Obstetric Haemorrhage management guideline (GL775) · Obstetric Haemorrhage management guideline (GL775) Approval . Approval Group Job Title, Chair of Committee Date Maternity & Children’s

Obstetric Haemorrhage management guideline (GL775)

Approval Approval Group Job Title, Chair of Committee Date Maternity & Children’s Services Clinical Governance Committee

Chair, Maternity Clinical Governance Committee

4th May 2018

Change History Version Date Author, job title Reason 9.0 Mar 2018 L Williams (Consultant

Anaesthetist C Harding (Consultant MW) P Bose (Consultant Obstetrician)

Reviewed – minor changes throughout to reflect Blood bank change to Transfusion Lab and clarification of controlled or uncontrolled MOH in emergency calls

9.1 Dec 2018 C Harding (Consultant MW) J Siddall (Consultant Obstetrician)

Amended to include info from GL910 Secondary PPH which is being withdrawn

9.2 March 2019 S Sengupta (Consultant Obstetrician)

MOH trigger change to >1500ml in line with AHSN and other local hospitals changes throughout

9.3 July 2019 S Sengupta (Consultant Obstetrician) N Benns (Clinical Risk Manager)

MOH proforma amended to reflect weighed blood loss rather than EBL and throughout guideline PPH risk factor poster added as appendix 5

Author: L Williams , C Harding, P Bose, T Hawkins Date: July 2019 Job Title: Consultant Anaesthetist, Consultant Midwife,

Consultant Obstetrician, Review Date: May 2020

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Group Director Urgent Care Version: V9.3 July 2019 V9.0 ratified 4/5/18

Location: Policy hub/ Clinical/ Maternity/ Lifesaving guidelines/ GL775 This document is valid only on date last printed Page 1 of 22

Maternity Lifesaving Guidelines – Obstetric Haemorrhage (GL775) July 2019

Overview: Obstetric haemorrhage remains a major cause of maternal mortality in the UK and is now the third leading cause of direct maternal deaths, accounting for approximately 10% of direct deaths. This does not represent a significant increase in mortality as deaths have decreased overall. Substandard management continues to be a significant contributor to mortality from haemorrhage. It is estimated that there are more than 4000 cases of severe haemorrhage each year in the UK.1

The definition of MOH varies widely. At the Royal Berkshire Hospital a major obstetric haemorrhage (MOH) should be called in the event of uncontrolled haemorrhage (where multidisciplinary support is needed) or any case where a blood loss of greater or equal to 1500ml is calculated or anticipated. In obstetric haemorrhage it is difficult to measure blood loss accurately, it is often under estimated. Transfusion Laboratory Actions Always inform the Transfusion Laboratory (bleep 298) as the situation changes, whether you escalate the MOH to the next level or stand down the MOH.

This guideline also contains: Major Obstetric Haemorrhage Flow Chart ........................................................................... 3 Management of Obstetric Haemorrhage (General guidelines) ............................................. 4 Antepartum Haemorrhage ................................................................................................... 9 Postpartum Haemorrhage .................................................................................................. 12 Monitoring Standards ......................................................................................................... 16

Appendix 1 – Major Obstetric Haemorrhage report form ................................................ 18 Appendix 2 – Emergency calls in obstetrics ................................................................... 19 Appendix 3 - Obstetric massive Haemorrhage protocol ................................................. 20 Appendix 4 – EMA090 – PPH on Rushey >500ml ......................................................... 21

Controlled MOH Issue 2 units of RBCs if required Ask if 3 units of Octaplas need thawing

Uncontrolled MOH Issue 4 units of RBCs Thaw 3 units of Octaplas (takes 40 minutes) Urgently run FBC and Clotting tests Issue blood components if FBC and clotting results abnormal



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Major Obstetric Haemorrhage Flow Chart

Further medical management options

• Carbetocin IV 100mcg (diluted to 10ml given over 2 mins) in theatre (do not use Oxytocin within 4 hours of administration of Carbetocin)

