Action plan for early (primary) postpartum hemorrhages (following the clinical recommendations of the Ministry of Health of Russia «Preventive measures, management tactics, anesthesia and intensive care in postpartum hemorrhages, 2019»)

When primary postpartum hemorrhage occurs, the emergency medical care is provided by the multidisciplinary team [1, 2].

The following procedures are provided simultaneously: informing, investigation into the causes of the hemorrhage, assessment of blood loss, arrest of hemorrhage and therapeutic measures.

Informing. It is necessary:

• to call the 2nd obstetrician-gynecologist and the 2nd midwife;
• to call an intensivist, a nurse anesthetist, a transfusiologist (if available) and a laboratory doctor (if available), to inform the duty doctor and the obstetrical remote consulting center (the team content responsible for the medical care delivery is specified according to the possibilities of the medical institution).
• to appoint the responsible doctor, who is a member of an ambulance crew, for performing the transfusion therapy (in the absence of the transfusiologist)
• to appoint the responsible doctor, who is a member of an ambulance crew, (usually an intensivist or a nurse anesthetist) for recording the events, infusion and transfusion therapy management, drug administration and vital signs.

Extent of blood loss:

1. Visually estimated volume + 30%.
2. Gravimetric method, that is a direct collection of blood into the measuring graduates and weighing of the blood-soaked sheets, swabs and surgical clothes.
3. On the basis of the clinical symptoms of hypovolemia (ATLS classification and shock index (SI):

Shock index = Pulse rate/systolic blood pressure. Shock index 1.1 and higher means hemorrhage together with debilitated general condition [10].

Action plan at the initial stage of the hemorrhage.

Extent of blood loss 500.0 – 750.0 ml (all the arrangements are performed for 10-20 minutes) [11, 12].

The functions of the anesthesiology service (anesthesiologist / nurse anesthetist) are performed upon the agreement of the obstetrician-gynecologist:

1. Anapnotherapy.
2. Vital signs control (blood pressure, pulse rate, respiratory rate, level of blood saturation, diuresis).
3. Infusion and transfusion therapy.
4. Coagulation disorders correction.
5. Anesthetic support.

Infusion and transfusion therapy

Infusion and transfusion therapy starts immediately. First, as the starting procedure up to 2000 ml of balanced heated crystalloid solutions are transfused. The volume of colloid solutions averages about 1500 ml [13, 14, 15]. The solutions can be administered prior to the beginning of blood transfusion, after crystalloid solutions administration or together with it.

Action plan for the inefficiency of the initial stage procedures.

When the extent of the vaginal postpartum blood loss reaches 1000 ml and the hemorrhage is not arrested, and/or there are shock symptoms, the patient is transferred to the operative room immediately. In massive blood loss, exceeding 25-30% of the total volume of the circulating blood, surgical procedures are to be provided no later than within 20 minutes.

Procedures at this stage are:

• Providing the anesthetic support
• Second blood sampling (clinical, hemostasiogram, Lee-White, urea, electrolytes)
• Providing the intraoperative reinfusion of autoerythrocytes (if possible)
• Uterotonic therapy
• Laparotomy or relaparotomy (if hemorrhage occurs after cesarean section) (blood loss 25-30% of the circulating blood volume) and uterine devascularization by means of:
  • compression sutures,
    and/or temporary clipping or major uterine vessels ligation,
    and/or internal iliac artery ligation and/or angiographic embolization;
  • hysterectomy (in case of inefficiency of the above-mentioned measures; the decision is made jointly).
• Repeated administration of tranexamic acid: slow intravenous administration of 15 mg/kg (usually 1000 mg: 2 ampoules of 5 ml, 100 mg/ml)
• Continuation of the intensive infusion and transfusion [16, 17, 18] therapy in order to correct hypovolemia, anemia, coagulopathy (Table 4). When calculating the volume of infusion and transfusion therapy one should bear in mind the need for transfusion in case of massive blood loss of fresh frozen plasma in a volume no less than 15-20 ml/kg. The administration of donor erythrocytes is performed not later than within 40 minutes, provided that indications and crossmatch are available. In massive blood loss the “massive transfusion protocol” is to be applied: erythrocytes, plasma, thrombocytes, cryoprecipitate at a ratio of 1:1:1:1.

Major indications for the transfusion of blood components:

• Massive blood loss: more than 25-30% of circulating blood volume or more than 1500 ml.
• Continuing hemorrhage.
• Laboratory parameters changes (Table 4).
• Upon the hemorrhage arrest and reaching the target laboratory parameters, the transfusion of blood components must be stopped.

NB! The drugs that increase the blood coagulation (Protromplex, thromboconcentrate, cryoprecipitate, activated Factor VII) [26, 27, 28] are used in case of confirmed hypocoagulation and continuing hemorrhage.