Case of the Month #45 Major Obstetric Haemorrhage - Part 1

A coordinated multidisciplinary team approach is required. Clear communication is key between all member of the MDT and with the women and any birthing partner(s).  

Once MOH has been declared, the following should attend the patient’s bedside (they should have already been alerted at a blood loss of 500-1000 ml): 

• The labour ward co-ordinator (Band 7 midwife)  

• Obstetric registrar  

• Obstetric anaesthetist 

• Healthcare support worker or Maternity Care assistant. 

Additionally, the Consultant obstetrician and anaesthetist should be informed and attend where bleeding continues. 

The MOH protocol should be initiated. This may differ between hospitals, but should involve alerting switchboard, blood bank, laboratory services, porters and theatre staff. Haematology input may also be required. 

The goal during resuscitation is to restore blood volume and oxygen carrying capacity/ delivery to vital tissues. The following steps should be followed- 

• Assessment of Airway and Breathing. Consider need to secure the airway. Apply 100% oxygen if maternal Sp02 is < 96% on air, or maternal conscious level is reduced. 

• Assess Circulation. Lie the patient flat. Ensure manual uterine displacement if APH to prevent exacerbation of hypotension secondary to aorto-caval compression. 

• Ensure Wide bore I.V. access (at least 16G) is established in at least 2 sites. 

• Take blood for 

• Urgent cross match 4 units Red Blood Cells (RBCs) 

• Point of care (POC) tests - TEG/ROTEM, venous lactate, venous Hb 

• Lab tests - FBC, U&Es, LFTs, coagulation screen, Clauss fibrinogen 

• Pulse, respiratory rate, blood pressure and temperature should be measured every 15 minutes. Normothermia avoids exacerbating any coagulopathy, and can be achieved with warmed fluids/ warming blankets etc. 

• Commence rapid infusion of warmed crystalloid with the aim of maintaining an adequate mean arterial pressure. The use of fluid warmers is advised and Rapid Infuser use should be considered if bleeding is rapid and ongoing. 

• Catheterise the bladder and measure hourly urine output (UO), aiming for at least 0.5 mls/kg/hr. MOH is a major cause of pregnancy-related Acute Kidney Injury. 

• Measurement of cumulative blood loss should be an ongoing process. 

• Ensure 1 gram of Tranexamic Acid has been given, if not already. 

• RBCs should be transfused and more ordered based on POC/ lab Hb levels and clinical observations (see below). 

• Consider immediate transfusion of O Negative blood if delay in obtaining group specific/ cross-matched blood or there is clinical instability. 

• Coagulation products should be ordered and transfused based on results from TEG/ROTEM. 

• Consider invasive blood pressure monitoring to improve cardiovascular monitoring and allow for serial blood sampling. 

• Consider central venous access if peripheral access is difficult or a need for vasopressors is anticipated. 

• The feasibility of Cell Salvage should be considered in all cases. 

• Definitive management of MOH depends on cause.  

• Consider the need to transfer to theatre or interventional radiology for surgical/ mechanical interventions. 

• Discussion with the duty haematologist is advised when > 6 units of RBCs have been transfused or there are evolving coagulation problems.