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Guideline for the management of Postpartum Haemorrhage and Massive Obstetric Haemorrhage

The following guideline is approved only for use at University College London Hospitals NHS Foundation Trust. It is provided as supporting information for the UCLH Injectable Medicines Administration Guide. Neither UCLH nor Wiley accept liability for errors or omissions within the guideline. Wherever possible, users of the Guide should refer to locally produced practice guidelines. UCLHs guidelines represent the expert opinion of the clinicians within the hospital and may not be applicable to patients outside the Trust. Document Control Information *Approved by: *Date approved: *Version: *Publication date: Review date: Author: Maternity Service Guideline and Information Group June 2009 1 June 2009 June 2011 2009 update: Aparna Reddy, Subspecialty Trainee in Maternal-Fetal Medicine Elisabeth Peregrine, Consultant Obstetrician Angie Velinor, Clinical Practice Facilitator Midwife Professor David Fish ,Medical Director Maternity Service Guideline and Information Group All Clinical Staff

Responsible Director and Responsible Committee: Target audience: Related documents/policies: Number of pages and appendices: Equalities Impact Assessment: Aspect/s of equalities duties that relate to this policy

Pages 19 Appendix 4 Low

UCL Hospitals is an NHS Foundation Trust comprising: the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital (incorporating The Middlesex Hospital)

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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Contents Section Page Number

1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0 16.0 17.0

Introduction ..................................................................................................... - 2 Aim.................................................................................................................. - 2 Scope.............................................................................................................. - 2 Definitions ....................................................................................................... - 2 Primary Postpartum Haemorrhage.................................................................. - 3 Management of a Primary Postpartum Haemorrhage..................................... - 3 Management of a Massive Obstetric Haemorrhage ........................................ - 5 Surgical Options in PPH.................................................................................. - 7 The Use of Blood Products (See Hospital Transfusion Policy)........................ - 8 Basic principles for use and storage of blood products (see Appendix) .......... - 8 Postpartum Haemorrhage on the Bloomsbury Birth Center ............................ - 8 Postpartum Haemorrhage at a Homebirth ...................................................... - 8 Secondary Postpartum Haemorrhage............................................................. - 9 Implementation, training and monitoring requirements ................................. - 10 Guideline Development Group 2008 ............................................................. - 11 Other groups consulted................................................................................. - 11 References.................................................................................................... - 11 -

Appendix 1. Procedure for obtaining blood products in the event of major obstetric haemorrhage. ............................................................................................................. - 13 Appendix 2. The Use of Blood Products (See Hospital Transfusion Policy) ............... - 14 Appendix 3. Procedure for insertion of B-Lynch Suture (B-Lynch 1997) .................... - 18 Appendix 4. Major Obstetric Haemorrhage Records Checklist ............................ - 18 -

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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

1.0 Introduction 1.1 The most recent report on confidential enquiries into maternal deaths in the United Kingdom (CEMACH 2007) identified 14 maternal deaths directly due to haemorrhage - three were due to placenta praevia, two to placental abruption and nine to postpartum haemorrhage (PPH). Haemorrhage is a continuing problem for obstetricians and midwives with a mortality rate of 0.80 per 100,000 maternities. Two women declined blood transfusions that would probably have saved their lives. 2.0 Aim 2.1 To provide guidance to midwifery, obstetric, anaesthetic, theatre, recovery and haematology staff on the management of PPH and massive obstetric haemorrhage. 3.0 Scope 3.1 This guideline applies to all obstetric, anaesthetic, midwifery, blood transfusion, nursing, theatre and recovery room staff. 3.2 The guideline specifically addresses the management of postpartum haemorrhage and massive obstetric haemorrhage, however as antepartum haemorrhage (prior to delivery) may precede postpartum bleeding and may itself represent massive obstetric haemorrhage, many of the principles detailed here would also apply in antepartum haemorrhage. 4.0 Definitions 4.1 Primary post partum haemorrhage (PPH) is defined as blood loss greater than 500 mls in the 24 hours following delivery and no signs of clinical shock. (1000ml post Caesarean section). (Rizvi, 2004. SCOGAP, 2002). It occurs after approximately 1:10 births, but is not always clinically significant. 4.2 Massive PPH is defined as blood loss of greater than >1500mls postpartum or signs of clinical shock (RCOG, 2009). It arises after approximately 1:500 births. 4.3 Secondary PPH is defined as blood loss greater than 500mls that commences between 24hours and 6 weeks post delivery. It occurs after approximately 1:100 births.

