28-year-old G1P1, 2 hours post normal spontaneous vaginal delivery. Quantitative blood loss (QBL) now 2,000 mL and rising. Two large-bore IVs placed. Received standard uterotonics and TXA without stabilization. JADA intrauterine balloon inserted. On NRB oxygen. 2 units PRBC administered so far.
Patient is visibly pale, diaphoretic, and becoming increasingly lethargic.
Clinical picture: Postpartum hemorrhage (PPH) with hemorrhagic shock. QBL >2,000 mL with ongoing bleeding, hemodynamically unstable despite initial interventions.
- Shock indicators: hypotension (SBP <90), tachycardia (HR 138), altered LOC, SpO₂ declining
- Shock Index (HR/SBP): 138/84 = 1.64 — critically elevated
- Standard uterotonic management has failed — uterotonics, TXA, and JADA device have not controlled bleeding
- This patient needs escalation to MTP — continued volume replacement alone is insufficient
OB-specific MTP criteria (per CC.03.004):
- For OB patients: MTP may be initiated after the 2nd unit of PRBC — nurse OR attending can initiate
- This patient has already received 2 units PRBC with continued hemorrhage and instability — MTP criteria are met
- Blood Bank may also suggest MTP activation after 8 units PRBC within a 2-hour window
- Do not wait — activation is a clinical decision based on the patient's condition, not a lab threshold
Call Blood Bank at x6544. Provide:
- Patient full name
- Date of birth
- MRN
- Location (OB unit, room number)
- OB unit phone number (for callback when products ready)
Confirm Type & Screen is resulted or order stat — required for type-specific products. Until available, O-negative can be emergency-released.
CRITICAL SAFETY: If no historical blood type on file, an initial AND confirmatory T&S specimen must be collected at DIFFERENT times. Collecting specimens at different times reduces the risk of mislabeled specimens with incorrect patient information. This type of error could result in the death of a patient.
- Primary RN: Notify charge, verify T&S, prepare IV lines and blood warmer for transfusion
- Provider: Place needed blood product orders in eRecord and document MTP activation as required; ordering products is not the activation step
- Charge RN: Notify nursing supervisor, assign runner/designee to Blood Bank
- Runner/designee: Collect patient label → go directly to Blood Bank for emergency release of first 2 units
- Supervisor: Coordinates ongoing cooler transport and additional resources
MTP activated. Provider order placed in eRecord. Runner sent to Blood Bank. First MTP shipment is arriving to the OB unit.
MTP cooler must be maintained at 1–10°C. Cannot exceed 10°C.
- If above 10°C: do NOT use any products — return entire cooler to Blood Bank
- Products from an out-of-range cooler will be discarded by Blood Bank
- Check temperature FIRST — before opening or verifying contents
Standard MTP release pattern:
- 4 PRBC in the cooler
- 4 FFP thawed at 37°C and released separately/as available, often 2 at a time
- 1 dose platelets: CSP in the cooler with a bright yellow sticker, or SDP in a basin
- Cryoprecipitate AHF — issued after 4 FFP have been given
- Two-patient identifiers: name + DOB (or MRN)
- Product tag signed by both RNs
- Emergency release paperwork signed by provider
- This verification is required for every single unit — no shortcuts during MTP
PRBC and FFP may be administered via blood warmer and rapid infuser.
- Consider rate carefully given postpartum physiology — discuss with provider
- These are the ONLY products that can go through warmer/rapid infuser
CSP platelets (bright yellow sticker, stored in cooler):
- Standard blood tubing ONLY
- NEVER through a blood warmer — heat destroys platelet function
- NEVER under pressure (no rapid infuser) — pressure damages platelets
- This is one of the most common and dangerous MTP errors
- Cryoprecipitate is at room temperature — NOT stored in the MTP cooler
- Do NOT run through blood warmer or rapid infuser
- Issued after 4 FFP have been given
- Thawed FFP should NOT be placed in the MTP cooler — it can raise cooler temperature and make PRBCs/CSP unusable
4 PRBC and 2 FFP administered. Patient remains hemodynamically borderline.
Provider orders first dose of platelets via warmer and rapid infuser.
The attending orders: "Hang 1 dose platelets via the blood warmer and rapid infuser."
Before hanging the platelets — do you see a problem with this order?
✓ RN catches the error and clarifies with provider. Platelets are administered correctly via standard blood tubing. The attending acknowledges the correction.
Next 2 FFP arrive separately after thawing; the cooler holding cold products reads 10°C.
Teaching moment: Platelets — CSP or SDP — should never go through a blood warmer or rapid infuser. Heat and pressure damage platelet function and can cause patient harm. The correct action is to speak up, question the order, and administer via standard blood tubing.
Runner returns with the next cooler. Temperature reads exactly 10°C.
Is this acceptable? What do you do?
✓ Team recognizes 10°C is the upper limit. Blood Bank notified at x6544. Coolants changed before adding more products. Transfusion continues safely.
Discussion: The policy states cooler cannot go above 10°C. At exactly 10°C, products are at the limit — they're still usable, but coolants should be changed before adding more PRBC. Blood Bank (x6544) should be notified. If the temperature were above 10°C, products must be returned and cannot be used.
Decision made to take the patient to OR for emergency surgical stabilization. Blood products are still infusing.
- Situation: Active PPH with MTP in progress
- Background: Delivery type, QBL, interventions so far (uterotonics, TXA, JADA), products given
- Assessment: Current hemodynamic status, trend, bleeding status
- Recommendation: Surgical stabilization, MTP to continue until control confirmed
- During OR transfer: anesthesia takes over hemodynamic management and product administration
- Should be documented on anesthesia record
- Blood products may continue infusing during transport — ensure IV access and lines secured
- MTP remains active — do not deactivate until surgical control is confirmed
Patient returns to PACU after surgical procedure. Hemodynamically stable. No active bleeding. PRBC currently infusing. No more products in cooler.
- Blood Bank continues preparing products until notified — every minute of delay = wasted products
- Provider OR designee (can be the RN) calls x6544 to discontinue
- This is the most time-critical step in deactivation
Provider closes related blood product orders/documentation in eRecord as appropriate. This closes the official documentation trail.
- All remaining products must be returned to Blood Bank
- MTP cooler must be returned
- Do not keep extra products "just in case" — Blood Bank needs them back
PACU nurse receives handoff from OR team including:
- Total blood products given by type
- MTP status (active vs. discontinued)
- Total QBL
- Surgical procedure performed
- Current hemodynamic status
- Document: total units by product type, MTP start/end time, vital signs at discontinuation
- MTP paper record (emergency release paperwork, product tags) → sent to medical records
- Unit tag(s) attached to Blood Bank Cumulative Transfusion Record
- After discharge: paper record scanned into the medical record
Use these questions to guide the team discussion. In self-guided mode, reflect on each question before moving on.
CC.03.004 — Clinical Practice Guideline: Massive Transfusion Process for Adult Patient
Blood Bank: x6544
How confident were you in your ability to manage an MTP on the OB unit?
How confident do you feel now in your ability to manage an MTP on the OB unit?