• Tranexamic acid 1g IV over 10 minutes (if not given already)

• Aim calcium > 1 (10% CaCl 10ml iv over 10 mins) • Aim glucose < 10 • Aim Potassium < 5 (Glucose / Insulin sliding scale will do

both) C id ll l

Major Obstetric Haemorrhage (MOH) • Blood loss > 1500mls • On-going MOH or clinical shock

Call for Help Call 2222, state ‘Major obstetric haemorrhage’ with location and whether controlled / uncontrolled Inform labour ward co-ordinator and alert theatres

Further surgical management options

• Intrauterine tamponade (Rusch balloon or latex free alternative)

• B-Lynch suture • Consider stepwise ligation uterine vessels • Consider uterine artery embolisation • Hysterectomy (call consultant gynaecologist)

2222 call alerts: • Obstetric SpR/SG 555 • Obstetric anaesthetist 142 • Consultant anaesthetist 149 • D/S Coordinator 340 • Mat unit Coordinator 179 • Mat theatre Coordinator 184 • ODP 268 • Transfusion laboratory 298 – state controlled or

uncontrolled

Resuscitation Airway, Breathing, Circulation Oxygen mask (10-15L/min aim Oxygen aim saturations 94%-98%) Intravenous fluid (Plasmalyte initially, up to 2L, then consider blood products) Red cell transfusion (O RhD neg, Group specific blood or cross matched blood as appropriate) and blood components as appropriate Consider Plasma (Octaplas) if >2 units blood transfused Aim Hb >80g/L, Platelets >50, Fibrinogen >200mg/dl Keep Patient warm – Fluid warmer and Bair hugger Early transfer to maternity theatre

Monitoring and investigations

• Site two 16g cannulae • Send bloods • Maternal pulse (preferably ECG) and SpO2 continuously • Blood pressure, respiratory rate 15 minute intervals • Urinary catheter (hourly urometer) • Hb testing (Haemacue) • Consider arterial line • Uterine height and contractility/PV loss • Keep contemporaneous records/MOWS • Weigh all swabs and estimate on going blood loss

Medical treatment

• Oxytocin • Bimanual compression • Empty bladder • Ergometrine 500mcg IM OR slow IV • Oxytocin infusion (30iu in 500mls N/Saline at 100mls/hr) • Carboprost (Haemabate) 250mcg intramuscular or

intramyometrial every 15 mins up to 8 doses • Misoprostol 1mg (5x 200mcg tabs) rectally

Transfusion Laboratory Will respond to MOH bleep, give them • Patient details • Clinical lead for MOH and contact number • State Controlled or Uncontrolled • Issue 2U of RBCs and defrost 3U Octoplas • State if going to use Emergency O neg RBCs • Send FBC, clotting (INR and APTR) + fibrinogen • Start MOH feedback form • Communicate with lab if clinical situation changes If the transfusion laboratory have NOT phoned back to the clinical area within 5 minutes of putting out the MOH bleep, then bleep the transfusion laboratory directly on bleep 298

Consider transfer to ICU Stand down Transfusion Laboratory and

porters when appropriate



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Management of Obstetric Haemorrhage (General guidelines) Clinical Management – follow procedure in Major Obstetric Haemorrhage Flow Chart above • If weighed blood loss >1500 ml and continuing inform Obstetric consultant on call • If weighed blood loss >/=1500 ml, or anticipated to be so, place 2222 telephone call

and declare Major Obstetric Haemorrhage; stating whether Controlled or Uncontrolled, with location

• Site 2 large bore IV cannulae (at least 16 g) and commence IV fluids • Send blood for group and save / cross match (if no valid sample), full blood count

(FBC), clotting studies (INR, APTR and Fibrinogen) as soon as possible; bottles and cards on delivery suite, in recovery and anaesthetic room between obstetric theatres. Whilst bleeding persists repeat all haematology investigations at frequent intervals (as indicated by results / clinical situation and advice from haematology) until the situation stabilises.

