One of the most important causes of maternal mortality is major obstetric haemorrhage. Major haemorrhage can occur in parturients either during the antepartum period, during delivery, or in the postpartum period. Early recognition and a multidisciplinary team approach in the management are the cornerstones of improving the outcome of such cases. The management consists of fluid resuscitation, administration of blood and blood products, conservative measures such as uterine cavity tamponade and sutures, and finally hysterectomy. Blood transfusion strategies have changed over the last decade with emphasis on use of fresh frozen plasma, platelets, and fibrinogen. Point-of-care testing for treating coagulopathies promptly and interventional radiological procedures have further revolutionized the management of such cases. Vaginal bleeding in placenta previa is classically painless and is usually seen in second or third trimester of pregnancy. Caesarean delivery is the procedure of choice in such cases with an increased risk of severe blood loss due to inadvertent incision through the placenta during surgery. Abruptio placentae refers to the abnormal separation of the normally sited placenta; the bleeding occurs due to separation of the placental lining from the uterus. This bleeding may occur per vagina or may be concealed in the form of a retroplacental clot. Clinical features include abdominal pain, increased uterine tone, vaginal bleeding, and premature labor with signs of foetal distress. In case the bleeding is concealed, clinical presentation could be of haemorrhagic shock, acute renal failure, and foetal death. Placenta accreta is a condition when the placenta is abnormally attached to the myometrium. Rarely blood vessels within the placenta or the umbilical cord traverse the foetal membranes overlying the lower uterine segment, and this condition is known as vasa previa. One of the most devastating causes of APH is uterine rupture, and it is associated with a very high incidence of foetal and maternal mortality. Clinical features include abdominal pain, uterine tenderness, nonassuring foetal heart rate, and ultimately hypovolaemic shock, which could lead to maternal death. Maternal resuscitation along with emergency surgery is the only definitive treatment. Surgical procedures needed could vary from any of the following: foetal delivery with repair of the ruptured uterine wall, ligation of the uterine and internal iliac arteries, or hysterectomy.

1. MASSIVE OBSTETRIC HAEMORRHAGE
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA
Dr Alka Mukherjee Nagpur 1

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN 2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. KEY FACTS
• Definition Blood loss of over 2000 ml (or > 30% of blood
volume) is defined as massive obstetric hemorrhage (MOH).
• There is a tendency to underestimate rather than over
estimate the actual blood loss.

4. TYPES
• Massive obstetric haemorrhage can occur
• Antepartum (placenta praevia, placental abruption and
placenta accreta) or
• Postpartum period (postpartum haemorrhage (PPH) due to
uterine atonia, genital tract trauma, retained placenta and
membranes or coagulopathy).
• Rare obstetric disorders such as amniotic fluid embolism
(afe) or acute inversion of uterus may also present with
massive obstetric haemorrhage.

6. INCIDENCE
• Antepartum haemorrhage (APH) : 3-5% of all pregnancies
a) Placenta praevia - 1/3th cases
b) Placental abruption – ¼ th cases
• Postpartum haemorrhage occurs in 2–10% of deliveries but
• Major obstetric haemorrhage - 3.7–5/1000 maternities.
• It is estimated that every year about 600 000 to 800 000
women die during childbirth around the world.
• In the developing world, PPH occurs in about 1 in 1000
deliveries.

8. • The eighth report of the confidential enquiries into maternal
deaths in the UK has listed PPH as the third most common
direct cause of maternal mortality
• Massive blood loss leads to sudden and rapid cardiovascular
decompensation and coagulopathy.
• Three delays have been identified as the causes of maternal
deaths due to massive obstetric haemorrhage:
• Delay in seeking medical care,
• Delay in reaching healthcare facilities and
• Delay in receiving appropriate care in a healthcare
institution.

9. • Involvement of a multidisciplinary team of
I. Anaesthetists,
II. Haematologists and
III. Intensivists is essential to improve outcome
•
• Special Massive Haemorrhage Protocols such as 'Code Blue'
should be in place for the effective, multidisciplinary
management of massive obstetric haemorrhage.

10. KEY IMPLICATIONS
• Massive obstetric haemorrhage causes significant maternal
morbidity and mortality as well as many ‘near misses.
Antepartum haemorrhage due to placental abruption and
intrapartum haemorrhage due to uterine rupture are
associated with increased perinatal mortality.
• Moreover, massive obstetric haemorrhage due to placenta
praevia may result in fetal complications secondary to
prematurity as well as severe maternal hypovolumia and
hypotension.