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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

5.0 Primary Postpartum Haemorrhage Principles of Care: Consider the four Ts as the causes of Primary PPH 1. Tone (Uterine atony ) 2. Trauma (Genital trauma including damage to vulva, vagina, cervix and uterus) 3. Tissue (Retained and invasive placenta ) 4. Thrombin (coagulopathy) (RCOG, 2009) 6.0 Management of a Primary Postpartum Haemorrhage All of these actions may occur simultaneously Call for help (Pull emergency bell. For team, see appendix 4) Rub up a contraction Ensure the woman is conscious, has a clear airway and is breathing and alert (AVPU score) Reassure the mother and her partner Check her pulse and blood pressure Lay down, with a head down tilt Give Oxygen by face-mask, 15 litres /min IV access with at least one Grey 16G cannula Take blood for Full Blood Count, baseline Clotting screen and Crossmatch 4 units (if current valid G&S sample not available in lab already) Clearly label specimens and forms, having checked patients details with the patient and against their wristband. Do not use sticky labels on blood transfusion sample. If current valid G&S available in laboratory request crossmatched blood by telephone. Give IV Crystalloid ( e.g. Hartmanns ) or Colloid ( e.g. Gelofusin ) stat Ensure bladder empty and Foleys catheter inserted. Attach urometer bag to monitor hourly urine output. Start a MEOWS chart to document maternal observations like respiratory rate, heart rate, blood pressure, oxygen saturation and fluid balance chart. Commence Oxytocin infusion - 40 iu Oxytocin in 500mls Normal Saline 0.9% at 125mls per hour (MOET 2007) Once bleeding is controlled, continue IV Oxytocin infusion and keep on labour ward for 4 hours minimum and await FBC results Ensure there is clear documentation of the sequence of events, plan of care and occurrence of timely review. All entries to be signed and name printed
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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

All inco and sanitary pads should be saved and weighed to measure the blood loss. This should continue whilst the patient is being monitored for ongoing loss. Cumulative loss to be clearly documented in the notes in this case.

TONE Expel clot from the vagina and uterine cavity with fundal massage Commence IV syntocinon 40iu in 500ml Normal Saline @ 125ml/hr over 4 hours. IV or IM ergometrine 500mcg Rectal misoprostol 800mcg Bimanually compress the uterus Consider IM Carboprost 250mcg every 15 minutes to a maximum of 8 doses (2mg)

TISSUE Commence IV syntocinon 40iu in 500ml Normal Saline @ 125ml/hr over 4 hours. Deliver the placenta if not delivered manually remove in the room if epidural is dense enough or take to theatre for manual removal of placenta if additional analgesia required. If placenta delivered check it is complete and clearly document in the notes. Give Augmentin 1.2g IV stat.

TRAUMA Check for obvious genital trauma. Ensure good lighting and visualise the cervix. Visualise the apex, apply pressure to the bleeding point and suture in the room if it is easily identified Transfer to theatre if not Examine the anus, vulva, vagina and cervix under direct vision Manually explore the uterine cavity to exclude trauma or retained placental tissue Consider laparotomy If the uterus is explored give IV 1.2g Augmentin stat.

THROMBIN Risk factors for the development of coagulopathy include: pre-eclampsia (particularly HELLP syndrome) and APH (particularly abruption). It may also complicate PPH due to other causes (Tone, Tissue, Trauma)
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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

The diagnosis should be suspected when bleeding continues despite the presence of an empty, well contracted uterus and in the absence of genital trauma. Ensure involvement of Anaesthetic team and Haematologist.

