Objectives

On successfully completing this topic, you will be able to:

• understand the definition and causes of major obstetric haemorrhage

• recognise and manage maternal collapse caused by obstetric haemorrhage

• understand the pharmacological and surgical options for the treatment of major obstetric haemorrhage

• make a plan to facilitate optimum management in your environment

• understand the concerns to be discussed with a woman declining blood and blood products during pregnancy.

Introduction

Major haemorrhage remains a leading cause of maternal mortality despite modern improvements in obstetric practice and transfusion services. In addition, all ‘near miss’ audits, in deve loped as well as developing countries, show major haemorrhage to be one of the leading causes of severe maternal morbidity.

Complications of haemorrhage associated with first-trimester bleeding due to miscarriage or ectopic pregnancy are not within the remit of the MOET course, although most general principles will apply.

Maternal mortality and incidence of major haemorrhage

The CMACE Confidential Enquiry into maternal deaths 2006 to 2008 showed a welcome reduction in deaths due to postpartum haemorrhage. However, despite a halving in the number of such deaths since the previous triennial report, obstetric haemorrhage remains a source of concern in the UK, with evidence of substandard care in three out of the five cases. In particular, a lack of routine observations in the postpartum period and failure to appreciate that significant (concealed) bleeding was occurring led to a lack of appropriate action including no early senior involvement. The report restates previous comments that all units should have procedures in place for the identification and management of major obstetric haemorrhage, and that regular skills training sessions should take place.