OB Hemorrhage Resources

The treatment of life-threatening post-partum haemorrhage (PPH) still remains challenging, and hysterectomy may be required to control the bleeding. We present 12 cases of severe PPH treated with recombinant factor VIIa (rFVIIa). We briefly describe the causes of the haemorrhage and the medical and surgical interventions before rVIIa administration. In 11 women there was a partial or good response to rFVIIa administration, while in one there was no response. In the four women undergoing a subsequent selective arterial embolization, the bleeding was significantly reduced although not completely stopped. From our experience with these 12 cases, and from previously reported cases, the use of rFVIIa may be of benefit in life-threatening PPH. However, treatment with rFVIIa, in addition to standard surgical and medical interventions, may not be definitive in every patient and a selective arterial embolization may be needed.

BACKGROUND: Empirical off-label use of recombinant activated factor VII (rFVIIa) has been reported to be effective in some cases of severe postpartum haemorrhage (PPH). Successful management of these patients has lead to more wide-spread use of rFVIIa in less severe cases without any evidence for the advantages of its administration.
METHODS: Until November 2006, we had administered rFVIIa to 38 parturients. Based on our initial experience with the first 12 patients, we prepared guidelines for the use of rFVIIa. During the existence of these guidelines, we made a retrospective comparison of the 26 women who received rFVIIa with another 22 women who were treated during the same time period without using rFVIIa.
RESULTS: The total amount of blood loss was significantly higher (11.3 +/- 4.5 vs. 8.0 +/- 3.1 l), and the coagulation screen revealed significantly longer partial thromboplastin time (APTT) and prothrombin time (PT) values and significantly lower fibrinogen values in patients receiving rFVIIa. The need for red blood cells, platelets and fibrinogen concentrate was significantly higher in these women. Although the response was considered good in two-thirds of the women, several patients received rFVIIa with a poor or no response as a result of arterial bleeding.
CONCLUSION: The decision to use rFVIIa resulted from a more profound haemorrhage. We did not gain any evidence to extend the use of rFVIIa into less severe cases of PPH. Furthermore, this policy would result in a profound increase in the overall costs of the treatment. Randomized placebo-controlled trials are urgently needed to optimize the use of rFVIIa in obstetric haemorrhage. PMID: 17488316

OBJECTIVE: To collect data from nine European countries for cases of obstetric hemorrhage between 2000 and 2004 in which recombinant activated factor VII (rFVIIa) was used.
METHODS: The cases were identified through national surveys. Standardized case report forms included sociodemographic details, past medical and obstetric history, and details of the progress and management of labor in which the postpartum hemorrhage occurred. Clinicians were asked to describe subjectively the effect of rFVIIa administration using two mutually exclusive categories: 1) bleeding reduced or 2) bleeding unchanged or worse.
RESULTS: A total of 113 forms were returned (88%) with 97 (86%) classified as treatment, and 16 (14%) as "secondary prophylaxis." Clinicians noted improvements after a single dose for 80% of women in the treatment group, and for 75% in the secondary "prophylaxis" group. However, rFVIIa failed in 15 cases (13.8%). Few serious adverse events were noted related to rFVIIa administration; there were four cases of thromboembolism, one myocardial infarction, and one skin rash.
CONCLUSION: Clinical reports and hematologic data suggest improvement for more than 80% of women after rFVIIa administration and few adverse effects.
LEVEL OF EVIDENCE: II.

BACKGROUND: Postpartum hemorrhage (PPH) remains among the 5 main causes of maternal death in developing and developed countries, and uterine atony is the most common cause (75-90%) of primary PPH. Uterine compression sutures running through the full thickness of both uterine walls (posterior as well as anterior) have recently been described for surgical management of atonic PPH. Christopher B-Lynch was the first to highlight this revolutionary principle, and other uterine compression suture techniques have since been described by Hayman and Cho.
OBJECTIVES: Step-by-step description of the B-Lynch brace suture and discussion of the current compression suture techniques.
CONCLUSIONS: The different uterine suture techniques have proved to be valuable and safe alternatives to hysterectomy in the control of massive PPH, and the present review can make the surgeon better aware of their effective use and the risks they may entail.

OBJECTIVE: The objective of this retrospective study is to reflect on our experience on an optimal management for major postpartum hemorrhage, which would prevent the occurrence and complications of disseminated intravascular coagulation and minimize maternal mortality and morbidity.
METHODS: Ten cases out of the 30,000 of total deliveries of severe obstetric hemorrhage associated with disseminated intravascular coagulation were studied. This study was carried out over a 7 year period, October 1988 through to September 1995, at the Obstetric Unit, King Khalid University Teaching Hospital, Riyadh, Kingdom of Saudi Arabia.
RESULTS: All of the 10 women received packed red blood cells, 8 had fresh frozen plasma, and 6 received platelet transfusion. The 10 cases developed disseminated intravascular coagulation following medical and surgical management, all women needed hysterectomy, 4 subtotal, 6 total, and 5 women had relaparotomy and pelvic packing. Two had bladder injuries. There was no maternal death.
CONCLUSION: An early resort to hysterectomy when conservative measures fail, will minimize maternal morbidity and mortality. In case of continuous bleeding after hysterectomy, pelvic packing proved to be effective.

BACKGROUND: Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed.
METHODS: We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention.
RESULTS: The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention. CONCLUSIONS: A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy.

Objective To determine the prevalence, causes, risk factors and acute maternal complications of severe obstetric haemorrhage. Design Population-based registry study. Population All women giving birth (307 415) from 1 January 1999 to 30 April 2004 registered in the Medical Birth Registry of Norway. Information about socio-economic risk factors was obtained from Statistics Norway. Methods Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models. Main outcome measure Severe obstetric haemorrhage (blood loss of > 1500 ml or blood transfusion). Results Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of ‡30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity, more than three and two times higher for emergency caesarean delivery and elective caesarean than for vaginal birth, respectively, and substantially higher for multiple pregnancies, von Willebrand’s disease and anaemia (haemoglobin <9 g/dl) during pregnancy. Admissions to an intensive care unit, postpartum sepsis, hysterectomy, acute renal failure and maternal deaths were significantly more common among women with severe haemorrhage. Conclusion The high prevalence of severe obstetric haemorrhage indicates the need to review labour management procedures. Demographic and medical risk factors can be managed with extra vigilance. Keywords Prevalence, risk factors, severe obstetric haemorrhage.

Severe bleeding is the single most significant cause of maternal death world-wide. More than half of all maternal deaths occur within 24 hours of delivery, most commonly from excessive bleeding. It is estimated that worldwide, 140,000 women die of postpartum hemorrhage each year-one every 4 minutes (1). In addition to death, serious morbidity may follow postpartum hemorrhage. Sequelae include adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan syndrome). Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. All obstetric units and practitioners must have the facilities, personnel, and equipment in place to manage this emergency properly. Clinical drills to enhance the management of maternal hemorrhage have been recommended by the Joint Commission on Accreditation of Healthcare Organizations (2). The purpose of this bulletin is to review the etiology, evaluation, and management of postpartum hemorrhage.

Multidisciplinary training for obstetric emergencies is an issue of current interest and debate in the UK. This paper presents a survey of current practice in obstetric emergency drill training in England and Wales. A wide range of training methods and opinions about these methods are demonstrated in this survey. There is much interest in improving the management of obstetric emergencies and this is to be encouraged. However, reliable methods to assess and thereby optimise methods are urgently required in order that women and their babies can realise the maximum benefit from these complex interventions.

OBJECTIVE: To determine the incidence and risk factors for standard and severe postpartum haemorrhage (PPH) in vaginally delivering nulliparous women, before and after risk stratification.
STUDY DESIGN: A population-based cohort study in an unselected cohort nulliparous women (N = 3464) in 'The Zaanstreek' district, The Netherlands. Risk stratification is part of routine care, where midwives cover all obstetrical care for women with low risk pregnancies.
RESULTS: The incidence of standard PPH (> or = 500 ml) and severe PPH (> or = 1000 ml) were 19 and 4.2%, respectively. A retained placenta occurred in 1.8%. These data show consistently slightly higher values as compared to studies in literature. The most important risk factors for standard and severe PPH were related to an abnormal third stage of labour-third stage > or = 30 min and retained placenta (in severe
PPH: odds ratio (OR) 14.1, 95% confidence interval (CI) 10.4-19.1). High birth weight and perineal damage were less important, but independent, significant risk factors. In the low risk group (N = 1416), incidence of severe PPH was 4.0%. Independent risk factors for severe PPH were third stage > or = 30 min (incidence 7.1%, OR 3.6) and retained placenta (incidence 1.2%, OR 21.6). In 25% of the women with a prolonged third stage (> or = 30 min), third stage was complicated due to retained placenta and/or severe PPH (1.8% of the low risk group).
CONCLUSIONS: The incidence of PPH in nulliparous women in this cohort was on average higher than published data, while the most important risk factors for standard and severe PPH, even after risk stratification, were the same. A prolonged third stage of labour has to be considered as abnormal, requiring specific action.

OBJECTIVES: To study the effectiveness of a large volume, fluid-filled tamponade balloon in the management of post-partum hemorrhage originating from the implantation site of low-lying placenta/placenta previa.
METHODS: A silicone, fluid-filled balloon was designed for tamponade function, with a filling capacity volume of 500 cc of sterile saline, and strength to withstand a maximum internal and external pressure of 300 mmHg. Five women with postpartum bleeding caused by low-lying placenta/placenta previa, and one woman with cervical ectopic pregnancy, underwent a tamponade balloon insertion as a conservative measure in the management of bleeding.
RESULTS: The tamponade balloon was used in five women with post-partum bleeding caused by low-lying placenta/placenta previa, and in one woman with cervical pregnancy. The balloon was effective in controlling post-partum hemorrhage originating from the placental site of the lower uterine segment, and bleeding from the implantation site of cervical ectopic pregnancy.
CONCLUSION: Hemostasis in cases of post-partum bleeding caused by low-lying placenta/placenta previa can be achieved by using a large volume, fluid-filled tamponade balloon.