Anticipate the need for & order blood components early; after transfusion of 68 red cell units order 1 pool of platelets & 4 units of FFP. The Blood Transfusion Laboratory will permit this first order of products to be issued empirically during a massive obstetric haemorrhage. If platelets are available in stock they can be issued in 10 minutes + transport time from lab to EGA. If no platelets in stock they will be ordered by the lab from the National Blood Service (Brentwood) & may take 2 2.5hrs to be available (depending on traffic) Further management will be determined on an individualised basis after liaison with the on call haematology SpR and may include: FFP, platelets, & cryoprecipitate. If intractable bleeding, unresponsive to conventional blood product transfusion & surgical / obstetric interventions, consider use of recombinant factor VIIa, only issued on after approval by Consultant Haematologist

7.0 Management of a Massive Obstetric Haemorrhage If the mother has lost 1500ml and is still bleeding: Call for help Inform the Consultant Obstetrician and Anaesthetist on call Dial 2222 and ask for the obstetric emergency team (see appendix 4). In addition ask switchboard to Fast Bleep Blood Transfusion- Major Haemorrhage or Fast Bleep 7060- Major Haemorrhage. When the blood transfusion staff answer state- Major Haemorrhage. Give the patients name, hospital number, ward / department, your name, bleep number / extension. Confirm with the laboratory staff whether a group and save sample is already held. The blood transfusion laboratory staff will automatically inform the haematology SpR. For clinical advice in daytime hours you can contact the haematology SpR on 07983 463485 and out of hours through switchboard. Designate one person to liaise with the Blood Transfusion Laboratory and document arrangement in the notes. Rub up a contraction Lay down, with a head down tilt

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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Give Oxygen by face-mask, 15 litres /min IV access with 2 Grey 16G cannulae Take bloods for FBC, clotting, fibrinogen, U&E, crossmatch blood.
Ensure blood transfusion samples are fully labelled hand including the signature of person taking sample, not use sticky label. (Incorrectly labelled samples will rejected; information must exactly match that CDR/EPR & patients ID wristbands). by do be on

Send samples by urgent transport. Contact the Medical Couriers on the Medical services direct line is 0207 014 1050 and then press option 1. Give the hospital account number 50288. Phone the blood transfusion laboratory to warn that urgent samples are en-route. Ask courier to take samples directly to the Blood Transfusion st Laboratory on 1 floor. Inform the security officer on the front desk (ext 5555) to direct the courier to the correct ward

Give Colloid IV under pressure Transfuse blood when available. For guidelines on the use of blood products see Appendix 1. Ensure bladder empty, insert Foleys indwelling catheter with urometer and maintain a strict fluid balance chart. Aim for 0.5 mls per kg / hr or 30 mls /hour urine output. Ensure involvement of the anaesthetist regarding the fluid management and need for central or arterial lines Monitor and record pulse, respiratory rate and blood pressure frequently on the MEOWS CHART according to the mothers condition Continuously monitor oxygen saturation with a pulse oximeter Take actions to determine the cause (see 4 Ts above) RCOG,2009 TRANSFER TO THEATRE AT AN EARLY STAGE FOR AN EXAMINATION UNDER ANAESTHETIC DO NOT DELAY

During a major haemorrhage one person should be nominated to liase with the laboratory staff / Haematology SpR regarding blood products requirement and availability

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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Transfer to the Intensive Care Unit as appropriate. Consultant Obstetrician/Anaesthetist decision. Ensure correct 2 identity labels on patients wrists: Must include full name, hospital number & date of birth. The information on ID wristbands must match those on EPR/ CDR or there may be a problem checking blood when issued, patient details on the blood product compatibility label will match those on given sample & EPR/CDR. Any problems with obtaining blood products during daytime hours contact the Transfusion Manager (extension 8523) or the Senior Biomedical Scientist in Transfusion (extension 8522). It is the responsibility of the most senior obstetrician present or the Labour ward Coordinator to coordinate the management of a massive PPH and delegate roles to the members of the team. One member of the team should be record the timing and details of the sequence of events.