11. RECOGNISE MASSIVE OBSTETRIC
HAEMORRHAGE (REVEALED AND CONCEALED)
• Visible blood loss > 2 litres
• On-going bleeding (>150 ml/minute)
• Loss of > 30% of blood volume as assessed by visible blood
loss or
• Rule of 30 :
• (rise in pulse > 30/minute,
• Drop in SBP by 30 mm hg,
• Increased respiratory rate > 30 /minute,
• A drop in haematocrit (packed cell volume) by 30%
• Shock index (pulse rate / systolic blood pressure) > 0.9

12. ENSURE IMMEDIATE RESUSCITATION
• Lower the head end of the bed and left lateral tilt (antepartum)
• Ensure adequate oxygenation - 15 litres of oxygen by mask
• Two large intravenous cannulae (14 G) Rapid infusion of
crystalloids 2 litres, colloids 1 litre to maintain blood volume
• Group specific o negative blood or uncross matched group specific
blood if haemodynamically unstable, whilst awaiting cross
matched blood
• Correct coagulopathy (platelets and 4 units of fresh frozen plasma
for every 6 units of blood transfusion)
• Send for urgent investigations: full blood count, urea and
electrolytes, clotting profile
• Commence monitoring - blood pressure, pulse, respiration,
oxygen saturation, urine output, ECG (if available)
• Consider arterial blood gases and central venous pressure
monitoring

13. IDENTITY AND MANAGE SPECIFIC CAUSE OF
MASSIVE OBSTETRIC HAEMORRHAGE
Antepartum
1. Placental abruption
• Expedite delivery , whilst correcting hypovolumia and
coagulation abonormalities.
• Emergency caeasrean section , if evidence of fetal
compromise and if the mother is haemodynamically stable.
2. Placenta praecia
• Expedite delivery after correcting hypovolumia and
cogulation abnormalities Gases and central venous pressure
monitoring

14. • Intrapartum:
1. Uterine rupture/ supra-levator broad ligament haematoma :
- Urgent laparotomy to control bleeding
- Consider pelvic arterial embolisation pre – or postsurgey , if
patient is stable.
2. Uterine trauma during caearean section - surgical
haemostasis +/- peripartum hysterctomy
3. Rapid onest of coagulopathy due to amniotic fluid embolism
- Urgent intensive care for ventilation and inotropic support
with correction of coagluation abnormalities.

15. • Postpartum
• Postpartum haemorrhage due to :
A. Uterine atony , uterine truma , coagulopthy , retained
placenta and membranes
B. Manage as per the Algorithm HAEMOSTASIS
• Acute uterine inversion
1. Immediate manual reposition of the fundus of the uterus
2. Use of O sullvan’s hydrostatic method.
C. Bleeding due to bleeding diathesis Correct the underlying
disorder (e.g platelets)

16. IMMEDIATE IMPLICATIONS
a. Hypovolumia, hypoxaemia and cardiac arrest.
b. Blood transfusion and effects of multiple blood transfusions
induding transfusion reactions, risk of infections and
transfusion associated acute lung injury (TRALI).
c. Acute renal failure.
d. Pulmonary oedema.
e. Coagulopathy
f. Risk of peripartum hysterectomy.
g. Intensive care treatment.

17. LONG-TERM IMPLICATIONS
• Psychological sequelae - delayed bonding with baby, post-
traumatic stress disorder.
• Sheehan's syndrome (pituitary necrosis and failure due to
massive obstetric haemorrhage leading to
panhypopituitarism).
• Impaired future fertility.
• Long – term anaemia.

18. • H - Ask for Help and hands on uterus(uterine massage)
• A - Assess (ABC) and resuscitate (crystalloids 21. colloids TI, oxygen by mask (15
l/min)
• E - Establish aetiology (atonic traumatic, coqulopathy or trauma), ensure
availability of Nood and administe ecbolics (drugs that contact the uterus -
Oxytocin ergometrine of Syntoneinne intramuscularly)
• M - Massage uterus
• O - Oxytocin infusion/prostaglandins - IVIM/per rectal (second line medications
to contract the uterus)
• S - Shift to theatre-3000 pressure or on anti - shock garment/bimanual
compression as appropriate
• T - Tamponade balloon/uterine packing - alter exclusion of tissue and trauma
• A - Apply compression sutures - B-Lynch/ modified
• S – systematic pelvic devascularisation - uterine/ovarian/ Quadruple internal ilac
• I - Interventional radiology and, if appropriate uterine artery embolisation
• S- Subtotal abdominal hysterectomy.