BACKGROUND: Hemorrhage remains a leading cause of severe maternal morbidity and death. In addition to the appropriate use of oxytocic agents for uterine atony, surgical techniques, including uterine tamponade, major vessel ligation, compression sutures, and hysterectomy, may be required. On the rare occasions they are needed, the instruments and equipment required for these surgical techniques may not be readily available.
OBJECTIVE: To record our experience with an obstetric hemorrhage equipment tray for surgical management of severe obstetric hemorrhage.
METHODS: A severe obstetric hemorrhage equipment tray was established and included packing (5-yard roll) and balloon device for uterine tamponade, straight (10 cm) eyed-needles and large curved eyed-needles for use with No. 1 suture, 3 Heaney vaginal retractors, 4 sponge forceps, and diagrams and instructions for the various types of compression sutures and tamponade techniques.
RESULTS: Of the 4400 deliveries that occurred at 1 tertiary maternity hospital during 2002, the obstetric hemorrhage tray was used on 9 occasions: 3 Caesarean sections with placenta previa (uterine tamponade used in 2 cases, compression sutures in 1); 2 Caesarean sections with uterine atony (compression sutures); 1 Caesarean section with placenta previa accreta (major vessel ligation and compression sutures); and 3 vaginal deliveries (suturing of cervical and vaginal lacerations in 2 of the cases, uterine tamponade used in the third case). In all cases, hysterectomy was avoided.
CONCLUSION: The ready availability of an obstetric hemorrhage equipment tray on the labour ward facilitates prompt surgical management of severe obstetric hemorrhage, and may reduce the need for blood transfusion and hysterectomy.

OBJECTIVE: To review the efficacy, morbidity, and subsequent pregnancy outcome after uterine compression sutures for severe postpartum hemorrhage.
METHODS: A 7-year review (2000-2006) of all uterine compression sutures for postpartum hemorrhage at one tertiary obstetric hospital.
RESULTS: During the 7 years, 28 uterine compression sutures were performed in 31,519 deliveries (1 per 1,126). All were done at the time of cesarean delivery: 22 in 4,870 cesarean deliveries in labor (1 in 221) and 6 in 3,819 elective cesarean deliveries (1 in 637). The indications for suture were atonic postpartum hemorrhage in 25 of 28 (89%), placenta previa in 2 of 28 (7%), and partial placenta accreta in 1 of 28 (4%). Hysterectomy was avoided in 23 of 28 women (82%). Blood transfusion was needed in 13 of 28 (46%), and intensive care in 5 of 28 (18%). Seven women had subsequent uncomplicated term pregnancies, all delivered by elective repeat caesarean delivery.
CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy.

OBJECTIVE: To compare the effect of 400 mug of oral misoprostol with 5 U of intravenous oxytocin in the reduction of postpartum blood loss and prevention of postpartum hemorrhage.
METHODS: In a prospective, double-blind, randomized controlled trial conducted in a tertiary maternity hospital 622 women received either 400 mug of oral misoprostol or 5 U of intravenous oxytocin after delivery of the anterior shoulder or within 1 min of delivery. The primary outcome was a hematocrit drop of 10% or greater 24 h postpartum. The secondary outcomes were a hemoglobin drop of 30 mg/L or greater, the use of additional oxytocin, an estimated blood loss greater than 1000 mL, manual removal of the placenta, a blood transfusion, and shivering and fever (>or=38 degrees C) as adverse effects of misoprostol.
RESULTS: There was no difference between the 2 groups regarding the primary outcome (a >or=10% hematocrit drop occurred in 3.4% and 3.7% of the participants in the oxytocin and misoprostol groups, P=0.98). The rate of use of additional oxytocin was higher in the misoprostol group (51% versus 40.5%, P=0.01). Shivering was confined to the misoprostol group (6.8%), and fever occurred in 12.5% of the women in the misoprostol group and 0.3% of the women in the oxytocin group.
CONCLUSION: The routine use of 400 microg of oral misoprostol was no less effective than 5 U of intravenous oxytocin in reducing blood loss after delivery, as assessed by change in postpartum hematocrit. The adverse effects of misoprostol were mild and self-limiting.

This article presents current understanding of the causes, pathophysiology, clinical, and laboratory diagnosis, and management of fulminant and low-grade DIC, as they apply to obstetric, pregnant, and gynecologic patients. General medical complications leading to DIC, which may often be seen in these patients, are also discussed. Considerable attention has been given to interrelationships within the hemostasis system. Only by clearly understanding these pathophysiologic interrelationships can the obstetrician/gynecologist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. Objective clinical and laboratory criteria for diagnosis of DIC have been outlined to eliminate unnecessary confusion and the need to make empiric decisions regarding the diagnosis. Particularly in the obstetric patient, if a condition is observed that is associated with DIC, or if any suspicion of DIC arises from either clinical or laboratory findings, it is imperative to monitor the patient carefully with clinical and laboratory tools to assess any progression to a catastrophic event. In most instances of DIC in obstetric patients, the disease can be ameliorated easily at early stages. Many therapeutic decisions are straightforward, particularly in obstetric and gynecologic patients. For more serious and complicated cases of DIC in these patients, however, efficacy and choices of therapy will remain unclear until more information is published regarding response rates and survival patterns. Also, therapy must be highly individualized according to the nature of DIC, patient's age, origin of DIC, site and severity of hemorrhage or thrombosis, and hemodynamic and other clinical parameters. Finally, many syndromes that are often categorized as organ-specific disorders and are sometimes identified as independent disease entities, such as AFE syndrome, HELLP syndrome, adult shock lung syndrome, eclampsia, and many others, either share common pathophysiology with DIC or are simply a form of DIC. These entities represent the varied modes of clinical expression of DIC and illustrate the diverse clinical and anatomic manifestations of this syndrome.

The pathophysiologic mechanisms, clinical, and laboratory manifestations of DIC are complex in part due to interrelationships within the hemostasis system. Only by clearly understanding these extraordinarily complex pathophysiologic interrelationships can the clinician and laboratory scientist appreciate the divergent and wide spectrum of often confusing clinical and laboratory findings in patients with DIC. Many therapeutic decisions to be made are controversial and lack validation. Nevertheless, newer antithrombotic agents, and agents that can block, blunt, or modify cytokine activity and the activity of vasoactive substances appear to be of value. The complexity and variable degree of clinical expression suggests that therapy should be individualized depending on the nature of DIC, age, etiology of DIC, site and severity of hemorrhage or thrombosis and hemodynamics and other appropriate clinical parameters. At present, treatment of the triggering event, low-dose heparin or antithrombin concentrate and wise choice of components when indicated appear to be the most effective modes of therapy.

OBJECTIVE: To determine the most effective method of delivering training to staff on the management of an obstetric emergency.
SUBJECTS: The research was conducted in a District General Hospital in the UK, delivering approximately 3500 women per year. Thirty-six staff, comprising of junior and senior medical and midwifery staff were included as research subjects. Each of the staff members were put into one of six multi-professional teams. Effectively, this gave six teams, each comprising of six members.
METHOD: Three teaching methods were employed. Lecture based teaching (LBT), simulation based teaching (SBT) or a combination of these two (LAS). Each team of staff were randomly allocated to undertake a full day of training in the management of Post Partum Haemorrhage utilising one of these three teaching methods. Team knowledge and performance were assessed pre-training, post training and at three months later. In addition to this assessment of knowledge and performance, qualitative semi-structured interviews were carried out with 50% of the original cohort one year after the training, to explore anxiety, confidence, communication, knowledge retention, enjoyment and transferable skills.
RESULTS: All teams improved in their performance and knowledge. The teams taught using simulation only (SBT) were the only group to demonstrate sustained improvement in clinical management of the case, confidence, communication skills and knowledge. However, the study did not have enough power to reach statistical significance. The SBT group reported transferable skills and less anxiety in subsequent emergencies. SBT and LAS reported improved multidisciplinary communication. Although tiring, the SBT was enjoyed the most.
CONCLUSION: Obstetrics is a high risk speciality, in which emergencies are to some extent, inevitable. Training staff to manage these emergencies is a fundamental principal of risk management. Traditional risk management strategies based on incident reporting and event analysis are reactive and not always effective. Simulation based training is an appropriate proactive approach to reducing errors and risk in obstetrics, improving teamwork and communication, whilst giving the student a multiplicity of transferable skills to improve their performance.

OBJECTIVE: To describe models used for the training of labour ward personnel in acute obstetric emergencies and to describe how these models have been evaluated and compared.
DESIGN: A systematic review of the following databases: Medline, the Cumulative Index of Nursing and Allied Health Literature, Embase, PsycLit, Allied and Alternative Medicine, Education Resources Information Center and the Cochrane Library using a structured search strategy.
SETTING: Labour ward.
POPULATION OR SAMPLE: Labour ward personnel.
INCLUSION CRITERIA: All papers that described or evaluated any form of drill or training in acute obstetric emergencies involving any personnel in a labour ward environment were included. Descriptions of training in developing countries were excluded.
METHODS: Papers were classified as editorials or commentaries, papers describing a training programme or papers evaluating a training method. A data collection form was used to extract relevant information by two investigators independently.
MAIN OUTCOME MEASURE: Description of training models.
RESULTS: Of 44 relevant papers, 22 were classed as editorials or commentaries. Six descriptions of training programmes were found and four papers involved an evaluation of such programmes. All evaluations involved the use of questionnaires to course participants. No studies comparing one form of training with another were found.
CONCLUSIONS: With regard to training in acute obstetric emergencies, few training programmes have been described, and even fewer have been evaluated. Training methods need to be developed, described and evaluated; further well-conducted research for this important intervention is urgently required.

Massive obstetric haemorrhage is a major cause of maternal death and morbidity; abruptio placentae, placenta praevia and postpartum haemorrhage being the main causes. A delay in the correction of hypovolaemia, a delay in the diagnosis and treatment of defective coagulation and a delay in the surgical control of bleeding are the avoidable factors in most maternal deaths caused by haemorrhage. The degree of hypotension is the first guide to the level of blood loss, except in abruptio placentae. A protocol incorporating the guidelines is shown. The rapid correction of hypovolaemia with crystalloids and red cells is the first priority, followed by blood component therapy as indicated by the haematocrit, coagulation tests, platelet count and clinical features. Serial monitoring of the response to treatment is essential. Oxytocin and prostaglandin will correct uterine atony, and appropriate surgical intervention is required for traumatic bleeding. Ligation of the uterine arteries, ovarian arteries and internal iliac arteries will usually control uterine bleeding, arterial embolization also being effective. Hysterectomy should be considered as well. Catastrophic bleeding may also arise in complications such as rupture of the liver and acute fatty liver of pregnancy. These rare complications are best managed by a multidisciplinary team involving the obstetrician, anaesthetist, haematologist, hepatologist and renal physician. The rupture of aneurysms in the splenic artery and in other branches of the aorta can result in massive haemorrhage during pregnancy and following delivery.