8.0 Surgical Options in PPH If bleeding from placental bed vessels at Caesarean section (particularly after placenta praevia) consider inserting a Rusch catheter (available on Delivery Suite) and inflating balloon with 500mls sterile water/saline (Johanson 2001) If the abdomen is not open and the maternal condition suggests blood loss greater than visible, consider intra-abdominal bleeding. Ultrasound may be helpful to look for intra-abdominal blood e.g. between liver and right kidney. However, do not allow scanning to delay laparotomy. If laparotomy is considered then discuss this with the Consultant on call. The Consultant must be present in theatre if laparotomy is performed Ensure hysterectomy set and Robinson drains are available.

Consider a B-Lynch suture particularly if there is an element of uterine atony: (See appendix 3 for procedure for insertion of B-Lynh Suture) Other techniques which can be considered are: Bilateral uterine artery ligation Arterial embolisation (REFER TO GUIDELINE FOR THE USE OF

INTERVENTIONAL RADIOLOGY) Hysterectomy


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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Transfer to Labour Ward Observational bay with 1:1 midwifery care or ITU if required.

9.0 The Use of Blood Products (See Hospital Transfusion Policy) 10.0 Basic principles for use and storage of blood products (see Appendix) Location of blood fridge and access code. Correct storage of blood products Use of blood warmers FFP Cryoprecipitate Platelets Recombinant Factor VIIa Cell salvage 11.0 Postpartum Haemorrhage on the Bloomsbury Birth Center As previous pathway: Early suturing of perineal trauma Stabilisation for 500ml blood loss If bleeding not controlled transfer to labour ward MEOWS chart, fluid balance and clear documentation

12.0 Postpartum Haemorrhage at a Homebirth The midwife should rub-up a contraction and administer Syntometrine IM or Ergometrine 500mcg IV. Deliver placenta Insert Foleys indwelling urinary catheter Monitor maternal observations (BP,RR,Pulse) and document in notes. Administer Misoprostol 800mcg PR Consider bimanual compression 2nd Midwife in attendance/ assistant/ relative Dial 999 and ask for a paramedic ambulance and arrange urgent transfer to hospital Inform the labour ward coordinator of the womens transfer from home to labour ward so that they can prepare staff, room and equipment Insert an intravenous cannula, and commence crystalloid fluids (eg. Hartmanns or normal saline) once the paramedics arrive. The midwife should accompany the woman in the ambulance to hospital to maintain continuity and reassurance. The second midwife should arrange the safe transfer of the baby to the hospital to be with the mother. Any woman transferred from a homebirth to hospital should be reviewed initially on labour ward
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GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

13.0 Secondary Postpartum Haemorrhage Community Management: Assess Observations of T.P.R. and B/P Check fundal height, tenderness and blood loss. Obtain blood for FBC, group and save serum. Give IV/IM ergometrine 500mcg

Stabilise Obtain IV access and commence IV crystalloid fluids if indicated.Transfer Refer to registrar on Delivery Suite. Inform LW co-ordinator Arrange ambulance transfer Midwife to accompany woman to hospital.

Hospital Management: Inform medical staff on arrival. Send bloods obtained, urgently. Initial assessment should be on Delivery Suite. The Obstetric team should resuscitate and evaluate as appropriate as described above for primary PPH

If not previously collected or implemented in the community arrange: Group and save serum (cross match if appropriate) full blood count Coagulation screen if indicated Bacteriology screen if appropriate - i.e. Blood cultures, hvs Obtain iv access and commence iv infusion if indicated Abdominal palpation and speculum examination should be performed. If the uterus is atonic and the cervical os open then retained products are more likely Retained products of conception and infection must be considered in all cases. The management of care will be determined by clinical findings. Ultrasound of the uterus may be indicated and should be performed by a trained operator. A negative scan does not completely exclude retained products.