• Good communication with Transfusion Laboratory essential. Keep them updated with the clinical situation and request blood components as appropriate. (2 units packed red cells will be issued and 3 units plasma (Octaplas) will be defrosted on the request of the clinicians). Laboratory staff rely on clear communication from clinical staff about the patient’s condition and if the bleeding is under control.

• Ensure porters are present for delivery of specimens and collection of blood • If gravid place patient in lateral position • Give Ranitidine 150 mg orally • Give Oxygen by face mask (10-15 litres per minute aiming for saturations between

94% - 98%)(12) • Alert theatre team and ODP • If weighed blood loss 1500ml and haemorrhage is uncontrolled, request consultant

obstetrician’s presence • Arrange for blood warmer and warming blanket from maternity theatres • Transfer patient to theatre at an early stage

Monitoring • Use Datix/ Phillips monitor and make written recordings on high dependency chart at

15 minute intervals • Continuous measurement of maternal pulse, preferably with ECG • Blood pressure set at 5-15 minute intervals as appropriate • SpO2 and record respiratory rate • Maternal temperature every 15 minutes • CTG (if antenatal and > 24 weeks)



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Location: Policy hub/ Clinical/ Maternity/ Lifesaving guidelines/ GL775 This document is valid only on date printed Page 4 of 22


• Catheterise and connect to hourly urometer • MOWS score • Uterine height and contractility/ tone • PV blood loss • Observe general appearance – pallor of skin, lips & nail beds • Hb with Haemacue (from theatre) • Arterial Blood Gas estimation • Arterial line monitoring and CVP (if clinically indicated and experienced staff available) Fluid Balance • Assign midwife/HCA to accurately record all fluids and medications given • Give IV fluids in following order

1. Plasmalyte up to 2 Litres (warmed) 2. Cross matched blood (or if not ready and situation urgent, give group specific

blood as soon as it is available, even if cross matching pending) 3. O Rhesus negative blood (appropriate to use if cross matched / group specific

blood not available and transfusion indicated urgently) 4. Plasma / Octaplas

At the RBH Octaplas is used in place of fresh frozen plasma (FFP). Recent national guidance2 states: “Plasma (or Octaplas at the RBH) should be as part of initial resuscitation in major haemorrhage in at least 1 unit plasma: 2 unit ratio with red cells until results from coagulation monitoring are available. Once bleeding is under control, further plasma should be guided by abnormalities in laboratory tests with transfusion trigger of PT and/ or APTT >1.5 times normal. If laboratory results are not available, and bleeding continues, further plasma (or Octaplas at the RBH) may be transfused in at least a 1:2 ratio with red cells, prior to moving on to blood product use guided by laboratory results. Use of plasma should not delay fibrinogen supplementation if it is required.” Octaplas dose of 15-20ml/kg is indicated on

a. clinical grounds (more than 2 units of packed red cells already given or if it is anticipated that 2 units of packed red cells will need to be given or if coagulopathy is suspected on clinical grounds), or

b. if a coagulopathy is demonstrated on coagulation testing (INR or APTR >1.5). Abnormal coagulation is less common in obstetric haemorrhage, it may be appropriate to transfuse plasma (Octaplas) without knowledge of clotting result. Transfusion Laboratory will call to confirm Octaplas is required before releasing to prevent wastage. If Octaplas does arrive on labour ward and is not required it must be returned to transfusion within 30 minutes to prevent wastage if not needed.



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5. Cryoprecipitate: Fibrinogen supplementation (with cryoprecipitate) should be given if fibrinogen levels fall below 200mg/dl. Cryoprecipitate is the standard source of fibrinogen in the UK and two five-donor pools will increase fibrinogen in an adult by approximately 100mg/dl.2

A low early fibrinogen level is a predictor of severity of haemorrhage. Do not delay fibrinogen supplementation if required.