BACKGROUND: Patients with severe traumatic injuries often present with coagulopathy and require massive transfusion. The risk of death from hemorrhagic shock increases in this population. To treat the coagulopathy of trauma, some have suggested early, aggressive correction using a 1:1 ratio of plasma to red blood cell (RBC) units.
METHODS: We performed a retrospective chart review of 246 patients at a US Army combat support hospital, each of who received a massive transfusion (>/=10 units of RBCs in 24 hours). Three groups of patients were constructed according to the plasma to RBC ratio transfused during massive transfusion. Mortality rates and the cause of death were compared among groups.
RESULTS: For the low ratio group the plasma to RBC median ratio was 1:8 (interquartile range, 0:12-1:5), for the medium ratio group, 1:2.5 (interquartile range, 1:3.0-1:2.3), and for the high ratio group, 1:1.4 (interquartile range, 1:1.7-1:1.2) (p < 0.001). Median Injury Severity Score (ISS) was 18 for all groups (interquartile range, 14-25). For low, medium, and high plasma to RBC ratios, overall mortality rates were 65%, 34%, and 19%, (p < 0.001); and hemorrhage mortality rates were 92.5%, 78%, and 37%, respectively, (p < 0.001). Upon logistic regression, plasma to RBC ratio was independently associated with survival (odds ratio 8.6, 95% confidence interval 2.1-35.2).
CONCLUSIONS: In patients with combat-related trauma requiring massive transfusion, a high 1:1.4 plasma to RBC ratio is independently associated with improved survival to hospital discharge, primarily by decreasing death from hemorrhage. For practical purposes, massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCs for all patients who are hypocoagulable with traumatic injuries.

OBJECTIVES: Following the results of the Confidential Enquiries into Maternal Deaths report, which claims two maternal deaths annually in the UK from postpartum haemorrhage, our aim was to assess the accuracy of 'visual estimation of blood loss' and produce suitable pictorial and written algorithms to aid in the recognition and management of massive obstetric haemorrhage.
DESIGN: Observational study to determine discrepancy between actual blood loss (ABL) and estimated blood loss (EBL).
SETTING: Teaching hospital.
POPULATION: Hundred and three obstetricians, anaesthetists, midwives, nurses and healthcare assistants.
METHODS: Clinical scenarios were reproduced in the form of 12 Objective Structured Clinical Examination (OSCE) style stations augmented with known volumes of whole blood. Individual staff estimated the blood loss visually and recorded their results. Digital photographs were used to produce a pictorial 'algorithm' suitable for use as a teaching tool in labour ward.
MAIN OUTCOME MEASURES: Areas of greatest discrepancy between EBL and ABL.
RESULTS: Significant underestimation of the ABL occurred in 5 of the 12 OSCE stations: 500-ml (50-cm diameter) floor spill, 1000-ml (75-cm diameter) floor spill, 1500-ml (100-cm diameter) floor spill, 350-ml capacity of soaked 45- x 45-cm large swab and the 2-l vaginal postpartum haemorrhage on bed/floor.
CONCLUSIONS: Accurate visual estimation of blood loss is known to facilitate timely resuscitation, minimising the risk of disseminated intravascular coagulation and reducing the severity of haemorrhagic shock. Participation in clinical reconstructions may encourage early diagnosis and prompt treatment of postpartum haemorrhage. Written and pictorial guidelines may help all staff working in labour wards.

OBJECTIVE: Postpartum haemorrhage (PPH) remains an important cause of maternal morbidity and mortality. With regard to morbidity, preservation of the uterus is of paramount importance in fertile women. The objective of the study was to describe the cumulative experience of a cohort of women that were treated with recombinant factor VIIa.
STUDY DESIGN: In this retrospective, descriptive study we approached all departments of obstetrics and gynaecology in the Netherlands to find out if they had used rFVIIa for this indication. Twenty-seven cases were reported to us. To evaluate each case, we used a standardized case record form.
RESULTS: The main cause of PPH was uterine atony (82%). In 21 cases rFVIIa was explicitly given to prevent a hysterectomy. This was successful in 16 cases (76%). Relevant reduction or complete cessation of bleeding after rFVIIa was noted in 24/27 cases (89%). There was a reduction in blood product requirements following rFVIIa administration. The dose of rFVIIa was variable and ranged from 16 to 128mug/kg.
CONCLUSION: There appears to be a role for the use of rFVIIa in PPH unresponsive to conventional therapy. Recombinant FVIIa can be helpful and avoid an emergency hysterectomy.

OBJECTIVE: To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.
DESIGN: Retrospective questionnaire survey.
SETTING: Three administrative regions of France.
POPULATION: All women who were pregnant or had recently given birth during the year before the survey.
METHODS: A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software).
RESULTS: Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care.
CONCLUSION: Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

BACKGROUND: Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required.
CASE: A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted.
CONCLUSION: Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.

OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock.
METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention.
RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death.
CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.

AIM: To determine the accuracy of the estimation of blood loss using simulated clinical examples.
SETTING: Over 100 attendees came together at a seminar about postpartum haemorrhage in June 2006. Five blood loss assessment stations were constructed, each containing a simulated clinical example. Each station was numbered and was made up of a variety of equipment used in birthing suites. Over 5L of 'artificial' blood was made. The artificial blood was similar to the colour and consistency of real blood.
SAMPLE: A convenience sample of 88 participants was given a response sheet and asked to estimate blood loss at each station. Participants included midwives, student midwives and an obstetrician.
RESULTS: Blood in a container (bedpan, kidney dish) was more accurately estimated than blood on sanitary pads, sheets or clothing. Lower volumes of blood were also estimated correctly by more participants than the higher volumes.
DISCUSSION: Improvements are still needed in visual estimation of blood loss following childbirth. Education programs may increase the level of accuracy.
CONCLUSION: We encourage other clinicians and educators to embark upon a similar exercise to assist midwives and others to improve their visual estimation of blood loss after birth. Accurate estimations can ensure that women who experience significant blood loss can receive appropriate care and the published rates of postpartum haemorrhage are correct.

Management of massive, life-threatening primary postpartum hemorrhage in the labor and delivery service is a challenge for the clinical team and hospital transfusion service. Because severe postpartum obstetrical hemorrhage is uncommon, its occurrence can result in emergent but variable and nonstandard requests for blood products. The implementation of a standardized massive transfusion protocol for the labor and delivery department at our institution after a maternal death caused by amniotic fluid embolism is described. This guideline was modeled on a existing protocol used by the trauma service mandating emergency release of 6 units of group O D- red cells (RBCs), 4 units of fresh frozen or liquid plasma, and 1 apheresis unit of platelets (PLTs). The 6:4:1 fixed ratio of uncrossmatched RBCs, plasma, and PLTs allows the transfusion service to quickly provide blood products during the acute phase of resuscitation and allows the clinical team to anticipate and prevent dilutional coagulopathy. The successful management of three cases of massive primary postpartum hemorrhage after the implementation of our new massive transfusion protocol in the maternal and fetal medicine service is described.

OBJECTIVE: To compare oral misoprostol with conventional oxytocics in the management of the third stage of labor.In a controlled trial, 1574 women were randomized into four groups, as follows: Group 1 received intravenous infusion of oxytocin 10 IU plus oral misoprostol 400 micro g, followed by two doses of oral misoprostol 100 micro g 4 hours apart; group 2 received oral misoprostol 400 micro g, followed by two doses of oral misoprostol 100 micro g 4 hours apart; group 3 received intravenous infusion of oxytocin 10 IU; and group 4 received intravenous infusion of oxytocin 10 IU plus intramuscular administration of methylergonovine maleate (Methergine) 0.2 mg. The incidence of postpartum hemorrhage and decrease in hemoglobin concentration from before delivery to 24 hours postpartum were the main outcome measures.
RESULTS: The primary outcome measures were similar in groups 2 and 3. The incidence of postpartum hemorrhage was 9% in group 2, compared with 3.2% in group 1 and 3.5% in group 4 (P <.01, and P =.01, respectively). There were no significant differences among the four groups regarding hemoglobin concentrations. Significantly more women needed additional oxytocin in group 2, when compared with group 4 (5.9% versus 2.2%; P =.01). The proportion of women requiring additional methylergonovine maleate was 4.8% in group 2, compared with 0.7% in group 1 and 1% in group 4 (P <.01 and P =.01, respectively).
CONCLUSION: Oral misoprostol alone is as effective as oxytocin alone for the prevention of postpartum hemorrhage; it is less effective than oxytocin plus methylergonovine maleate and oral misoprostol plus oxytocin.

BACKGROUND: Post-partum haemorrhage (PPH) is a potentially life-threatening complication of childbirth occurring in up to 10% of births. The NSW Department of Health (DoH) issued a new evidence-based policy (Framework for Prevention, Early Recognition and Management of Post-partum Haemorrhage) in November 2002. Feedback from maternity units indicated that there were deficiencies in the skills and experience is needed to develop the written protocols and local plans of action required by the Framework.
METHODS: All 96 hospitals in NSW that provide care for childbirth were surveyed. A senior midwife completed a semistructured telephone interview.
RESULTS: Ninety four per cent of hospitals had PPH policies. Among hospitals that provided a copy of their policy, 83% were dated after the release of the DoH's Framework, but 22% contained an incorrect definition of PPH. Only 71% of respondents in small rural and urban district hospitals recalled receiving a copy of the Framework. There was considerable variation in the frequency of postnatal observations. Key factors that impede local policy development were resources, entrenched practices and centralised policy development. Enabling factors were effective relationships, the DoH policy directive (Framework), education and organisational issues/time.
CONCLUSIONS: Greater assistance is needed to ensure that hospitals have the capacity to develop a policy applicable to local needs. Maternity hospitals throughout the state provide different levels of care and NSW DoH policy directives should not be 'one size fits all' documents. Earlier recognition of PPH may be facilitated by routine post-partum monitoring of all women and should be consistent throughout the state, regardless of hospital level.

In the UK, maternal mortality due to haemorrhage appears to be rising, with obstetric haemorrhage accounting for 3-4% of the red cells transfused. Allogeneic blood transfusion carries risks such as administration errors, transmitted infections and immunological reactions. The supply of blood is decreasing, partly due to the exclusion of donors who have themselves received a blood transfusion since 1980, in order to stop transmission of variant-Creutzfeldt-Jakob disease. The cost of blood is significantly increasing, partly because it is now leucocyte-depleted to minimize viral transmission. Various blood conservation techniques can reduce exposure to allogeneic blood thereby reducing risk and conserving the blood supply. These include preoperative autologous donation, acute normovolaemic haemodilution and intra-operative cell salvage. Preoperative autologous donation may produce anaemia, does not eliminate transfusion risk, cannot be used in an emergency and is not acceptable to Jehovah's Witnesses. It should be reserved for exceptional circumstances (rare blood type or unusual antibodies). Acute normovolaemic haemodilution may induce anaemia and cardiac failure and cannot be used in an emergency. It may have a limited role in combination with other techniques. Intra-operative cell salvage is more effective and useful in obstetrics than the other techniques, overcomes their shortcomings and is endorsed by CEMACH, OAA/AAGBI Guidelines, the National Blood Service and NICE.

When caring for patients receiving massive transfusion, the nurse will be required to perform ongoing assessments and apply critical thinking to provide optimum care and avoid further complications. The perianesthesia nurse must be aware of the hemodynamic and coagulation changes of pregnancy when caring for an obstetric patient in the PACU to optimize patient outcomes. Understanding the causes of obstetric hemorrhage, which may result in the need for massive transfusion, will enable the nurse to anticipate and prevent potentially deadly complications.