19. KEY AETIOLOGICAL FACTORS
Antepartum
• Placenta praevia
• Placental abruption.
• Rupture of an undiagnosed secondary abdominal pregnancy.
• Uterine rupture.

20. INTRAPARTUM
• Amniotic fluid embolism (AFE) with coagulopathy.
• Uterine rupture secondary to previous uterine scar or grand
multiparity, especially with injudicious use of oxytocin.
• Surgical complications (extension of uterine angular tear
during caesarean section).

21. POSTPARTUM
• Uterine Atonic uterus, ruptured uterus, uterine inversion.
• Broad ligament tears with resultant haematoma.
• Placental: Placenta praevia, placental abruption, retained
placenta.
• Vaginal: Laceration and tears, haematoma.
• Coagulopathy: Preexisting coagulopathy, treatment with
anticoagulants, obstetric causes - HELLP, amniotic lluid
embolism, chorioamnionitis.
•

22. KEY POINTERS TO MASSIVE OBSTETRIC
HAEMORRHAGE
• Visible blood loss 2 litres.
• Ongoing bleeding (150 ml/minute).
• Loss of > 30% of blood volume as assessed by visible blood loss
(estimated blood loss or EBL expressed as the percentage of
estimated blood volume = EBL/100 ml/kg).
• Rule of 30' (Rise in pulse 30/min, drop in systolic blood pressure
by 30 mmHg, increased respiratory rate > 30/minute, a drop in
haematocrit (packed cell volume) by 30%) which is suggestive of
at least 30% loss of blood volume.
• Shock index (pulse rate/systolic blood pressure) > 0.9. Normal
shock index is between 0.5-0.7 as the pulse rate is less than
systolic blood pressure. Tense, tender abdomen with evidence of
intrauterine death (massive placental abruption)

23. KEY ACTIONS: MASSIVE OBSTETRIC
HAEMORRHAGE PRIOR TO DELIVERY
• Placental abruption - premature separation of a normally
situated placenta.
• Maternal risks include haemorrhage secondary to
accumulation of blood in the retro-placental space after
separation of placenta as well as, in severe cases, bleeding
into the uterine cavity as well as within the myometrial
fibres.
• Activation of the extrinsic pathway of coagulation results in
disseminated intravascular coagulation
• Fetal risks include hypoxic cerebral injury as well as
intrauterine death.

24. PREDISPOSING FACTORS
• Preeclampsia.
• Placental ischaemia secondary to vasculopathy (e.g,
systemic lupus erythematosus (SLE), chronic renal disease).
• Multiparity.
• Abdominal trauma (road traffic accidents domestic
violence).
• Substance use(e.g cocaine)

25. CLINICAL PRESENTATION
1. Vaginal bleeding that is associated with abdominal pain or
discomfort - ('revealed' bleeding)
2. blood con accumulate behind the separated placenta and hence,
mo bleeding may be noted - (concealed haemorrhage)
3. Rarely, it may be 'mixed' (a combination of the above).
• On examination, the patient may be pale and may be in constant
pain.
• Abdominal examination may confirm a very tense, lender 'woody
hard' uterus (especially in a concealed haemorrhage),
• In severe cases of placental abruption –
 the fetal heart rate may be absent
 patient may show signs of coagulopathy.
 Observed blood loss may be out of proportion to the clinical
condition and this may point to a mixed' haemorrhage.

26. MANAGEMENT
• Immediate management -
i. Active resuscitation to ensure a patent airway, breathing
and maintaining circulation with intravenous fluids, blood
and blood products as well as correction of coagulopathy.
ii. Left lateral tilt
iii. Administration of high flow oxygen (15 l/minute) at the
outset.
iv. A multidisciplinary input involving haematologists and
anaesthetists is essential.
v. Delivery should be planned once the patient is
haemodynamically stable.
vi. Emergency caesarean section may be considered for fetal
reasons (i.e. Evidence of fetal compromise).