6. Platelets: In major haemorrhage aim to keep platelets >50x109/l; national guidance suggests that platelets should be requested if there is on-going bleeding and the platelet count has fallen below 100x109/l.2

7. Obtain advice from haematology consultant on clotting results and blood component replacement if results are outside local guidelines stated above or if bleeding continues despite patient receiving Octaplas, platelets and cryoprecipitate.

Clinical Management If antepartum, the consultant obstetrician may consider expediting delivery. Post-partum, stop the bleeding:

• Rub up a uterine contraction

• Commence bimanual compression of the uterus. Medical management: OR intravenously

• If Carbetocin used at Caesarean section, do not use Oxytocin for at least 4 hours • Oxytocin infusion (30 units in 500 ml Saline started at 100ml/hr.) (Oxytocin guideline

GL925) or

• Carbetocin 100mcg IV (unlicensed for vaginal deliveries currently but safe and effective) - dilute to 10ml in NSaline and give IV over 2 mins in theatre with full monitoring.

• Carboprost (Haemabate) 250micrograms directly intramuscular every 15 minutes up to 8 doses.

• Misoprostol 1mg (5 x 200 mcg tablets) rectallyTranexamic acid 1g IV (but the patient will require postoperative Tinzaparin due to theoretical risk of increased thromboembolism)



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Surgical options: • Consider a Bakri balloon to tamponade the uterus (Bakri guideline GL909)

• Consider a Vaginal Pack if there is bleeding from the lower genital tract (Vaginal pack guideline GL931)

• Laparotomy to insert B Lynch suture using Number 1 Monocryl (W7309)

• To contact an interventional Radiologist for Uterine artery embolisation, contact switchboard and ask them to page the Interventional Radiologist on call.

• Open the broad ligament and ligate the uterine artery on both sides

• Ligation of the internal iliac arteries.

• Subtotal or total hysterectomy may be required. Contact the on call gynaecology consultant via switchboard and ask to attend urgently within 30 minutes.

• Clamp\compress the aorta (below the renal arteries) as a temporary life saving and time buying manoeuvre.

• Consider Recombinant Factor VIIa therapy only in discussion with a consultant haematologist. Factor VIIa is not normally recommended in the management of major haemorrhage but may be appropriate after discussion with consultant haematologist in extremis.

Oxytocic drugs – mode and duration of action Oxytocic Mode action Onset action Duration action

Syntometrine (Oxytocin + Ergometrine)

Smooth muscle uterus 2-5 mins Several hours

Oxytocin (Synthetic Oxytocin)

Smooth muscle uterus IV less 1 min IM 3-7 mins

IV short duration IM 30-60 mins

Misoprostol (E1 Prostaglandin analogue)

Smooth muscle uterus 20 mins 20-40 mins

Ergometrine Vasoconstriction to increase uterine contractions & vasoconstriction

IV 1 min IM 2-3 mins

2 hours

Haemabate Smooth muscle uterus 20-30 mins 3 hours Carbetocin (Synthetic analogue Oxytocin)

Increased frequency contractions & increased uterine tone

2 mins 4 hours

Tranexamic acid Inhibits fibrinolysis 3 hours If bleeding is not getting under control despite transfusion of all blood components covered by the MOH policy, and the patient is haemodynamically unstable then contact a Consultant Haematologist on bleep 922 and inform the Transfusion Laboratory (bleep 298) that there is a catastrophic MOH



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Post-operative care

• Decide between need for intensive care or higher levels of care on labour ward (HDU policy - CG489)

• Watch for recommencement of blood loss • Address venous thromboembolism risk Some women will decline transfusion, notably Jehovah’s Witnesses. The RBH has adopted a guideline developed with advisers from this religious group and reviewed by professional experts.