PURPOSE OF REVIEW: Despite evidence that active management of the third stage of labour reduces the incidence of postpartum haemorrhage, expectant management is still widely practised. Factors accounting for this situation include the desire for a more natural experience of childbirth, the philosophy that active management is unnecessary in low-risk women, and avoidance of the adverse effects of conventional uterotonic agents. This review will evaluate the various strategies currently used for the prevention of primary postpartum haemorrhage.
RECENT FINDINGS: Since publication of the first systematic review comparing active with expectant management in 1988, active management of the third stage using oxytocics has become increasingly adopted. Recent surveys, however, show that there are still wide variations in practice around the world. Recent interest has focused on the use of misoprostol for the prevention of postpartum haemorrhage. Carbetocin, an oxytocin receptor agonist, shows promise but has not been evaluated for use after vaginal births.
SUMMARY: Active management of the third stage of labour is superior to expectant management in terms of blood loss, postpartum haemorrhage and other serious complications, but is associated with unpleasant side effects and hypertension when ergometrine is included. Intramuscular oxytocin results in fewer side effects. Oral and rectal misoprostol has been extensively assessed and found to be less effective than conventional oxytocics with more side effects. Until alternative regimes of misoprostol are studied in large controlled trials, misoprostol is not recommended for routine use in the third stage of labour. Of the remaining uterotonic agents evaluated, intramuscular carbetocin appears the most promising.

PURPOSE OF REVIEW: This review will summarize the latest publications on the causes, prevention and treatment of maternal collapse during pregnancy and the postpartum period. It will also explore some future trends particularly in the area of education and team working.
RECENT FINDINGS: Active management of the third stage of labour has been shown to decrease the incidence of postpartum haemorrhage. Inadequate or prolonged resuscitation following major postpartum haemorrhage can lead to myocardial damage. Guidelines that are followed and the use of drills and simulators may increase effective team working and lead to earlier recognition and treatment of maternal collapse. Some cases of amniotic fluid embolism resemble anaphylaxis and should be treated as such. Important evidence-based guidelines on the management of antithrombolytic prophylaxis and the management of pulmonary embolism have recently been published, which should help clinicians clarify their medical care plans. New resuscitation guidelines in the UK will probably mean that all healthcare workers (including obstetricians and midwives) will need appropriate training every year.
SUMMARY: Understanding the causes of maternal collapse, its early recognition and prompt resuscitation should decrease both maternal and fetal morbidity and mortality. There is increasing evidence that effective preventative measures and improved multidisciplinary team working may have an important impact on maternal and fetal well-being.

OBJECTIVE: We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006.
STUDY DESIGN: This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined.
RESULTS: Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20.
CONCLUSION: Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.

Acute postpartum hemorrhage is the leading worldwide cause of maternal mortality, such deaths being usually related to the development of hemorrhagic shock and its consequences, especially the multiple organ dysfunction syndrome. Obstetricians should be aware of the clinical manifestations and principles of management of hemorrhagic shock. Initial assessment of the bleeding patient requires monitoring blood pressure, pulse, capillary refill, mental status and urinary output. This allows estimation of the amount and the rate of blood loss and helps direct treatment. Hemorrhagic shock is a condition in which inadequate perfusion of organs results in insufficient availability of oxygen to satisfy the metabolic needs of the tissues. A catabolic state develops. The consequences of these changes are inflammation, endothelial dysfunction, and disruption of normal metabolic processes in vital organs. Once these events become established, the process of shock is often irreversible, even if volume and red cell deficits are corrected. The principal goals of management are controlling the source of the blood loss; restoring adequate oxygen carrying capacity; and maintaining adequate tissue perfusion. Patients with severe postpartum hemorrhage are at risk of developing hypothermia, an insidious complication that contributes substantially to morbidity and mortality. It must be prevented or treated promptly. Successful treatment of exsanguinating postpartum hemorrhage depends on efficient collaboration among all members of the patient care team, and a management plan based on an understanding of the pathophysiology of shock and tailored to the individual patient's situation.

Massive postpartum hemorrhage (PPH) is a major cause of maternal mortality in the United Kingdom and worldwide. Life-threatening PPH occurs with a frequency of 1 in 1000 deliveries in the developed world. In the latest triennial Why Mothers Die: Confidential Enquiries into Maternal Deaths in the United Kingdom (1997-1999), PPH was the fifth most common cause of maternal mortality. In this review, we discuss the role of medical management in primary PPH and the use of the "tamponade test" when such management fails. The less radical surgical options discussed include uterine compression sutures, uterine or internal iliac artery ligation, and arterial embolization, all of which have the advantage of potentially preserving reproductive function. Radical surgical options, including subtotal or total hysterectomy, are not discussed in this review. A systematic or algorithmic method of tackling the problem is described. The suggested management approach is likely to reduce maternal morbidity from bleeding, hysterectomies, and maternal deaths.

OBJECTIVE: Massive postpartum hemorrhage is a major cause of pregnancy-related death in the United States. To date there is no diagnostic test to identify those women with intractable hemorrhage who will need surgery. Delay in making this decision can be catastrophic. The successful use of the inflated stomach balloon of a Sengstaken-Blakemore tube as a therapy for obstetric hemorrhage has been reported previously. Using the insertion of the Sengstaken-Blakemore tube as a diagnostic test has not been reported. An inflated Sengstaken-Blakemore balloon catheter creates tamponade and identifies those who will or will not need surgery. This is the basis for the "tamponade test." We evaluated the tamponade test in the management of women with massive postpartum hemorrhage.
METHODS: In this prospective study, 16 cases of intractable postpartum hemorrhage were managed by the tamponade test. All 16 women had persistent bleeding despite the maximal and optimal application of conservative measures. Their condition deteriorated, such that surgical intervention was considered mandatory. It was at this predefined end point that the tamponade test was applied.
RESULTS: Fourteen (87.5%) had a positive tamponade test result and therefore did not require surgery. Two (12.5%) had a negative test result and underwent laparotomy.
CONCLUSION: This diagnostic test rapidly identifies those patients with postpartum hemorrhage who will require a laparotomy. Even when results are positive, life-threatening hemorrhage is arrested and time is also allowed to correct any consumptive coagulopathy.

The common hemorrhagic complications of pregnancy remain among the leading causes of maternal mortality. We review new methods of diagnosis and offer suggestions for management. Abruptio placenta, disseminated intravascular coagulation, placenta previa, uterine rupture, and postpartum hemorrhage are included in this review

Obstetric hemorrhage is still a significant cause of maternal morbidity and mortality. Prevention, early recognition, and prompt intervention are the keys to minimizing complications. Resuscitation can be inadequate because of under-estimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs. All members of the obstetric team should know how to manage hemorrhage because timing is of the essence. Good communication with the blood bank ensures timely release of appropriate blood products. A well-coordinated team is one of the most important elements in the care of a compromised fetus. If fetal anoxia is presumed, there is less than 10 minutes to permanent fetal brain damage. Antepartum anesthesia consultation should be encouraged in parturients with medical problems.

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training.
DESIGN: A prospective randomised controlled trial.
SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK.
POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied.
METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre.
MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention.
RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965).
CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

This article reviews our experience with the use of intrauterine tamponade with balloon catheters in the management of severe postpartum hemorrhage. This is a case series report of 23 patients with postpartum hemorrhage unresponsive to medical therapy managed with intrauterine balloon tamponade. We identified these patients by International Classification of Diseases (ICD-9) codes and by reviewing labor and delivery logs. Balloon tamponade was attempted in 23 patients. When properly placed, catheters controlled postpartum hemorrhage in 18 of 20 cases (90%). In two cases, hysterectomy was required despite successful placement of the catheter. For hemorrhage due to uterine atony, our success rate was 100% (11/11 cases). In three cases, technical difficulties led to placement failure. For bleeding due to retained placenta, our success rate was 80% (4/5; failure with placenta percreta). Vaginal bleeding was stopped with the catheter in two of three cases of amniotic fluid embolus and in one case after dilation and curettage for postpartum septic shock. Thus balloon tamponade is an effective adjunct in the treatment of severe postpartum hemorrhage, especially when due to uterine atony when medical therapy fails.

Introduction: The leading causes of pregnancy-related death are embolism (20%), hemorrhage (17%), and pregnancy-induced hypertension (16%).The Obstetric and Mechanical Engineering Departments at Stanford University worked together to create inexpensive devices that were used in high fidelity simulations to replicate 2 of the leading causes of maternal mortality: hemorrhage and eclampsia (seizure). Methods: The mechanisms were designed to behave as similarly as possible to a human patient. The engineering team designed the eclampsia mechanism to jostle the mannequin's head at a frequency and randomness that matched those observed in human generalized seizures. The hemorrhage mechanism was designed to give visual and tactile cues similar to the actual physiology of a pregnant uterus. Both devices were remote controlled. Results: The hemorrhage mechanism was used in a scenario of an amniotic fluid embolism with severe postpartum hemorrhage. The final flow rate was adjustable between 525 and 600 mL/min. The trainees' rapid response and control of the postpartum hemorrhage was deemed to be a vital part of a successful maternal resuscitation. The seizure mechanism was used in a simulation of a pregnant woman in labor with evidence of severe preeclampsia. If the trainees did not recognize the need for treatment of the preeclampsia, the patient simulator had a 45- to 60-second seizure. If corrective actions were not taken, another seizure occurred. Conclusions: The use of remote controlled mechanical devices designed to accurately replicate the visual, auditory, and tactile cues of hemorrhage and eclampsia enhanced high fidelity simulation training in obstetrical emergencies.

REVIEW ARTICLE: Post-partum hemorrhage is an obstetrical emergency. Pelvic artery embolisation offers an alternative to surgical intervention and increases the rate of conservative treatment. The objective of this review was to study the scientific literature on obstetrical outcomes following uterine-sparing arterial embolisation performed for post-partum hemorrhage in a prior pregnancy. A Medline and Sciencedirect search were performed in order to review all the French and English reports about pregnancy following pelvic arteries embolisation for post-partum hemorrhage. Nineteen articles were identified and 13 were selected for inclusion. We have included the fertility follow-up of a total of 168 women who underwent pelvic arteries embolisation for post-partum hemorrhage. We highlight the clinical success of embolisation in 154 of the 168 patients (92%). Following the embolisation procedures, 7 hysterectomies were required and 4 patients died. Two of the 4 deaths occurred in women who were transferred from an outlying institution to a tertiary referral center. In this population, 45 pregnancies were described. Among these pregnancies, 32 resulted in live births (71%), 8 were miscarriages (18%) and 5 patients carried out voluntary termination of pregnancy (11%). The cesarean section rate was 62%. Post-partum hemorrhage occurred in 6 cases leading to 2 hysterectomies. In conclusion, pelvic arterial embolisation offers a safe and conservative alternative to surgical interventions for post-partum hemorrhage in well-selected patients desiring to preserve future fertility.