27. • If intrauterine death is diagnosed, delivery should be
expedited by performing artificial rupture of membranes
(ARM) and commencement of oxytocin infusion.
• Postpartum haemorrhage should be anticipated due to
coagulopathy as well as Couvelaire uterus (presence of
blood within the myometrial fibres results in their
disruption, leading to uterine apoplexy).

28. PLACENTA PRACVIA
• Placenta Previa to the extension of the placenta wholly or
partially to the lower uterine segment.
• Massive obstetric haemorrhage ensues as the progressive uptake
of the lower segment with advancing gestation leads to
separation of the placenta, resulting from bleeding from the
placental attachment. Such bleeding is therefore maternal with
no direct effect on the fetus.
• latrogenic preterm delivery in the 'maternal interest as well as
effects of prolonged maternal hypotension may result in
detrimental effects on the fetus.
• Paucity of muscle fibres and hence the inability of the lower
segment to contract and retract after birth increases the risk of
atonic postpartum haemorrhage.

29. CLINICAL FEATURES
a. 'Painless, causeless and recurrent' vaginal bleeding typical
of placenta praevia.
b. 'Non-engaged' presenting part or abnormal lie or
presentation with a soft non- tender uterus - clinch the
diagnosis.
c. Uterine tenderness may be rarely present as placenta
praevia if associated with co-existing abruption in 10 % of
cases.
d. Ultrasound examination - confirm the diagnosis and
e. A digital vaginal examination should be avoided in all cases
of massive antepartum haemorrhage prior to excluding the
diagnosis of placera praevia.

30. MANAGEMENT
• Initial management involves active resuscitation
• vaginal birth is not possible in major degree placenta
praevia. - emergency caesarean section should be
performed by an experienced operator, once the woman is
stabilised.
• Postpartum haemorrhage should be anticipated and
managed effectively (the lower uterine segment has fewer
muscle fibres and hence is not effective in controlling
bleeding from the placental site).

31. MASSIVE OBSTETRIC HAEMORRHAGE:
POSTPARTUM
• As massive atonic postpartum haemorrhage is a
major cause of maternal morbidity worldwide
Management Algorithm
“HAEMOSTASIS” in detail.

34. H - ASK FOR HELP AND HANDS ON THE
ABDOMEN (UTERINE MASSAGE)
• Alert all members of the (including the haematologist and
the hospital porter in case of an emergency through the
hospitals board (e.g. 'Code blue' protocol).
• A multidisciplinary approach
• Monitoring and management of fluid, electrolytes &
coagulation parameters
• Uterine massage should be commenced early (as 80% of
postpartum haemorrhages occur secondary to uterine
atony)

35. A- ASSESS (VITAL PARAMETERS, BLOOD LOSS)
AND RESUSCITATE
• The woman should be positioned flat and resuscitation should begin
with administration of high-flow oxygen (10-15 l/min) via a face mask
regardless of her oxygen Saturation.
• Body temperature should be maintained.
• Two large-bore cannulae (preferably 14 gauge) should he inserted in
either arm and Hartmann's or normal saline infusion should be
commenced.
• Up to 2 litres of Crystalloids may be infused rapidly over 1-2 hours for
initial stabilisation, Colloids like gelatin (Haemacel) or hydroxyethyl
starch (1-2 litres) may also be needed to achieve haemodynamic
stability.
• Pulse, blood pressure and respiration should be recorded every 15 min
utes. Additional monitoring includes pulse oximetry and indwelling
urinary catheter for hourly urine out put. A central venous pressure
(CVP) and an arterial line should be considered in cases of severe PPH

36. ESTABLISH AETIOLOGY; ENSURE AVAILABILITY OF BLOOD,
ECBOLICS (BOLUS OF OXYTOCIN, SYNTOMETRINE,
ERGOMETRINE)
• The cause of massive postpartum haemorrhage- identify -
(4Ts: tone, tissue, trauma and thrombin)
• The uterus should be examined for contraction and
retraction; it may also be worthwhile to check for free fluid
in the abdomen, if the history suggests trauma (previous
caesarean section, difficult instrumental delivery) or if the
patient's condition is worse than what would be expected
based on the estimated blood loss.
• Exclude any trauma to the genital tract and to ensure
completeness of the placenta and membranes