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Antibiotics (co-amoxiclav 1.2g iv tds) after bacteriology screen should be given to all women prior to evacuation of the uterus. If the woman is stable the erpc should be delayed until 24 hours post- commencement of antibiotics. She should complete a 5 day course of antibiotics post-op. If necessary ERPC can be carried out on the emergency gynaecology list. The surgery should be performed or supervised by an experienced surgeon (Senior SpR / Consultant). She should be consented for examination under anaesthetic and evacuation of retained products and the risks of infection, trauma to the uterus, bleeding and perineal breakdown and resuturing discussed and documented. Ultrasound guidance during the procedure is preferable.

14.0

Implementation, training and monitoring requirements Implementation Dissemination of this guideline will occur through the senior clinical obstetric and midwifery leads by verbal means e.g. handover / ward meetings and visual display of new guideline in all ward areas and through the website. Training: Awareness of the guideline for all clinical staff groups will be raised at trust induction, annual trust update days, skills & drills and targeted teaching for junior doctors. Monitoring:

The following describes the plan for monitoring the implementation and on-going performance of practice in the context of this guideline.
PPH What When Continously with weekly summaries of results summarized into a monthly Who How

Audit of documentation in maternal notes to ensure the effectiveness of the management of PPH

Named junior doctor with oversight from Risk Manager

Report to Women's Health Audit Day Group and/or to intrapartum governance group, which is also responsible for monitoring actions.

The Maternity Service reserves the right to change the monitoring arrangements within its guidelines and operational guidance to meet the needs of the service.

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15.0

Guideline Development Group 2008 Sasha Wilson, Clinical Nurse Specialist, Transfusion Rory Bell, Consultant Anaesthetist Jan Halsey, Lecturer Practitioner Jackie Baxter, Research and Development Midwife Monica Ellis, Midwifery Lead for Community Sharon Murrell, Labour Ward Manager Guideline Development Group 2005 Dr Elisabeth Peregrine, Senior Registrar Mr Pran Pandya, Consultant Obstetrician Dr Rory Bell, Consultant Anaesthetist Jan Halsey, Lecturer Practitioner and Supervisor of Midwives Maureen McCabe, Midwifery Group Practice Manager

16.0 Other groups consulted Consultant Obstetricians Junior Obstetric Staff Midwives Supervisors of Midwives Consultant Midwives Hospital Transfusion Team

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17.0 References: 1. Better blood transfusion- Appropriate use of blood. DoH National Guidance. HDC 2002/009. Available at: www.doh.gov.uk/blood/bbt.htm 2. B-Lynch C. et al (1997) The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. BJOG 104:372-375 3. CEMACH (2007) Saving Mothers Lives: Reviewing maternal deaths to make motherhood safer. The 7th Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom 4. Johanson R et al (2001) Management of massive postpartum haemorrhage: use of a hydrostatic balloon catheter to avoid laparotomy. BJOG 108: 420-422 5. MOET: Managing obstetric emergencies and trauma (2007). Edited by Grady K, Howell C, Cox C. 2nd edition. RCOG 6. OBrien P, El-Refaey H, Gordon A, Geary M, Rodeck CH. (1998) Rectally administered misoprostol for the treatment of postpartum haemorrhage unresponsive to oxytocin and Ergometrine descriptive study. Obstet Gynecol 92:212-214 7. ODrife J. (1997) Management of primary postpartum haemorrhage. BJOG 104: 275-277 8. Rizvi F, Machkey R, Barrett T, McKenna P, Geary M. (2004). Successful reduction of massive postpartum haemorrhage by use of guideline and staff education. British Journal of Obstetrics and Gynaecology 111 (5)495-498 9. Scottish Obstetric Guideline and Audit Project (SCOGAP) (2002). The management of postpartum Haemorrhage. 2002 10. Sokolic V et al (2002) Recombinant factor VIIa (rFVIIa) is effective at massive bleeding after caesarean section- a case report. Coll Antropol 26: 155-157 11. UCLH Clinical Guideline (2007). Blood Component Transfusion Policy and Procedure. Available at: http://insight/departments/AcuteHospitalsBoard/Pathology/HaematologyPathology /BloodTransfusion/Documents/Blood%20Component%20Transfusion%20Policy% 20and%20Procedure%20(V3.0%20May%2007).doc 12. Zupanicic SS et al (2002) Successful use of recombinant factor VIIa for massive bleeding after caesarean section due to HELLP syndrome. Acta Haematol 108: 162-163 13. RCOG (2009) Prevention and management of post partum haemorrhage. Green top guideline. Royal College of Obstetricians and Gynaecologists
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Appendix 1. Procedure for obtaining blood products in the event of major obstetric haemorrhage.
BLOOD TRANSFUSION CONTACT NUMBERS Blood Transfusion Laboratory: Use Trust Emergency Number 2222. In addition to requesting the obstetric emergency team, state Fast bleep Blood Transfusion major haemorrhage or Fast bleep 7060 major haemorrhage the laboratory will respond immediately & Haematology SpR will be informed.