OBJECTIVE: Visually estimated blood loss has long been known to be imprecise, inaccurate, and often underestimated, which may lead to delayed diagnosis and treatment. Our purpose is to determine whether a brief didactic course can improve visually estimated blood loss and whether prior clinical experience influences estimation of blood loss.
METHODS: Reconstituted whole blood was obtained from the blood bank, and simulated scenarios with known measured blood loss were created using common surgical materials. Visually estimated blood loss was performed by medical personnel before and after a 20-minute didactic session. Percent errors of estimated blood loss were calculated and comparisons were made before and after the lecture. The effects of actual blood volume and clinical experience on estimation of blood loss were assessed.
RESULTS: A total of 53 participants assessed 7 scenarios. There were significant reductions in error for all scenarios. Median percent error in estimated blood loss was not influenced by clinical experience, either before or after the didactic session. Blood loss tends to be overestimated at low volumes and underestimated at high volumes.
CONCLUSION: Error in estimating blood loss is dependent on actual blood loss volume. Medical students and experienced faculty demonstrate similar errors, and both can be improved significantly with limited instruction. This educational process may assist clinicians in everyday practice to more accurately estimate blood loss and recognize patients at risk for hemorrhage-related complications.

We performed a systematic review to identify all studies evaluating the success rates of treatment of major postpartum hemorrhage by uterine balloon tamponade, uterine compression sutures, pelvic devascularization, and arterial embolization. We included studies reporting on at least 5 cases. All searches were performed independently by 2 researchers and updated in June 2006. Failure of management was defined as the need to proceed to subsequent or repeat surgical or radiological therapy or hysterectomy, or death. As the search identified no randomized controlled trials, we proceeded to search for observational studies. This identified 396 publications, and after exclusions, 46 studies were included in the systematic review. The cumulative outcomes showed success rates of 90.7% (95% confidence interval [CI], 85.7%-94.0%) for arterial embolization, 84.0% (95% CI, 77.5%-88.8%) for balloon tamponade, 91.7% (95% CI, 84.9%-95.5%) for uterine compression sutures, and 84.6% (81.2%-87.5%) for iliac artery ligation or uterine devascularization (P = 0.06). At present there is no evidence to suggest that any one method is better for the management of severe postpartum hemorrhage. Randomized controlled trials of the various treatment options may be difficult to perform in practice. As balloon tamponade is the least invasive and most rapid approach, it would be logical to use this as the first step in the management

Blood loss during normal delivery was measured in 37 primiparas and 25 multiparas who had no obstetric or medical complications and who underwent normal delivery in a teaching hospital following spontaneous onset of labour at term. Measured blood loss was significantly greater than the estimated volume of blood loss. In primigravidas, the mean ( +/- SE, standard error of the mean) estimated blood loss was 260 +/- 12 ml and the mean measured blood loss was 401 +/- 29 ml. In multiparas the mean estimated blood loss was 220 +/- 10 ml and the mean measured blood loss was 319 +/- 41 ml. The mean estimated blood loss was significantly lower (P less than 0.05) than the mean measured blood loss in both groups. The size of the discrepancy between measured and estimated blood loss was proportional to the measured blood loss. These findings show that visual estimation of blood loss was grossly inaccurate.

Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley's in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000-2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor's hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death. The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of cases in BJOG 1997. This has made a significant impact on the conservative surgical management of massive PPH. There are now over 1300 successful applications of this technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho's Square Suture and Haymen's modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery. The current list of publications of successful application of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to enquiries@cblynch.com. Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.

Any woman who gives birth can have post-partum haemorrhage which may threaten her life. PPH is one of the leading causes of maternal mortality and an important cause for serious morbidity in the developing and developed world. We are at the threshold of major developments in its prevention and treatment due to changing ideas about its definition and medical and surgical management. The implementation of these changes is an essential part of a wider commitment towards saving mothers from complications of childbirth.

Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.

BACKGROUND: Postpartum hemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used, but none has been uniformly successful.
CASE: Two women with postpartum hemorrhage due to uterine atony after cesarean for twins are presented. Neither responded to medical management. In the first subject, O'Leary uterine artery ligation and utero-ovarian branch ligations were done without benefit. The B-Lynch suture immediately sustained correction of hemorrhage in both subjects. Magnetic resonance imaging and hysterosalpingogram after the first case showed no uterine defects.
CONCLUSION: The B-Lynch suture might be a valuable addition to the surgical treatment of postpartum hemorrhage due to uterine atony.

Obstetric haemorrhage is a leading cause of maternal death and the most common contributor to serious obstetric morbidity. Maternal mortality audit data suggest that appropriate preparation and good emergency management leads to improved outcome. The aim of this study was to assess facilities relevant to major obstetric haemorrhage management in all units in Australia and New Zealand that offer operative obstetric services. The questionnaire was divided into ten sections: demographics, facilities, staffing, policies and guidelines, drugs, procedures, equipment, point of care testing, availability of O negative blood and free comments. Responses were received from 240 (76.4%) of the 314 hospitals surveyed (187 public and 53 private). One hundred and nine units (45%) had fewer than 500 deliveries per year Distances to referral facilities were frequently very large. Of the 90 hospitals (38.1%) without an onsite blood bank, 12 did not have a supply of blood for emergencies. Half of all units (n=121) had on-site intensive care or high dependency facilities and 72.9% (n=175) had an on-site cardiac arrest team. Only 58.8% of units (n=141) had a written haemorrhage protocol. Findings are presented in the context of other literature, including evidence-based guidelines. Haemorrhage responds well to appropriate treatment, although careful preparation and anticipation of problems is required. In our region geographical factors and different systems of healthcare complicate provision of obstetric services. Where facilities are limited, women should be offered antenatal transfer to a larger centre.

OBJECTIVE: To audit reported clinical practice in relation to four national obstetric guidelines on The Preparation of the Foetus for Preterm Delivery, The Management of Mild, Non-proteinuric Hypertension in Pregnancy, The Management of Pregnancy in Women with Epilepsy and The Management of Postpartum Haemorrhage.
DESIGN: Questionnaire surveys before and after dissemination of the guidelines.
SUBJECTS: One hundred and sixty one consultants and senior specialist registrars in Scotland.
RESULTS: The response rates to the baseline and follow-up surveys were 85% and 74% respectively. Over 90% of the obstetricians kept the guidelines for reference and 85% had been prompted to change or reconsider their practice. Reported compliance improved significantly for six out of twenty nine recommendations covering: the use of tocolysis in women at risk of pre-term labour; the use of prophylactic antibiotics or entry to a clinical trial for pre-term, pre-labour rupture of the membranes; the initiation of steroid therapy in women with insulin-dependent diabetes mellitus; and the prescribing of periconceptual folic acid and vitamin K to women with epilepsy. There were no significant improvements in relation to mild, non-proteinuric hypertension or post-partum haemorrhage.
CONCLUSIONS: There were significant improvements in the reported management of women at risk of preterm labour and those with epilepsy. However, reported practice in relation to mild, non-proteinuric hypertension and post-partum haemorrhage has improved little. This is possibly because the guidelines for these topics were relatively complicated to understand and apply, and established patterns of practice more resistant to change.

The objective of this review was to evaluate and summarize the current literature on the unlicensed use of the novel agent recombinant activated factor VII (rFVIIa) in the management of major postpartum hemorrhage. After a systematic electronic search without temporal limits on MEDLINE, EMBASE, OVID and SCOPUS, the bibliographic references of all retrieved studies and reviews were additionally assessed for further reports of clinical trials. Unpublished works were also identified by searching abstracts from the most eminent conferences on this topic. In total, there were 31 studies that fulfilled our inclusion criteria. These studies incorporated 118 cases of massive postpartum hemorrhage treated with rFVIIa. The median age of the patients was 31.4 years, and cesarean section appeared to increase the risk of postpartum hemorrhage. At a median dose of 71.6 mug/kg, rFVIIa was reported to be effective in stopping or reducing bleeding in nearly 90% of the reported cases. Based on the evidence from the literature, we give some recommendations on the use of rFVIIa in massive postpartum hemorrhage. Nevertheless, although these reports suggest the potential role of rFVIIa in treating massive postpartum hemorrhage refractory to standard therapy, we advise particular caution in interpreting these results, as they are derived from few and uncontrolled studies. Further evidence is needed using well-designed clinical trials to better assess the optimal dose, the effectiveness, and the safety of rFVIIa in such critical bleeding conditions.

Recombinant activated factor VII (rFVIIa) was originally developed for the treatment of bleeding in patients with haemophilia A or B and inhibitors. Over the past ten years, it has been successfully used to prevent or control bleeding in several other nonhaemophilic bleeding conditions. Among the newer 'off-label' clinical applications of rFVIIa, there is increasing evidence of its effectiveness in treating obstetric and gynaecological bleeding unresponsive to conventional therapy. The existing literature on the use of rFVIIa in obstetrics and gynaecology is summarised in this review. Although supported by few and uncontrolled studies, on the whole, the published data suggest a potential role of rFVIIa in the management of obstetric and gynaecological intractable bleeding. However, further evidence is needed to improve the assessment of its optimal dose, effectiveness and safety in such conditions.

Hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. This emphasizes the importance of a working knowledge of the indications for and complications associated with blood product replacement in obstetric practice. This article provides current information regarding preparation for and administration of blood products, discusses alternatives to banked blood in the obstetric population, and introduces pharmacological strategies for treatment of hemorrhage.

The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH. Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings. In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis. Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care. Inability to stabilize a patient who is in hemorrhagic shock rapidly results in death. To address these individual factors, we propose a continuum of care model for PPH, including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transportation, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the greatest impact for saving women's lives. This model should be developed and tested to be region-specific.

OBJECTIVE: To compare rectally administered misoprostol to intravenously administered oxytocin for the management of third-stage labor.
STUDY DESIGN: Subjects were randomized to receive two, 200-microg misoprostol tablets rectally (study medication) plus 2 mL saline in Ringer's lactate intravenously or two lactose tablets rectally plus 20 units oxytocin in Ringer's lactate intravenously (control medication). Blood loss was determined by estimation, measurement, and change in hematocrit values from admission to postpartum day 1. Subjects were excluded if cesarean delivery was required.
RESULTS: A total of 325 women underwent analysis. By estimation, 21% of subjects and 15% of controls had postpartum hemorrhage (P =.17). By using measured blood loss, we determined that 70 of 154 (46%) study subjects and 61 of 161 (38%) control subjects had postpartum hemorrhage (P =.17). For 36 (23%) misoprostol subjects and 18 (11%) oxytocin subjects at least one additional agent was required to control bleeding (P =.004).
CONCLUSION: Rectal misoprostol (400 microg) was no more effective than intravenous oxytocin in preventing postpartum hemorrhage.