• Consider cell salvage (Cell salvage guideline - GL754) • Recommendations include administration of erythropoietin 300 U/kg per week without

delay • Iron supplementation intravenously, Venofer 200mg x 3 doses/ week or Ferinject

(Venofer guideline GL784 & Ferinject guideline - GL783) • Vitamin B12 and folic acid • Consider transfer to ITU • Hyperbaric oxygen therapy in life-threatening situations Summary of management • Summon extra and senior staff • Request blood components early • Check fibrinogen early • Restore rapidly an adequate circulating blood volume and oxygen carrying capacity of

the blood • Give O2 by face mask guided by saturation monitoring(12) • Stop / treat the cause of the blood loss • Higher levels of care on delivery suite • Restore and maintain normal coagulation. • Debrief patient at earliest opportunity • Complete adverse incident form • Complete MOH feedback form • All cases of MOH of 3000mls or more, or that have major concerns around

management will be discussed at Maternity Clinical Risk Management Committee. • Step down Major Haemorrhage Call once situation resolved/under control and return

unused blood to Transfusion Laboratory. • Inform Transfusion Laboratory and portering staff once MOH under control and stand

down



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Antepartum Haemorrhage Overview: Severe antepartum haemorrhage (APH) occurs about 3-5% of pregnancies. The main differential diagnoses are placenta praevia, placental abruption, bleeding of unknown origin and vasa praevia.

Risk factors: Common risk factors for Placenta Praevia and placental abruption:

• Maternal Age • Parity • Multiple Pregnancy • Cigarette smoking • Cocaine abuse

Risk factors for Placenta Praevia:

• Previous caesarean section (10-15%) • Previous TOP & D&C • Previous MROP • Previous myomectomy/TCRE

Risk factors for Placental Abruption:

• Pregnancy Induced Hypertension /PET • Preterm rupture of membranes • Fibroids, previous abruption • IUGR & external trauma • Substance abuse • Polyhydramnios • Low BMI • Assisted reproductive techniques • Maternal Thrombophilia’s

The clinical presentation is vaginal bleeding + one or more of • Abdominal pain • Uterine tenderness • CTG abnormality • Intra-uterine death • Uterine hyper tonus Author: L Williams , C Harding, P Bose, T Hawkins Date: July 2019 Job Title: Consultant Anaesthetist, Consultant Midwife,


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Clinical Management • Contact Obstetric Registrar and SHO • Contact obstetric anaesthetist • Inform duty obstetric consultant • Assess for signs of clinical shock; maternal pulse, BP & O2 saturations • Take clinical history to identify risk factors for abruption and placenta

praevia if there is no maternal compromise • Inform Transfusion Laboratory, stating whether controlled or uncontrolled • Site 2 large bore cannulae 16 g or larger • Take blood for group, cross match (2 units initially) and clotting studies

(INR, APTR and Fibrinogen) • Position woman with left lateral tilt • Assess airway and give oxygen via facemask with target oxygen

saturations of 94-98% • Keep woman warm • Start fluid replacement with Plasmalyte, up to 2 litres • Use O neg or group specific red cells in cases of life threatening blood loss • Correct coagulopathy • Analgesia if required • Avoid vaginal & rectal examinations in cases of suspected placenta

praevia • Kleihauer test should be performed in rhesus D-negative women

Monitoring Use Datix/Phillips monitoring equipment and use high dependency chart to record readings:

• Record vital signs every 15 minutes • Hourly temperature • Assess MOWS score • Catheterise and monitor hourly urine output • Document all fluids given • Document drugs and doses given • If EBL >/= 1500 mls institute Major Obstetric Haemorrhage Flow Chart



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When mother stable, assess condition and viability of fetus.