When the Blood Transfusion staff answer state Major Haemorrhage Give patients name, hospital number, ward/ department, your name, bleep number / ext number Confirm with transfusion lab if group and save sample already held.

Clinical Advice Haematology SpR: Major Haemorrhage mobile phone (In hours) 07983 463 485. Out of hours contact On-call Haematology SpR via switchboard. During a major haemorrhage one person should be nominated to liaise with the lab/ Haematology SpR regarding product requirements & availability.

Take samples for: Group & save (if no current sample in lab), full blood count, coagulation screen & fibrinogen. Do not use sticky label on transfusion sample, ensure full name, hospital number & date of birth correct st Send by urgent courier directly to lab 1 floor 60 Whitfield St. The Medical Couriers can be contacted on 0207 014 1050 and then press option 1 & give account number 50288. Inform the security guard on the front desk (ext.5555) to direct the courier to correct location immediately upon arrival (for sample collection & blood deliveries. Ensure Blood Transfusion laboratory staff know that URGENT samples are en route

Assess degree of urgency


Blood needed immediately Use uncrossmatched group O negative: Bleeding Hb < 5g/dL or 40-50% EBV loss. Blood needed 10 50 minutes (from receipt of sample) Use uncrossmatched group specific blood. Fully compatible blood. Blood needed > 50mins (from receipt of sample)

Location of uncrossmatched emergency group O Rh D negative blood 6 units of uncrossmatched group O Rh D negative are stored in Labour ward blood fridge.
Convert to group specific or fully crossmatched blood as soon as available.

Anticipate coagulopathy:
If you anticipate red cell transfusion of 6- 8 units in 1- 2 hours, ANTICIPATE NEED FOR & ORDER BLOOD COMPONENTS EARLY. Empiric treatment may be required in advance of laboratory results being

available, especially if ongoing blood loss, evidence of microvascular bleeding. Repeat FBC & clotting screen after transfusion of each batch of products. FFP & Platelets are likely to be required even if results were normal at baseline.

Platelets Order 1 unit FFP Cryoprecipitate 9 Aim for >75 x 10 /L Order 4 units for adult. Aim for Fibrinogen > 1.0g/dL 9 Aim for > 100 x 10 /L if CNS/ multiple (12-15mls/Kg If fibrinogen not corrected trauma Aim for INR<1.5xmean UCLH-2009 13 by FFP order 2 pools -(=10 Published date: 10mins Availability: IssuedJune 2009+ transport control units) for adult. Review date: June if none in stock at time but up to 2.5 hrs 2011 Availability: Allow Availability: Allow 30mins to Policies, procedures and guidelines only current on date printed refer to Insight for definitive version 30mins to defrost. UCLH defrost.