This paper will examine the literature on blood loss at delivery and report the findings of a small pilot study where midwives and doctors were asked to estimate blood loss at simulated stations. The results were analysed using simple frequency distribution. This simple study demonstrated that midwives and other health professionals underestimate blood loss at delivery by 30-50%. The implication for midwives is that there is a need to double their estimated blood loss at delivery when it is over 500 ml.

BACKGROUND: Acidosis, hypothermia, and coagulopathy were identified more than 20 years ago as a deadly triad for patients presenting with exsanguinating hemorrhage. This led to fundamental changes in initial management of severely injured patients. Despite major advances, hemorrhage remains a leading cause of early death in trauma patients. Recent studies report most severely injured patients to be coagulopathic at admission, before resuscitation interventions, and that traditional massive transfusion practice grossly underestimates needs. The hypothesis for this study is that our pre-intensive care unit (ICU) massive transfusion (MT) protocol does not adequately correct coagulopathy, and that early uncorrected coagulopathy is predictive of mortality.
METHODS: Data maintained in our Trauma Research Database were reviewed. Univariate logistic regression analysis was used to analyze the association of early ICU international normalized ratio (INR) and outcomes, including survival.
RESULTS: Ninety-seven of 200 patients admitted during 51 months (ending January 2003) and resuscitated using our standardized ICU shock resuscitation protocol received MT (> or =10 units packed red blood cells [PRBC]) during hospital day 1 (age, 39 +/- 2; ISS, 29 +/- 1; survival, 70%.) All patients required emergency operating room and/or interventional radiology procedures and arrived in the ICU 6.8 +/- 0.3 hours after admission. Coagulopathy, present at hospital admission (pre-ICU INR, 1.8 +/- 0.2), persisted at ICU admission (initial ICU INR, 1.6 +/- 0.1). Pre-ICU resuscitation, 9 +/- 1 L crystalloid fluid, 12 +/- 1 units PRBC, 5 +/- 0.4 units fresh frozen plasma (FFP), was consistent with our MT protocol by which FFP was not given until after 6 units PRBC. ICU resuscitation involved 11 +/- 1 L lactated Ringer's solution (LR) and 10 +/- 1 units PRBC. Mean pH was normal within 8 hours. Mean temperature increased from approximately 35 degrees C to >37 degrees C within 4 hours. In the ICU during resuscitation, patients received 10 +/- 1 units FFP for coagulopathy; the ratio of
FFP:PRBC was 1:1. Mean INR decreased to 1.4 +/- 0.03 within 8 hours and remained nearly constant for the remaining 16 hours of ICU resuscitation, indicating moderate coagulopathy. Statistical analysis found severity of coagulopathy (INR) at ICU admission associated with survival outcome (p = 0.02; area under receiver operator curve [ROC] = 0.71.)
CONCLUSION: These data indicate acidosis and hypothermia to be well managed. Coagulopathy was not corrected in the ICU despite adherence to pre-ICU MT and ICU protocols, likely because of inadequate pre-ICU intervention. More aggressive pre-ICU intervention to correct coagulopathy may be effective in decreasing PRBC requirement during ICU resuscitation, and, because of the association with increased mortality, could improve outcome. We have revised our pre-ICU MT protocol to emphasize early FFP in a
FFP:PRBC ratio of 1:1. We think that treatment of coagulopathy can be improved with the development of standardized protocols, both empiric and data driven.

BACKGROUND: Prostaglandins have mainly been used for postpartum haemorrhage (PPH) when other measures fail. Misoprostol, a new and inexpensive prostaglandin E1 analogue, has been suggested as an alternative for routine management of the third stage of labour.
OBJECTIVES: To assess the effects of prophylactic prostaglandin use in the third stage of labour.
SEARCH STRATEGY: The Cochrane Pregnancy and Childbirth Group's Trials Register (February 2007) and PubMed (July 2006).
SELECTION CRITERIA: Randomized trials comparing a prostaglandin agent with another uterotonic or no prophylactic uterotonic (nothing or placebo) as part of management of the third stage of labour. The primary outcomes were blood loss 1000 ml or more and the use of additional uterotonics.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligibility and trial quality and extracted data.
MAIN RESULTS: Thirty-seven misoprostol and nine intramuscular prostaglandin trials (42,621 women) were included. Oral (seven trials, 2849 women) or sublingual misoprostol (relative risk (RR) 0.66; 95% confidence interval (CI) 0.45 to 0.98; one trial, 661 women) compared to placebo may be effective in reducing severe PPH and blood transfusion (RR 0.31; 95% CI 0.10 to 0.94; five oral misoprostol trials, 3519 women). The severe PPH analysis of oral misoprostol trials was not totalled due to significant heterogeneity. Compared to conventional injectable uterotonics, oral misoprostol was associated with higher risk of severe PPH (RR 1.32; 95% CI 1.16 to 1.51; 16 trials, 29,042 women) and use of additional uterotonics but with fewer blood transfusions (RR 0.81; 95% CI 0.64 to 1.02; 15 trials, 27,858 women). Additional uterotonic data were not totalled due to heterogeneity. Misoprostol use is associated with significant increases in shivering and a temperature of 38 degrees Celsius. There are scarce data comparing injectable prostaglandins with the conventional injectable uterotonics on severe PPH and the use of additional uterotonics, the primary outcomes of this review. AUTHORS'
CONCLUSIONS: Misoprostol orally or sublingually at a dose of 600 mcg shows promising results when compared to placebo in reducing blood loss after delivery. The margin of benefit may be affected by whether other components of management of the third stage of labour are used or not. As side-effects are dose-related, research should be directed towards establishing the lowest effective dose for routine use, and the optimal route of administration. Neither intramuscular prostaglandins nor misoprostol are preferable to conventional injectable uterotonics as part of the management of the third stage of labour especially for low-risk women.

BACKGROUND: Postpartum haemorrhage is a leading cause of maternal morbidity and mortality. Active management of the third stage of labour, including use of a uterotonic agent, has been shown to reduce blood loss. Misoprostol (a prostaglandin E1 analogue) has been suggested for this purpose because it has strong uterotonic effects, can be given orally, is inexpensive, and does not need refrigeration for storage. We did a multicentre, double-blind, randomised controlled trial to determine whether oral misoprostol is as effective as oxytocin during the third stage of labour.
METHODS: In hospitals in Argentina, China, Egypt, Ireland, Nigeria, South Africa, Switzerland, Thailand, and Vietnam, we randomly assigned women about to deliver vaginally to receive 600 microg misoprostol orally or 10 IU oxytocin intravenously or intramuscularly, according to routine practice, plus corresponding identical placebos. The medications were administered immediately after delivery as part of the active management of the third stage of labour. The primary outcomes were measured postpartum blood loss of 1000 mL or more, and the use of additional uterotonics without an unacceptable level of side-effects. We chose an upper limit of a 35% increase in the risk of blood loss of 1000 mL or more as the margin of clinical equivalence, which was assessed by the confidence interval of the relative risk. Analysis was by intention to treat.
FINDINGS: 9264 women were assigned misoprostol and 9266 oxytocin. 37 women in the misoprostol group and 34 in the oxytocin group had emergency caesarean sections and were excluded. 366 (4%) of women on misoprostol had a measured blood loss of 1000 mL or more, compared with 263 (3%) of those on oxytocin (relative risk 1.39 [95% CI 1.19-1.63], p<0.0001). 1398 (15%) women in the misoprostol group and 1002 (11%) in the oxytocin group required additional uterotonics (1.40 [1.29-1.51], p<0.0001). Misoprostol use was also associated with a significantly higher incidence of shivering (3.48 [3.15-3.84]) and raised body temperature (7.17 [5.67-9.07]) in the first hour after delivery.
INTERPRETATION: 10 IU oxytocin (intravenous or intramuscular) is preferable to 600 microg oral misoprostol in the active management of the third stage of labour in hospital settings where active management is the norm.

OBJECTIVE: To review the treatment options presented on the New York State Health Care Proxy for Jehovah’s Witnesses, which is signed by pregnant women when they present for care. METHODS: Chart reviews were performed for all women who presented to labor and delivery at our institution from 1997 to 2002 and identified themselves as Jehovah’s Witnesses. A patient was included in the study if a completed health care proxy was available in her chart. Data were derived from the health care proxy and from the Mount Sinai School of Medicine’s Blood Product Checklist for Jehovah’s Witness Patients. Variables of interest included age, race, parity, and antenatal and perinatal complications. RESULTS: A total of 61 patients were identified. Of these, 39.3% agreed to accept a variety of donated blood products, 9.8% would accept donated packed red blood cells, and 50.1% would accept neither from a homologous donor. With respect to nonstored autologous blood, 55% of respondents would accept either intraoperative normovolemic hemodilution or transfusion of their own blood obtained by a cell salvage system. No significant differences in responses were noted for any of the above-mentioned variables. CONCLUSION: This review refutes the commonly held belief that all Jehovah’s Witnesses refuse to accept blood or any of its products. In this population of pregnant women, the majority were willing to accept some form of blood or blood products. This information can be used to help health care providers counsel a patient when she is initially faced with considering these issues and may help to remove the stigma of accepting one of the options. (Obstet Gynecol 2004;104:541– 4. © 2004 by The American College of Obstetricians and Gynecologists.)

In the successful management of a pregnant Jehovah's Witness, many issues must be addressed beyond those normally required for routine prenatal care. The clinician who undertakes such care should be well versed in the potential complications related to blood refusal, the antepartum management of anemia, and the intrapartum management of obstetric hemorrhage. Furthermore, these patients should be delivered in a tertiary care center because this increases their options for obtaining alternative management of hemorrhage. A woman who is well informed about her options can then decide exactly what she wants done in the event of a life-threatening obstetrical hemorrhage.

Jehovah’s Witnesses comprise a unique obstetric population. Their refusal of blood stems from an interpretation of a literal translation of the Bible, and it is this belief that puts them at an increased risk of morbidity and mortality if hemorrhage occurs. Many Jehovah’s Witnesses feel that accepting a blood transfusion will lead them to eternal damnation. A patient’s self-determination, or autonomy, allows her to make decisions regarding her care. The decision to refuse blood or blood products has been upheld in court. This brings a new twist to the physician’s obligation to “do no harm.” When one undertakes the care of one of these patients, it is important to understand the ethical and medicolegal ramifications. The decision to be the primary caregivers can only be made once the physicians have decided they can let the patient die when all other options have been exhausted. This commentary discusses the ethical concerns and reviews the alternatives available to a Jehovah’s Witness. (Obstet Gynecol 2003;102:173– 80. © 2003 by The American College of Obstetricians and Gynecologists.) Several unique issues arise when health professionals agree to provide obstetric care to observant Jehovah’s Witnesses. It has been shown that if such women have an obstetric hemorrhage, they are at a 44-fold increased risk of maternal mortality.1 Both ethical and medical concerns should be considered before undertaking the care of one of these patients.

