitate
Tranexamic Acid
Other
Fluid Therapy
Hartmann’s -1000mls
Volplex (500mls)
Other Fluids
(Insert Time for each unit given)
Vol / time
Continued over……….
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 10 of 12
Code Blue
Guideline No: 1.6A
Medication
Time
Ergometrine IV 500mcg
(2 doses max)
Misoprostol PR
Syntocinon /Normal saline IV
Carboprost IM 8 doses max
Dose
Time
Dose
Time
Dose
Time
Dose
…. mcg
40iu/500ml
250mcgs
Antibiotics:
Other;
Blood Loss Before transfer to theatre
Swabs
Incontinence sheets
Bed sheets
Drapes
Floor
Trough
Other
Total Measured Blood Loss
Total Estimated blood loss
Amount
FINALTOTAL Blood Loss:
(1. 2. and 3. i.e. Before,
In and After theatre)
=
=
=
1. Total EBL before transfer to theatre =
Blood Loss in Theatre
Suction
Swabs
Incontinence sheets
Bed sheets
Drapes
Floor
Trough
Other
Total Measured Blood Loss
Total Estimated blood loss
Team Debrief & Learning
Points Discussed:
=
=
2. Total EBL in Theatre =
Blood Loss After Theatre
Swabs
Incontinence sheets
Bed sheets
Other
Total Measured Blood Loss
Total Estimated blood loss
3. TOTAL BLOOD after Theatre =
Code Blue Stand Down
Date:
=
=
Time:
Signature of Code Blue Organiser ……………………….Name ……..……………..
Signature of Scribe……………………………………….Name………………………..
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 11 of 12
Code Blue
Guideline No: 1.6A
Appendix Four
ANAESTHETIC CODE BLUE LAMINATE
Haematology Direct Line ext 2088
2 x 16G Cannulae
Ensure Initial Bloods Sent
FBC, Clotting (incl fibrinogen), X match, U+Es, LFT +/- ABG
Consider:
 Arterial line/arm board
 Fluid warmers/Bair Hugger
 Antacids/Antibiotics/Haemoccue
1st Wave
6 units blood
(or if required immediately, request 2 units O Neg
blood and/or 6 units group compatible blood)
Chase initial blood results
FFP will be Thawed
2nd Wave
On request
4 units blood
4 units FFP
Send FBC and Clotting once FFP given
+/- ABG
Discuss clinical status and results with consultant haematologist
3rd Wave
On request
4 units blood
1 unit platelets
4 units FFP
Send FBC and Clotting once FFP and platelets given
+/-ABG
Discuss clinical status and results with consultant haematologist
4th Wave onwards On request
6 units blood
Clotting products guided by results, aim for:
PT & APTT < 1.5 x control (FFP)
Platelets > 100 (platelets)
Fibrinogen >1.5 g/l (cryoprecipitate
Date of Original document; September 2003
Date Amended: October 2012 Version 5
Review date; October 2015
Page 12 of 12
Code Blue
Guideline No: 1.6A