• Prompt delivery if fetus is alive or unable to stabilise mother • Ultrasound examination to exclude placenta praevia before any vaginal

examination • Patients with Placenta Praevia need delivery by caesarean section • In cases of intra-uterine death consider vaginal delivery but anticipate

PPH. An emergency caesarean section may be necessary for obstetric reasons e.g. transverse lie or if maternal shock is un-correctable

• Consider corticosteroids to women between 24 and 34 weeks gestation, that are at risk of preterm birth

Complications of APH • Anaemia • Infection • Maternal shock • Renal tubular necrosis • Consumptive coagulopathy • Postpartum haemorrhage • Complications of blood transfusion • Fetal hypoxia • Small for gestational age and fetal growth restriction • Prematurity • Fetal death • Venous thromboembolism



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Postpartum Haemorrhage See also Appendix 4 below, PPH Obstetric Haemorrhage on Rushey Birth Centre PPH>500ml

1° PPH occurs immediately after completion of the second or third stage of labour up to 24 hours and can be due to

Antenatal risk factors: • Multiple pregnancy • Pre-eclampsia • Obesity • Anaemia • Placenta praevia • Previous APH/PPH • Maternal age > 40 years

Risk factors in labour: • Placental abruption • Prolonged labour • Induction of labour • Pyrexia in labour • Operative vaginal delivery • Retained placenta • Elective or emergency

caesarean section

Commonest causes of postpartum haemorrhage • Genital tract trauma • Uterine atony • Retained products of conception (including the complete placenta) • Iatrogenic damage • Ruptured uterus • Broad ligament haematoma • Uterine inversion • Extra-genital bleeding (sub-capsular liver rupture) • Bleeding disorders • Other causes, including fibroids Clinical management of primary PPH • Call for help • Rub up a contraction • Commence Bimanual compression of uterus until help arrives • If the bleeding is from the placental bed of an intact uterus give

Ergometrine 500 mcg intramuscularly. Do not give to women with hypertension- seek senior adviceSite 2 large bore cannulae (16g or larger)



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• Take blood for Group and X match 2 units, FBC and clotting studies (INR, APTR and Fibrinogen)

• IV fluids Plasmalyte 2 Litres • Oxytocin infusion (30 units in 500 ml Saline started at 100ml/hr) or

Carbetocin 100mcg (diluted to 10ml and given iv over 2 min) in theatre with monitoring.

• Misoprostol 1mg (5 x 200 mcg tablets) rectally • Carboprost (Haemabate) 250 micrograms directly intramuscular every 15

minutes up to 8 doses. Observe patient for further bleeding. The Obstetric and duty anaesthetic registrars must be informed if patients continue to bleed after the second dose of ergometrine has been administered. If the patient continues to trickle despite 2nd doses of Uterotonics, consider EUA rather than further drug treatment.

Monitoring Use Datix/Phillips monitor and record

• Maternal pulse and SpO2 continuously and document every 15 mins

• Blood pressure every 15 mins

• Respiratory rate every 15 mins

• Temperature hourly

• Assess MOWS score

• Catheterise and measure hourly urine output

• Observe fundal height and vaginal blood loss regularly. If necessary mark height of fundus with marker pen

If the patient continues to bleed make arrangements for EUA

• Ensure senior obstetricians and anaesthetists are fully aware of the situation.

• Prepare patient for theatre

• Inform theatre staff and ODP

• Treat uterine atony with: 1. Misoprostol 1mg (5 x 200 mcg tablets) rectally 2. Carboprost (Haemabate) 250 micrograms directly intramuscular

every 15 minutes up to 8 doses

• At EUA examine the uterine cavity, cervix and genital tract injuries and consider a Bakri Balloon or Vaginal Pack



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If the bleeding still persists but at < 100 ml/hr

• Restart Oxytocin infusion or consider Carbetocin 100mcg IV (in theatre) • Seek senior advice • Observe the patient and wait • Keep blood available If there is continuous bleeding from uterus despite medical treatments, consider EUA. If EBL >1500 mls and haemorrhage continuing, inform consultant obstetrician If EBL >/= 1500 mls or patient is clinically shocked follow Major Obstetric Haemorrhage Guideline and institute Major Obstetric Haemorrhage Flow Chart 2° PPH occurs from 24 hours to 12 weeks after delivery.

Causes: The usual cause is due to retained products of conception and accompanied by a degree of infection.