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Appendix 2 The Use of Blood Products (See Hospital Transfusion Policy) The decision to transfuse blood or other blood product, the volume of transfusion and the urgency it is required should be based upon several factors: Estimated and measured blood loss to date Ongoing bleeding Clinical condition Response to colloid / crystalloid Intercurrent illness Last recorded haemoglobin

The benefits should be weighed against the potential complications of transfusion, including transfusion reaction, infection and adult respiratory distress syndrome. This should be discussed with the woman if possible by the obstetric SpR or consultant and anaesthetist and the discussion recorded in the notes. Blood loss is often underestimated. In a 70Kg adult: One unit of red cells increases Hb by approx 1g/dL. 500ml loss = 10% loss (approx 1g/dL fall in Hb) 2000ml loss = 40% loss (approx 4-5g/dL fall in Hb) Hb & HCT measurements may not accurately reflect the extent of blood loss in the acutely bleeding patient.

The following basic principles should be followed for the storage and use of blood products: Refer to hospital to Blood Transfusion hospital policy/ procedure on Intranet for detailed guidance. The blood fridge is on labour ward (central area). Blood removal must be documented in Blood Fridge register. Platelets are a room temperature product & should be delivered directly to clinical area; they must not be stored in the blood fridge if platelets are refrigerated they will become inactive. FFP & Cryoprecipitate should both be delivered directly to the clinical area and transfused as soon as possible. Cryoprecipitate must not be put in a blood fridge & must be transfused with 4 hours of being defrosted. The patient must be wearing an ID wristband & the details on this must exactly match those on the blood component label. The blood/ blood product must be checked against ID wristband. Incorrect blood component transfused is the most frequently reported serious hazard of transfusion. Transfusion of each unit should commence as soon possible after collection & must be within 30 minutes of retrieval from the fridge. Blood warmers should be used if possible and are essential for rapid transfusion, rates > 50ml/Kg/hour.
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All blood products must be administered via a line which has an integral 170200 micron screen filter; a standard blood line. The line should be primed with blood product. A standard blood line can be used for all products but if available a blood component line with smaller priming volume should be used for FFP, platelets & cryoprecipitate. A new line must be used for platelets & other products must not be transfused through that line. The pink traceability section of each blood component tag must be signed, detached & placed in collection box. If using uncrossmatched O negative blood the patients details must also be completed. This is a legal requirement. The type of blood transfused will be dictated by the clinical situation, but the order of preference is as follows: - Cross - matched blood - Group - specific, but un - Crossmatched blood- this should be available within 20 minutes. - Uncrossmatched O negative blood (6 units available in the Labour Ward - Fridge code for the fridge 1111)

Please refer to the separate guideline for women who refuse blood products If the use of FFP, platelets or Cryoprecipitate is being considered, the SpR or anaesthetist should liase directly with the on call Haematology SpR and the consultant obstetrician should be aware of the situation. FBC & coagulation screens should be repeated after the transfusion of each batch of blood components, this will support decision making for ongoing clinical management. Transfusion of further components may be required before laboratory test results become available & clinical advice from Haematologist should be sought.

Fresh frozen Plasma (FFP) Anticipate coagulation factor deficiency after blood loss replacement > 1- 1.5 x estimated blood volume (EBV) loss. Fluid resuscitation will further reduce coagulation factor levels because of dilution. FFP may be required early (> 0.5 EBV) if there is ongoing blood loss and fluid replacement. It is indicated if PT/aPTT > 1.5 x control. The dose is 12 - 15 mls/Kg body weight (4 packs for an adult). Empirical treatment may be necessary if evidence of generalised bleeding and coagulation tests are not available.

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UCL HOSPITALS NHS FOUNDATION TRUST

GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Cryoprecipitate Fibrinogen deficiency may develop when > 1 EBV replaced. This should be treated if Fibrinogen levels < 1.0g/dl and fibrinogen less than 0.5 strongly associated with microvascular bleeding. The dose is 1 unit /5 Kg body weight (10 -15 units for an adult). The new pooled product has 5 units/pool therefore standard dose = 2 pools. Platelets Be prepared to request platelets in advance of need if there is abnormal platelet function (aspirin) or persistent active bleeding. Target values: 50 x 109/l but 100 x 109/l if abnormal platelet function. The dose is: 1 -2 pooled packs of platelets for an adult. Recombinant Factor VIIa Recombinant factor VIIa maybe a useful treatment for women with severe PPH despite attempts to correct coagulopathy and optimal surgical management. It is unlicensed but maybe considered when the following points apply and should be discussed with the haematology consultant on call for transfusion: Severe haemorrhage from multiple sites particularly bleeding from large raw areas despite attempting local measures to control Severe haemorrhage despite attempts to correct coagulopathy with fresh frozen plasma, cryoprecipitate and platelets For maximum benefit it should be given prior to the onset of complications associated with massive transfusion. Do not use if the overall outlook is so poor that arresting haemorrhage is unlikely to improve outcome. In obstetrics it may be appropriate if internal iliac ligation, uterine artery embolisation or hysterectomy is being considered or if the woman refuses blood products A coagulation screen and D-dimers should be checked immediately before and 15 minutes after rFVIIa administration.

The following are relative contraindictions: Women with known thrombotic tendency Women with a history of a recent thrombotic event e.g. pulmonary embolism, myocardial infarction, thrombotic cerebrovascular event
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UCLH-2009 Published date: June 2009 Review date: June 2011 Policies, procedures and guidelines only current on date printed refer to Insight for definitive version

UCL HOSPITALS NHS FOUNDATION TRUST

GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Women who have recently undergone coronary angioplasty and/or stent insertion Women with severe peripheral vascular disease Women with liver disease Women with disseminated intravascular coagulation

Tranexamic Acid The use of Tranexamic acid is not recommended in the context of massive obstetric haemorrhage unless there is a specific blood disorder and only after discussion with the consultant haematologist. Cell Salvage Consider the use of cell salvage, particularly during a major obstetric haemorrhage situation where the mother refuses blood products. A cell salvage machine is available in main theatres at UCH; it must only be operated by an individual experienced in its use. Cell salvage in this situation should only be used after approval by a Consultant Anaesthetist & the Consultant Obstetrician as there is a theoretical risk of amniotic fluid embolism. Any blood salvaged from the patient must be filtered using a Leucoreduction filter during re-infusion.

UCLH-2009 Published date: June 2009 Review date: June 2011 Policies, procedures and guidelines only current on date printed refer to Insight for definitive version

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UCL HOSPITALS NHS FOUNDATION TRUST

GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Appendix 3 Procedure for insertion of B-Lynch Suture (B-Lynch 1997) 1. Open uterus if caesarean has not been performed 2. Cavity is swabbed out and examined 3. Exteriorise uterus 4. Bi-manual compression to assess the likelihood of success of the B-Lynch suture. 5. 70mm round bodied hand needle with a No.2 vicryl suture 6. Puncture uterus 3cm below the right lower edge of the uterine incision and 3 cm medial to the right lateral border. 7. Bring needle back out 3cm above the upper incision margin and about 4cm medial to the lateral border 8. Pass over the fundus about 3 4 cm from the right cornual border. 9. Pull suture under moderate tension assisted by manual compression by the assistant. 10. Pass the needle through the posterior wall of the uterus at the same level as the upper anterior entry point and place a suture across the posterior wall exiting at the same position on the left side 11. Pass the suture over the fundus about 3-4cm from the left cornual border and enter the uterus above and below the incision as for the first side. 12. Pull the two ends of the suture 13. Tie with a double throw on the first knot followed by two further knots. 14. Close lower transverse uterine incision Fig. 1. Parts (a) and (b) demonstrate the anterior and posterior views of the uterus showing the application of the B-Lynch Brace suture. Part (c) shows the anatomical appearance after competent application. (B-Lynch et al, 1997)

UCLH-2009 Published date: June 2009 Review date: June 2011 Policies, procedures and guidelines only current on date printed refer to Insight for definitive version

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UCL HOSPITALS NHS FOUNDATION TRUST

GUIDELINE FOR THE MANAGEMENT OF POSTPARTUM HAEMORRHAGE AND MASSIVE OBSTETRIC HAEMORRHAGE

Appendix 4

UCLH-2009 Published date: June 2009 Review date: June 2011 Policies, procedures and guidelines only current on date printed refer to Insight for definitive version

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