37. ECBOLICS
• Once atonic uterus has been identified as the cause of PPH,
measures should be taken to ensure uterine contraction and
retraction
• Syntocinon (5 units) should be administered intramuscularly
and
• If bleeding persists, syntometrine (combination of oxytocin 5
U and ergometrine 0.5 mg) or
• Ergometrine (0.5 mg) should be administered with in severe
preeclampsia)

39. ENSURE AVAILABILITY OF BLOOD AND BLOOD
PRODUCTS
• Replacement of the circulating blood volume with
crystalloids and colloids should be followed by restoration of
the oxygen-carrying capacity of the blood and correction of
any derangements in coagulation.
• The aim of blood and fluids should be to replenish the
previous loss in the first hour followed by maintenance
fluids to replace continuing loss and maintain normal vital
parameters.
• If coagulopathy is suspected, the haematologist should be
involved and fresh frozen plasma (FFP), cryoprecipitate and
platelets administered as required.

40. • In massive obstetric blood loss, rapid infusion of FFP may be
required to replace clotting factors other than platelets.
• With every 6 units of blood transfusion, 1 litre of FFP should
be administered.
• Maintain the platelet count above 50 000 by infusing
platelet concentrates when indicated.
• Cryoprecipitate may also be needed if the patient develops
disseminated intravascular coagulation (DIC) and her
fibrinogen drops to less than 1 g/dl (10 g/l).

41. MASSAGE THE UTERUS
• Uterine massage helps stimulate uterine contraction and
retraction and should be commenced very early. It may act
synergistically with the uterotonic drugs.
• Compression of aorta - to gain temporary control of bleeding
by applying the fist directly in the midline, just above the
umbilicus and the uterus with the heel of the hand pressing
down on the aorta.
• In a low-resource setting, anti-shock garments may also be
used if available, during transfer to operating theatre or to
another referral centre.

42. OXYTOCIN INFUSION PROSTAGLANDINS
• Syntocinon 40 units added to 500 ml of normal saline and
infused at a rate of 125 ml/hour
• Avoid fluid overload, as fatal pulmonary and cerebral
oedema with convulsions may occur secondary to dilutional
hyponatraemia.
• An indwelling transurethral catheter – MUST
• Monitoring urine output – MUST, it also helps to keep the
bladder empty and promote uterine contractions.

43. a. Prostaglandins - (15-methyl prostaglandin 2 alpha) 250
microgm intramuscularly, once every 15 minutes for a
maximum of eight doses (2 mg).
b. Rectal misoprostol (600-1000 ug) - low cost & easier
storage.
c. Tranexamic acid (starting dose of 1-4 g followed by 1 g 8 –
hourly ) may be considered for PPH if administration of
uterotonics has failed to stop the bleeding, or it is thought
that the bleeding may be partly due to trauma.

44. S-SHIFT TO THEATRE
• If the patient continues to bleed despite initial management
(i.e 'HAEMO) it is best to transfer her to the theatre (for
'STASIS).
• Theatre provides an environment suitable for continuous
monitoring and resuscitation and facilitates an examination
to exclude any retained placental tissue or membranes.
• A bimanual compression can be carried out at this stage to
squeeze the uterus between the abdominal and vaginal
hands.

45. T-TAMPONADE BALLOON
• Uterine tamponade with a balloon is easy to perform and takes
only a few minutes.
• It arrests the bleeding and may prevent coagulopathy due to mas
sive blood loss and the need for further surgical procedures.
1. Sengstaken-Blakemore oesophageal catheter (SBOC)
2. the Rusch urological hydrostatic balloon
3. Bakri balloon
• Usually a volume of about 300 to 400 ml may be required to exert
the desired counter-pressure to stop bleeding from the uterine
sinuses. If the tamponade arrests the bleeding (i.e. positive), the
chances of the patient requiring any further surgical intervention
are remote.
• ‘Tamponade test' has a positive predictive value of 87% for the
successful management of PPH

46. APPLY COMPRESSION SUTURES
• The patients parity should be considered prior to attempting
conservative surgical measure.
• This will help avoid too little being done too late
• It is prudent to discuss with the anaesthetist regarding the
ability to withstand continued bleeding, whilst conservative
surgical measures are attempted.
• This is vital in developing countries where the patient might
have lost a significant amount of blood by the time she
reaches the referral center .
• In such situations, radical measures such as total or subtotal
hysterectomy to save the patient’s life

47. • Conservative surgical measures include
compression sutures which include classical B
– Lynch or vertical or horizontal brace sutures
using a delayed absorbable suture material.

