- Quantify blood loss.
- Initiate additional measures to control bleeding based on severity of obstetric hemorrhage.
- Blood loss >500 mL and <1000 mL at vaginal delivery or >1000 mL and <1500 mL at cesarean delivery with ongoing excessive bleeding and/or mild tachycardia and/or hypotension.
- Get help and notify obstetric hemorrhage team.
- Continue to monitor vital signs and quantify blood loss.
- Ensure intravenous access with a large gauge catheter(s).
- Begin bimanual uterine massage.
- Increase oxytocin flow rate (avoid direct intravenous injection of undiluted oxytocin).
- Volume resuscitation, preferably with blood and blood products if bleeding is heavy and coagulopathy is imminent.
- Give a second uterotonic (eg, methylergonovine, carboprost tromethamine).
- Examine for lacerations, retained products of conception, uterine inversion, and other causes of bleeding. Consider bedside ultrasound of uterus. Treat as appropriate (eg, repair lacerations, curettage, reposition uterus, etc).
- If cesarean delivery: Apply conservative surgical interventions to control bleeding (eg, uterine artery/ovarian artery ligation, uterine compression sutures).
- Blood loss >1000 mL and <1500 mL at vaginal delivery or >1500 mL at cesarean delivery with ongoing excessive bleeding and/or hemodynamic instability.
- Do all of the above.
- Draw blood for baseline labs (complete blood count, coagulation studies) and clot observation test.
- Insert intrauterine balloon for tamponade.
- Transfuse two units packed red cells and one to two units fresh frozen plasma. Activate a massive transfusion protocol if bleeding is heavy and transfusion of four or more units of blood is likely.
- If vaginal delivery: Move the patient to an operating room to perform conservative surgical interventions to control bleeding.
- Consider selective arterial embolization only if patient is hemodynamically stable. This should preferably be performed in an operating room or hybrid suite if available. Bleeding patients should only be moved to a radiology suite for embolization if they are hemodynamically stable and blood products are being replaced at a rate that can exceed that of the bleeding. Arterial embolization outside of an operating room is not an option in situations where there is catastrophic bleeding in a decompensating patient.
- If cesarean delivery: Continue to apply conservative surgical interventions to control bleeding (eg, uterine artery/ovarian artery ligation, uterine compression sutures).
- Blood loss >1500 mL, ongoing excessive bleeding, and hemodynamic instability despite initial therapy.
- Initiate massive transfusion protocol (transfuse appropriate ratio of red cells, fresh frozen plasma/cryoprecipitate, and platelets).
- If conservative surgical interventions are not successful, perform hysterectomy. Hysterectomy should not be delayed in women who require prompt control of uterine hemorrhage to prevent death.
- Keep patient warm.
- Treat acidosis.
- Check ionized calcium and potassium levels every 15 minutes once a massive transfusion protocol has been initiated and treat hypocalcemia and hyperkalemia aggressively. Continue until the emergency has been contained and the protocol for massive transfusion has been stopped.
- Maintain oxygen saturation >95%.
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