Investigations: • Vaginal swabs • Blood cultures if pyrexia > 38°C • Bloods for FBC &CRP • Pelvic USS if more than 6 weeks postpartum

Treatment of possible infection: If suspected infection/sepsis apply Sepsis bundle and give antibiotics within one hour. Tazocin and Clindamycin are standard treatment. See Antibiotic guideline for Obstetrics GL787.

Clinical management of secondary PPH This should be the same as for primary PPH in an acute situation. In a non-acute situation the following should be considered • take history

• examine patient

• swabs from vagina

• FBC (everyone) and cross match if anaemic/shocked

• if the internal os is open – arrange ERPC under GA

• if the uterus is soft or enlarged– arrange ERPC under GA Author: L Williams , C Harding, P Bose, T Hawkins Date: July 2019 Job Title: Consultant Anaesthetist, Consultant Midwife,


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• if the pelvis is tender (including cervical excitation) prescribe antibiotics and arrange appropriate admission/surgical treatment/out patient review

• DO NOT ask for ultrasound examination to aid management

• Repeat presentations with PPH must be seen by the specialist trainee (ST3 or above) or specialty doctor on duty

• All postnatal readmissions with PPH should be reported through clinical incident reporting as rates have to be audited.

In response to a GP referral it is usually most convenient to arrange non-urgent admission the next day, starved and prepared for an ERPC. Women who require ERPC

1. Take swabs from uterine cavity before instrumentation at ERPC.

2. Tissue removed at ERPC must be sent for histological evaluation.

Post Haemorrhage Most women will accept transfusion of blood products. The aim is to restore the Hb concentration to >80g/L. For Hb 80-100 g/L consider Venofer (GL794) or Ferinject (GL783) infusion (see relevant guideline) Some women will decline transfusion, notably Jehovah’s Witnesses. The RBH Trust has adopted a guideline developed with advisers from this religious group and reviewed by professional experts.

• Consider cell salvage • Recommendations include administration of erythropoietin 300 U/kg

per week without delay • Iron supplementation intravenously, Venofer 200mg x 3 doses/ week • Vitamin B12 and folic acid • Consider transfer to ITU • Hyperbaric oxygen therapy in life-threatening situations

Complete Adverse Incident Form Debrief patient at earliest opportunity Trustwide Policy - Blood Transfusion Policy (CG028)



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Monitoring Standards Auditable Standard Monitoring method Frequency of

monitoring Review Group / Committee

All maternal on-going blood loses ≥ 1500 mls will be defined as “A Major Obstetric Haemorrhage” and an emergency call will me made dialling 2222 and stating “Major obstetric haemorrhage” to summon immediate assistance from obstetric SpR, obstetric anaesthetist, delivery suite coordinator , portering staff, on-call consultant obstetrician presence will be required for on-going haemorrhages, consultant anaesthetist and maternity unit coordinator will be informed, and Transfusion Laboratory alerted.

Review of all records of women who have had a MOH (≥ 1500 mls)

Quarterly audit report

Maternity Audit Forum

All women with a postpartum haemorrhage will be managed as stated in the obstetric haemorrhage guideline




In all cases of major obstetric haemorrhage, a fluid balance chart will be completed; this will be filed in the maternal health care record.




A “Major Obstetric Haemorrhage” form and an incident form will be fully completed in all cases when a woman sustains an on-going blood loss ≥ 1500 mls.

Review of all records of women who have had a MOH (≥1500mls)



Major obstetric haemorrhages will be monitored through the maternity dashboard; if the dashboard becomes RED it will trigger an interim review.

Case review by Consultant Obstetricians if the dashboard shows a red flag

Monthly Maternity Clinical Risk Committee

References: 1. Royal College Obstetricians & Gynaecologists. Green top guideline 47

(May 2015) Blood transfusion in obstetrics 2. A practical guideline for the haematological management of major

haemorrhage. Hunt et al. British Journal of Haematology, 2015, 170, 788–803.

