Post-partum haemorrhage in theatre

(Quick Reference Summary for Anaesthetists)

Predict and prepare – refer to SAFER form in pink Obstetric notes

If high risk – give 5 iu Oxytocin post delivery and start 40iu infusion over 4 hours +/- TXA 1g

If very high risk – also give Ergometrine 500mcg IV or IM (not in pre-eclampsia or hypertension)

If >500ml blood loss and ongoing bleeding

Consider patient weight and circulating volume (100ml/kg).  Resuscitate with up to 1.5L warmed crystalloid initially; anticipate need for early blood +/- products particularly in smaller women.

Discuss need for additional uterotonics with surgeon who can directly assess uterine tone.

Moderate PPH >1000ml and ongoing bleeding or clinical shock

Activate major obstetric haemorrhage call – 2222 and/or consultant anaesthetist & obstetrician. 

Give TXA 1g slowly if not already given & consider Ca²⁺.  Keep patient warm (blankets, Bair hugger). 

Give high flow O2 via trauma mask.  Insert 2nd large gauge (14/16G) cannula, take blood for FBC/UE/Coag/Lactate.  Consider Haemaccue.  Discuss likely causes and progress with surgeon.

Ensure appropriate uterotonics (unless uterine tone remains excellent and other cause likely):

• Additional 5iu Oxytocin slow IV (max total 10iu) and 40iu infusion if not already commenced
• Ergometrine 500mcg (diluted to 10ml given slow IV, or undiluted IM). Contraindicated in hypertensive disease or pre-eclampsia.  Ensure antiemetic given, ideally prior.
• Carboprost (Haemabate, Prostaglandin F2a) 250mcg IM – can repeat up to 8 doses at 15 min intervals. Contraindicated in asthma, cardiac/renal/hepatic/pulmonary disease.
• Misoprostol 1g can be given rectally by the surgeon.

Severe PPH >1500ml and ongoing bleeding

Likely to need general anaesthesia and arterial line +/- central line.  Call senior anaesthetist and consultant surgeon if not already present.

Call 2222 for MOH.   Cross match 4 units, consider O neg/group specific blood, FFP, cryoprecipitate, platelets as appropriate.  Use Haemaccue for point of care Hb.  Communicate concerns to surgeon.

Target Hb >7g/dL, Fibrinogen >2, INR/APTR<1.5, Plt >75.  We do not have access to ROTEM and laboratory results may be too slow therefore may need to be given on clinical grounds especially if consumptive (AFE, abruption, HELLP) or torrential (accreta, rupture) cause likely.  Get Belmont/Level 1.

AAGBI blood transfusion guidelines 2016 (Obstetrics section) – no FFP until 4 units RCC given (unless consumptive cause likely in which case early FFP recommended – this will be a clinical decision in BGH); if no coagulation results available at that point give 4 units FFP then continue 1:1 RCC:FFP until all results available. Platelet transfusions are infrequently required.  Give cryoprecipitate if Fib<3.

Leave epidural in if EBL >1500ml or <50kg.  Check bloods (FBC/Coag) 6h post op – Dalteparin can be given or epidural removed at this point if all satisfactory (if removing epid – wait further 6h prior to LMWH).  Repeat dose of antibiotics after EBL >1500ml.  Remember to ‘stand down’ MOH via 2222.

Ensure urometer for post-op fluid balance, consider site of post-op care (likely LW or ITU).