OBJECTIVE: Obstetric hemorrhage is a significant cause of maternal morbidity and death. Postpartum hemorrhage that cannot be controlled by local measures has traditionally been managed by bilateral uterine artery or hypogastric artery ligation. These techniques have a high failure rate, often resulting in hysterectomy. In contrast, endovascular embolization techniques have a success rate of >90%. An additional benefit of the latter procedure is that fertility is maintained. We report our experience at Stanford University Medical Center in which this technique was used in 6 cases within the past 5 years.
STUDY DESIGN: Six women between the ages of 18 and 41 years underwent placement of arterial catheters for emergency (n = 3) or prophylactic (n = 3) control of postpartum bleeding. Specific diagnoses included cervical pregnancy (n = 1), uterine atony (n = 3), and placenta previa and accreta (n = 2).
RESULTS: Control of severe or anticipated postpartum hemorrhage was obtained with transcatheter embolization in 4 patients. A fifth patient had balloon occlusion of the uterine artery performed prophylactically, but embolization was not necessary. In a sixth case, bleeding could not be controlled in time, and hysterectomy was performed. The only complication observed with this technique was postpartum fever in 1 patient, which was treated with antibiotics and resolved within 7 days.
CONCLUSIONS: Uterine artery embolization is a superior first-line alternative to surgery for control of obstetric hemorrhage. Use of transcatheter occlusion balloons before embolization allows timely control of bleeding and permits complete embolization of the uterine arteries and hemostasis. Given the improved ultrasonography techniques, diagnosis of some potential high-risk conditions for postpartum hemorrhage, such as placenta previa or accreta, can be made prenatally. The patient can then be prepared with prophylactic placement of arterial catheters, and rapid occlusion of these vessels can be achieved if necessary.

PURPOSE: An increasing number of women with cirrhosis are conceiving and carrying their pregnancies to term. However, the maternal mortality rate remains high (10-61%). This case report describes the management of a parturient with esophageal varices and thrombocytopenia. She was also a Jehovah's Witness.
CLINICAL FEATURES: A 25-yr-old Jehovah's Witness parturient with portal hypertension and esophageal varices secondary to cryptogenic cirrhosis was referred to our obstetrical unit at eight weeks gestation. In addition she was thrombocytopenic with platelet counts ranging from 42,000-67,000 x microl(-1). Her esophageal varices were banded prophylactically on three occasions during her pregnancy. Magnetic resonance imaging at 32 wk gestation showed extensive caput medusa and dominant midline varix. Therefore, the planned mode of delivery was changed from Cesarean section which could result in massive hemorrhage, to elective induction of labour with an assisted second stage. The patient refused any blood product transfusion except acute hemodilution and cell saving if necessary during labour and delivery. Despite elaborate preparations for a planned vaginal delivery, she underwent an unanticipated rapid labour. Spinal analgesia was provided to facilitate smooth assisted vacuum delivery.
CONCLUSION: Multidisciplinary care is the key for a successful outcome in parturients with cirrhosis. Periodic examination and banding of esophageal varices is recommended during pregnancy. Active consideration should be given to availing of the benefits of regional anesthesia.

BACKGROUND: It has been estimated that worldwide, over 125,000 women die of postpartum hemorrhage each year. The traditional management of this condition includes the use of oxytocics, such as oxytocin, ergometrine, and prosta- glandins, before proceeding to ligation of the internal iliac arteries and even hysterectomy. The B-Lynch technique is a surgical procedure that may be used to arrest postpartum hemorrhage resulting from uterine atony.
CASES: This paper describes simple modifications of this technique that make this procedure less complex to perform. Three clinical case scenarios illustrate the context in which the sutures may be used.
CONCLUSION: Compression sutures placed into the post-partum uterus may provide a simple first surgical step to control bleeding when routine oxytocic measures have failed. We suggest that the technique we have described is a simple procedure and should be tried before more complex interventions are used.

Massive obstetric haemorrhage is a life-threatening emergency that remains a major cause of maternal mortality. Conventional management is aimed at optimising uterine tone, replacing circulating volume and blood products, and surgery to achieve haemostasis. Recently there have been numerous reports of the (unlicensed) use of recombinant activated factor VII in the management of major obstetric haemorrhage. We report our experience of using it in the treatment of major post-partum haemorrhage in four previously healthy parturients. The published reports of recombinant activated factor VII use in post-partum haemorrhage (unrelated to pre-existing coagulopathies) are compared.

OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock.
DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review.
SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day.
POPULATION: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms.
METHODS: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion.
MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart.
RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output.
CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

OBJECTIVE: To evaluate the feasibility, safety and effectiveness of the non-pneumatic anti-shock garment for resuscitation and haemostasis following obstetric haemorrhage resulting in severe shock.
DESIGN: During a six-week period, the author served a locum tenens as the obstetrician consultant for the Memorial Christian Hospital, Sialkot, Pakistan. All women who suffered from severe obstetric haemorrhage were managed with the anti-shock garment as the first intervention. The data for this report were collected from hospital chart review.
SETTING: Sialkot is a city of about three million and Memorial Christian Hospital is one of two major obstetric hospitals. There is no blood bank at Memorial Christian Hospital or elsewhere in Sialkot. The Memorial Christian Hospital laboratory is able to draw donor blood, type and cross match blood, and process it for transfusion 24 hours per day.
POPULATION: During the six weeks of this study, in June and July 2001, there were 764 deliveries and 34 other admissions within a week following deliveries outside the hospital. Seven women with obstetric haemorrhage who developed severe shock were managed with the anti-shock garment. One woman, who was later found to have mitral stenosis, developed dyspnea upon placement of the anti-shock garment and therefore it was removed within 5 minutes. This report concerns the six women who were able to tolerate the anti-shock garment without untoward symptoms.
METHODS: As soon as severe shock was recognised in the hospital, the anti-shock garment was placed. Crystalloid solutions were given intravenously over the first hour at a rate of 1500 mL per estimated litre of blood loss, then at a maintenance rate of 150 mL/hour. Vital signs every 15 to 30 minutes, hourly urine output and intermittent oxygen saturation were used to monitor patients during the use of the anti-shock garment. When sufficient blood transfusion had been given to restore the haemoglobin to >7 g/dL, the anti-shock garment was removed in segments at 15-minute intervals with documentation of vital signs before removal of each subsequent portion.
MAIN OUTCOME MEASURES: Restoration of mean arterial pressure of 70 mmHg and clearing of sensorium were considered as signs of effective resuscitation. Haemorrhage was considered controlled if the blood loss was less than 25 mL/hour. Morbidity included any complications noted in the medical chart.
RESULTS: Restoration of blood pressure and improvement of mental status occurred within 5 minutes in two patients who were pulseless and three who were unconscious or confused. All patients had improvement of mean arterial pressure to greater than 70 mmHg within 5 minutes. Duration of anti-shock garment use ranged from 12 to 36 hours and none of the six women had significant further bleeding while the anti-shock garment was in place. Patients were comfortable during use of the anti-shock garment and no adverse effects were noted apart from a transient decrease in urine output.
CONCLUSIONS: The anti-shock garment rapidly restored vital signs in women with severe obstetric shock. There was no further haemorrhage during or after anti-shock garment use and the women experienced no subsequent morbidity. A prospective randomised study of the anti-shock garment for management of obstetric haemorrhage is needed to further document these observations.

BACKGROUND: Randomized controlled trials of how best to administer fresh frozen plasma (FFP) in the presence of ongoing severe traumatic hemorrhage are difficult to execute and have not been published. Meanwhile, coagulopathy remains a common occurrence during major trauma resuscitation and hemorrhage remains a major cause of traumatic deaths, suggesting that current coagulation factor replacement practices may be inadequate.
METHODS: We used a pharmacokinetic model to simulate the dilutional component of coagulopathy during hemorrhage and compared different FFP transfusion strategies for the prevention or correction, or both, of dilutional coagulopathy. Assuming the rates of volume replacement and loss are roughly equal, we derived the hematocrit and plasma coagulation factor concentration over time based on the rate of blood loss and replacement, the hematocrit and coagulation factor concentration of the transfusate, and the hematocrit and plasma factor concentration at the time when FFP transfusion begins.
RESULTS: Once excessive deficiency of factors has developed and bleeding is unabated, 1-1.5 units of FFP must be given for every unit of packed red blood cells (PRBC) transfused. If FFP transfusion should start before plasma factor concentration drops below 50% of normal, an
FFP:PRBC transfusion ratio of 1:1 would prevent further dilution.
CONCLUSION: During resuscitation of a patient who has undergone major trauma, the equivalent of whole-blood transfusion is required to correct or prevent dilutional coagulopathy.

Hemorrhage is a major cause of trauma deaths. Coagulopathy exacerbates hemorrhage and is commonly seen during major trauma resuscitation, suggesting that current practice of coagulation factor transfusion is inadequate. Reversal of coagulopathy involves normalization of body temperature, elimination of the causes of disseminated intravascular coagulation (DIC), and transfusion with fresh-frozen plasma (FFP), platelets, and cryoprecipitate. Transfusion should be guided by clinical factors and laboratory results. However, in major trauma, clinical signs may be obscured and various factors conspire to make it difficult to provide the best transfusion therapy. Existing empiric transfusion strategies for, and prevailing teachings on, FFP transfusion appear to be based on old studies involving elective patients transfused with whole blood and may not be applicable to trauma patients in the era of transfusion with packed red blood cells (PRBCs). Perpetuation of such concepts is in part responsible for the common finding of refractory coagulopathy in major trauma patients today. In this review, we argue that coagulopathy can best be avoided or reversed when severe trauma victims are transfused with at least the equivalent of whole blood in a timely fashion.

Recombinant factor VIIa (rFVIIa) was developed in the early 1990s to provide "bypassing" hemostatic therapy for hemophilia A and B patients with inhibitors. More recently, it has been licensed for use in patients with inherited deficiency of factor VII. Since it was licensed for use in hemophilia with inhibitors in the US, Europe, and other countries for these specific indications, it has been used selectively but in a wide array of clinical settings for uncontrolled hemorrhage in individuals without an inherited bleeding disorder. Many of these uses have been described in the medical literature as case reports or small, uncontrolled series. Several randomized clinical trials (RCT) for these "off-label" medical uses have been published in recent months and will serve as the focus of this review. In particular, a review of an RCT for spontaneous intracranial hemorrhage that has demonstrated clinical efficacy in reducing both mortality and volume of central nervous system hemorrhage will be offered. A brief discussion of hypothesized physiologic mechanisms of supraphysiologic doses of rFVIIa will introduce the clinical discussion of these broad off-label uses. Since rFVIIa is a very expensive therapy, possible strategies for optimizing its use in the these settings will be presented.