3. Royal College Obstetricians & Gynaecologists. Green top guideline 52 (May 2009, revised April 2011) Prevention & management of postpartum haemorrhage

4. Confidential Enquiry into Maternal and Child Health, Why Mothers Die 2006-2008 CMACE

5. Drife J. Management of primary post-partum haemorrhage. British Journal of Obstetrics and Gynaecology 1997; 104: 275-7

6. Holdcroft A, Thomas TA. Principles and Practice of Obstetric Anaesthesia and Analgesia



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7. Managing Obstetric Emergencies and Trauma 2003, pages 151-163 8. High Risk Pregnancy (3rd Edition) James, Steer, Weiner, Gonik pp 1606-

1617 9. National Institute of Clinical Excellence. Intraoperative Blood Cell Salvage

in obstetrics. Guidance 144. London. NICE 2005. 10. Royal College of Obstetricians & Gynaecologists (2011). Green top

guideline 63: Antepartum Haemorrhage. 11. Saving Lives, Improving Mothers’ Care Surveillance of maternal deaths in

the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13. December 2015

12. O’Driscoll BR et al (2017) BTS Guideline for oxygen use in adults in healthcare and emergency settings Thorax 2017; 72: Suppl 1 i1‐i89



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Lifesaving Guidelines – Obstetric Haemorrhage (GL775) July 2019

Appendix 1 – Major Obstetric Haemorrhage report form – available from http://www.royalberkshire.nhs.uk/major-haemorrhage.htm

Author: L Williams , C Harding, P Bose, T Hawkins Date: July 2019 Job Title: Consultant Anaesthetist, Consultant Midwife, Consultant Obstetrician, Review Date: May 2020 Policy Lead: Group Director Urgent Care Version: V9.3 July 2019

V9.0 ratified 4/5/18 Policy hub/ Clinical/ Maternity/ Lifesaving guidelines/ GL775 This document is valid only on date last printed Page 18 of 22

http://www.royalberkshire.nhs.uk/major-haemorrhage.htm


Appendix 2 – Emergency calls in obstetrics




Appendix 3 - Obstetric massive Haemorrhage protocol OPERATING THEATRE ACTION CARD

MANAGE UTERINE TONE IF NOT ALREADY GIVEN

Carbetocin 100mcg iv (given routinely for LSCS but safe and effective after vaginal deliveries) OR

Oxytocin 5 units IV (max twice) or 30 units in 500ml saline infusion at 100 ml/hr (not if Carbetocin already given)

Ergometrine 500mcg IM Carboprost 250mcg IM/IU (max 8 times, (Haemabate) 15mins apart) Misoprostol 1000mcg PR / IU

Clinical evidence of uncontrolled bleeding > 1500, or Shocked Patient Activate Major Obstetric Haemorrhage (MOH) Protocol

MANAGE SURGICAL BLEEDING

EUA Perineal Repair

Manual Removal of Placenta (MROP) Rusch Balloon B-Lynch Suture

Uterine artery embolisation Hysterectomy

MANAGE COAGULOPATHY Blood Components As per MOH Protocol Tranexamic Acid 1g IV over 10 mins

Once bleeding controlled, aim for: Hb > 80 Platelets > 50 Fibrinogen > 200

ALSO REMEMBER: Biochemistry: Adjuncts: ‘MOH bloods’: Calcium > 1 Cellsaver FBC (10% Calcium Chloride 10ml IV over 10 mins) (need second ODP) Clotting + Fibrinogen (Send early) Glucose < 10 Active Warming Crossmatch Potassium < 5 (Fluid Warmer and Bair Hugger) (purple, blue and pink bottles) (Glucose / Insulin Sliding Scale will do both) Consider U+E and calcium (yellow

bottle)




Appendix 4 – EMA090 – PPH on Rushey >500ml




Appendix 5 – PPH risk factors poster



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Location: Policy hub/ Clinical/ Maternity/ Lifesaving guidelines/ GL775 This document is valid only on date last printed