Obstetric haemorrhage

Haemorrhage remains a major cause of maternal morbidity and mortality in the developed and developing world. It can be defined as an estimated blood loss of more than 1500 ml, with ongoing blood loss. Postpartum haemorrhage is the most common cause, and accounts for about 50% of cases. Initial management involves patient assessment, estimation of blood loss, obtaining appropriate help, monitoring and resuscitation. Bleeding may be stopped with drugs that promote uterine contraction (oxytocin, ergometrine or prostaglandins) or with external/internal tamponade, arterial ligation and, if all else fails, hysterectomy. Recent advances include the use of recombinant factor VIIa and interventional radiology. Cell salvage and thromboelastography are also emerging as new and helpful techniques. Early anaesthetic involvement should form part of this multidisciplinary management. Clinical circumstances may dictate choice of anaesthetic for examination and delivery. In emergency cases, haemodynamic stability and coagulation status have to be considered, and a general anaesthetic is usually indicated. However, in elective cases, regional anaesthesia is now accepted even if significant blood loss is anticipated. Locally developed protocols, with regular ‘fire drill’ practice sessions, are essential.