48. SYSTEMATIC PELVIC DEVASCULARISATION
• If the compression sutures fail - ligation of blood vessels supplying
the uterus
• These include ligation of both uterine arteries , followed by tubal
branches of both ovarian arteries proximal to the ovarian
ligament (called the 'quadruple ligation').
• Uterine artery ligation is straightforward once the uterovesical
fold of peritoneum is incised and the bladder is reflected down. A
window is made in the broad ligament just lateral to the uterine
vessels and the needle is passed through this opening.
• Medially, the needle is passed through the lower uterine
myometrium, about 2 cm from the lateral margin, thus getting a
good bite and then the sutures are tied. The same procedure is
repeated on the other side.

49. • Internal iliac artery ligation is an option if bleeding persists.
• This requires an experienced surgeon who is familiar with the
anatomy of the lateral pelvic wall.
• Bilateral internal iliac artery ligation has been found to reduce the
pulse pressure by up to 85% in arteries distal to the ligation.
• This translates to an acute reduction in the blood flow by about
50% in the distal vessels.
• Success rate - 40% and 75% and invaluable for avoiding a
hysterectomy.
• Potential complication include haematoma formation in the
lateral pelvic wall, injury to the ureters, laceration of the iliac
vein and accidental ligation of the external iliac artery.
• Ligation of the main trunk of the internal iliac artery .may result in
intermittent claudication of the gluteal " muscles due to
ischaemia. Examining the femoral pulse prior to completely
ligating the internal iliac artery vital.

50. INTERVENTIONAL RADIOLOGY
• In women who are not acutely compromised or bleeding
severely, interventional radiology can be considered. The
success rates may be as high as 85-95% and the entire
procedure may take about 1 hour.
• Uterine artery embolization helps to avoid radical
procedures and preserve future fertility.
• Complications - vessel perforation, haematoma, infection
and tissue necrosis.

51. SUBTOTAL OR TOTAL ABDOMINAL
HYSTERECTOMY
• If the bleeding is predominantly from the lower segment (as in
PPH following a major degree placenta praevia)
- Total abdominal hysterectomy
- Subtotal hysterectomy may be performed if the bleeding mainly
from the upper segment & the cause is ‘unresponsive uterine
atony, lower morbidity and mortality rates and requires less time
to perform.
• Due to the anatomical changes of pregnancy - important to
exercise utmost care to prevent visceral trauma, especially of the
bladder and ureters.
• It is also important to clamp the ovarian ligament medially to
avoid non-intentional or inadvertent oophorectomy.

52. POSTOPERATIVE CARE
• Women with massive obstetric haemorrhage often need
multi-organ support.
• Hence, transfer to an intensive care unit or high dependency
unit should be considered for monitoring.
• Thromboprophylaxis should be considered once the
coagulation parameters return to normal.

53. COMPLETE THE '3 E' AFTER EVERY OBSTETRIC
EMERGENCY
A. Examine - for heart rate, blood pressure, uterine
contractility, vaginal bleeding and monitor urine output.
Replenish lost fluid, blood and blood products adequately
B. Explain the delivery events possible reasons, complications
and future plan of care to the patient (I e. debrief).
C. Escalate - incident reporting form and to senior colleagues as
well as to the team to identify learning points to
continuously improve patient care

54. KEY PITFALLS
• Failure to accurately estimate blood loss and involve senior
and multidisciplinary input.
Too little done too late
• Too little estimation of blood loss,
• Too little fluid replacement,
• Too little ecbolics,
• Too little replacement of blood and clotting factors,
• Too late referral or involvement of multidisciplinary team
• Too late laparotomy and surgical haemostasis.

55. KEY PEARLS
• Young fit women may maintain their blood pressure until
significant blood loss occurs
• Systematic management of massive obstetric haemorrhage
with the use of algorithms with multidisciplinary input will
help save lives.
• Use of 'Shock index' and 'Rule of 30 may help in estimating
actual blood loss, when the vital signs are maintained
despite significant blood loss