Emergency treatment of massive obstetric haemorrhage

Call for help (Most senior obstetric anaesthetist and obstetrician)

Airway
Breathing
Circulation
Drugs/disability
Emergency surgery

Oxygen 100% via a facemask

Full left lateral for APH – Head down, legs up

Two large-bore i.v. cannulae

 Take blood at the same time for: 
    Crossmatch 6 units 
    Full blood count 
    Coagulation studies 

 Communication is vital: 
    Mobilise porters 
    Notify theatre staff, request a cell saver with separate suction for amniotic fluid 
    Alert the blood bank and haematologist

 Concurrently: 
    Warm all resuscitation fluids, 
    Crystalloid, 2 litres maximum 
    Colloid, 1.5 litre maximum 
    Use group specific or O Rh negative blood whilst waiting 
    Ask somebody to set up a Level 1 warmer and Rapid infusion (or similar) device 
    Monitor haematocrit and haemoglobin 
    Restore normovolaemia

 If massive bleeding continues: 
    Give 4 units FFP and 10 units cryoprecipitate 
    Consider platelets 
    Use coagulation studies to guide the use of further blood products 
    Peri-operative monitoring as per the AAGBI guidelines 
    Consider invasive monitoring

 Drugs to consider: 
    Oxytocin (postpartum haemorrhage, given slowly) 
    Ergometrine (postpartum haemorrhage) 
    Carboprost (Hemabate, postpartum haemorrhage, not in asthmatic) 
    Tocolytic drugs (Placenta praevia and uterine rupture, beware of hypotension)
    Antifibrinolytics if no contraindications 
    rFVIIa (NovoSeven)

References:

[i] BJA-CEACCP; Massive haemorrhage in pregnancy

[ii] UK Blood Transfusion & Tissue Transplantation Services

[iii] AAGBI - Blood Transfusion and the Anaesthetist

[iv] AAGBI - Standards of Monitoring

[v] Entrez PubMed; Treatment of life threatening bleeding in O&G, NovoSeven (rFVIIa)