OBJECTIVE: We hypothesised that patients with massive postpartum hemorrhage (PPH), defined as blood loss >1,500 ml, may benefit from the use of activated recombinant factor VII (rFVIIa).
DESIGN: Retrospective cohort study. Setting. Department of Obstetrics & Gynaecology, Dow University of Health Sciences. Population. Thirty-four women with a diagnosis of massive PPH. Methods. All patients with PPH who were admitted to the Department of Obstetrics & Gynecology and Surgical Intensive Care Unit of Civil Hospital Karachi, Pakistan, were included in the study. From March 2005 to October 2006, 34 patients fulfilled the criteria of massive PPH, of which 18 received rFVIIa to control bleeding, and 16 patients did not. Availability and cost of rFVIIa were the factors in drug allocation. Main outcome measures. Maternal mortality, correction of coagulopathy, the amount of blood products transfused and preservation of fertility.
RESULTS: Patients receiving rFVIIa had lower maternal mortality (5/18, 28% versus 8/16, 50%, OR 0.04 (0.002, 0.83)), and received a lower number of packed red cell transfusions (4.0+/-4.46 versus 9.61+/-6.7, p value 0.007), against the comparison group. Patients receiving rFVIIa had lower activated partial thromboplastin (median: 13.0; 25-75th percentile: -25.0, -8.0, signed rank p<0.0001), and lower prothrombin times (median: -8.8; 25-75th percentile: -24.2, -4.8), after administration of drug. There was no significant difference in the rate of hysterectomy between the 2 groups (11/18 (61%) versus 6/16 (38%)). No adverse event attributable to rFVIIa was observed in the study.
CONCLUSION: Activated recombinant factor VII can be a life-saving drug in patients with massive PPH.

OBJECTIVE: To determine if the timing of the administration of prophylactic oxytocin influences the incidence of postpartum hemorrhage caused by uterine atony, retained placenta, and third-stage duration.
STUDY DESIGN: Parturients who presented for vaginal delivery were randomized in a double-blinded fashion to receive oxytocin, 20 units in a 500-mL crystalloid intravenous bolus, beginning upon delivery of either the fetal anterior shoulder or placenta. For all patients, the third stage of labor was managed with controlled cord traction until placental expulsion, followed by at least 15 seconds of fundal massage. Patients were excluded if they had a previous cesarean section, multiple gestation, antepartum hemorrhage, or bleeding disorder.
RESULTS: A total of 1486 patients were enrolled: 745 in the before-placenta group and 741 in the after-placenta group. The groups were similar with respect to gestational age, fetal weight, labor duration, maternal age, parity, and ethnicity. The incidence of postpartum hemorrhage did not differ significantly between the two groups (5.4% vs 5.8%; crude OR, 0.92; 95% CI, 0.59 to 1.43). There were no significant differences between the two groups with respect to incidence of retained placenta (2.4% vs 1.6%; OR, 1.49; 95% CI, 0.72 to 3.08), or third-stage duration (7.7 minutes vs 8.1 minutes; P =.23).
CONCLUSIONS: The administration of prophylactic oxytocin before placental delivery does not reduce the incidence of postpartum hemorrhage or third-stage duration, when compared with giving oxytocin after placental delivery. Early administration, however, does not increase the incidence of retained placenta.

Postpartum hemorrhage (PPH) is one of the top 5 causes of maternal mortality in developed and developing countries. The incidence of PPH is 40% after vaginal delivery and 30% after cesarean section. Criteria for PPH are based on the amount of blood loss. In clinical obstetrics, exact measurement of blood loss is often difficult. The most important treatment of PPH is red blood cell (RBC) transfusion. In the past few years, increasing concern has arisen about this treatment. Despite the introduction of several new guidelines, transfusion criteria still vary widely between clinicians. The decision whether to prescribe RBC transfusion is mostly based on postpartum hemoglobin (Hb) values. RBC transfusion should be aimed to reduce morbidity and especially to improve health-related quality of life (HRQoL). In this review, etiology, epidemiology, treatment, and prevention of postpartum hemorrhage are described. Special attention is given to the role of RBC transfusion in the treatment of PPH and the effects of RBC transfusion on HRQoL.
TARGET AUDIENCE:: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES.: After completion of this article, the reader should be able to summarize the new guidelines related to transfusion criteria, explain the importance of reducing morbidity related to improving quality of life issues, and list infectious and noninfectious complications of a red blood cell transfusion.

Postpartum haemorrhage remains a significant complication of childbirth in the UK and worldwide. The most common cause of postpartum haemorrhage is uterine atony, but placent accreta is becoming more frequent. In these situations tamponade may be required. The successful use of the inflated stomach balloon (300ml) of a Sengstaken-Blakemore tube has been reported previously. We describe an innovative method of 'tamponade' which is simple and effective, using the Rüsch urological hydrostatic balloon catheter. In two cases of failed medical therapy for PPH, where the catheter has been tried, further surgical interventions have been avoided.

OBJECTIVE: To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada.
DESIGN: Retrospective cohort study.
SETTING: Canada between 1991 and 2004.
POPULATION: All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia).
METHODS: Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models.
MAIN OUTCOME MEASURES: Postpartum haemorrhage, postpartum haemorrhage with hysterectomy, postpartum haemorrhage with blood transfusion and postpartum haemorrhage by subtype.
RESULTS: Rates of postpartum haemorrhage increased from 4.1% in 1991 to 5.1% in 2004 (23% increase, 95% CI 20-26%), while rates of postpartum haemorrhage with hysterectomy increased from 24.0 in 1991 to 41.7 per 100,000 deliveries in 2004 (73% increase, 95% CI 27-137%). These increases were because of an increase in atonic postpartum haemorrhage, from 29.4 per 1000 deliveries in 1991 to 39.5 per 1000 deliveries in 2004 (34% increase, 95% CI 31-38%). Adjustment for temporal changes in risk factors did not explain the increase in atonic postpartum haemorrhage but attenuated the increase in atonic postpartum haemorrhage with hysterectomy.
CONCLUSIONS: There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.

Massive postpartum haemorrhage is a major cause of maternal and fetal morbidity and mortality. Management mainstays include transfusion therapy, uterotonic agents and surgery. The "off label" use of recombinant activated factor VII appears to have an evolving role in the management of massive postpartum haemorrhage refractory to conventional treatments. The current literature is reviewed.

OBJECTIVE: To accurately measure blood loss during childbirth in a developing country.
METHOD: The alkaline hematin technique was used to quantify blood lost during delivery and 24 h postpartum in 158 women in Pemba Island, Zanzibar.
RESULT: Women were found to lose less blood during childbirth and 24 h postpartum than previously reported. Compared with laboratory values, nurse-midwives approximated blood loss accurately (mean difference, i.e., mean underestimation by nurse-midwives, 4.90 mL); however, their imprecision was greater for higher laboratory values.
CONCLUSION: This study may prompt further investigation, as no comparable data exist for developing countries where maternal mortality is high and severe anemia prevalent.

Tamponade techniques using a uterine balloon in management of postpartum haemorrhage has been reported increasingly in recent years. The aim of this retrospective study is to evaluate the use of the Rusch hydrostatic balloon in the management of severe postpartum haemorrhage not controlled by medical measures. All women had risk factors for PPH. The Rusch balloon was used in all cases of PPH apart from traumatic PPH, which is considered as a contraindication for its use. The Rusch balloon was successful in seven out of the eight cases treated. We have introduced guidelines for using the Rusch balloon and they are provided in this paper.

OBJECTIVE: To evaluate the blood ordering practice and blood transfusion for Caesarean sections at our institution and to compare the estimated blood loss between anaesthetists and obstetricians.
METHODS: A review of 126 patients undergoing both elective and emergency Caesarean section was undertaken in 2002. Information collected included the number of blood units cross-matched preoperatively, type of surgery (emergency or elective), type of anaesthesia, parity of the patient, estimated blood loss by both anaesthetists and obstetricians, intraoperative and postoperative transfusion within 48 hours and pre and post operative haemoglobin (Hb) and haemocrit (Hct).
RESULTS: A total of 215 units were cross-matched for 126 patients undergoing Caesarean section delivery. A small amount (9.5%) were transfused intraoperatively and 5.5% postoperatively. The average blood loss estimated by anaesthetists was 498 +/- 176 ml and that by obstetricians was 592 +/- 222 ml. The calculated blood loss based on patients blood volume and drop in Hct was 787 +/- 519 ml. The cross-match transfusion ratio was 9.7.
CONCLUSION: Only 13% of our patients needed blood transfusion. The mean blood loss was estimated to be more by the obstetricians as compared to the anaesthetists. We recommend that the practice of routine cross-match practice prior to Caesarean section should be re-looked by institutions practicing obstetric anaesthesia.

PURPOSE: To evaluate the efficacy and safety of arterial embolization (AE) for treatment of primary postpartum hemorrhage (PPH), and the factors associated with clinical success.
MATERIAL AND METHODS: A retrospective analysis of all patients undergoing AE for primary PPH at three institutions (N = 43) from 1996 through 2007 was conducted. Patients with an antepartum diagnosis of invasive placenta were excluded from the study. Mean patient age was 31 years +/- 5 (range, 21-40 y). Eighteen women (42%) were primiparous. Delivery details, transfusion requirements, hematology and coagulation results, embolization details, and clinical outcomes were collected. Clinical success was defined as cessation of bleeding without the need for repeat embolization, laparotomy, or hysterectomy after embolization; or death. The Fisher exact test was used to analyze nonparametric data.
RESULTS: The clinical success rate was 79% (n = 34). Four patients underwent successful repeat embolization. Two of 35 patients who had not undergone hysterectomy before embolization underwent hysterectomy for continued bleeding (without repeat embolization). One underwent hysterectomy 2 weeks after AE for uterine necrosis. One of eight patients who had undergone hysterectomy before AE required a laparotomy for a large retroperitoneal hematoma, and one patient died from cerebral anoxia secondary to hypotension despite repeat embolization. Clinical success was not related to mode of delivery, cause of PPH, transfusion requirements, time from delivery to embolization, or hysterectomy before AE (P > .05). Patients with active extravasation visualized angiographically were more likely to require repeat embolization (five of 13 [38%] vs 0 of 30 without extravasation; P < .01).
CONCLUSIONS: AE for primary PPH is safe and effective. Repeat embolization may be necessary in patients with active extravasation on angiography.

Obstetrical disseminated intravascular coagulation (DIC) is usually a very acute, serious complication of pregnancy. The DIC diagnostic criteria in obstetrics (the obstetrical DIC score) help with making a prompt diagnosis and starting treatment early. These DIC diagnostic criteria, in which higher scores are given for clinical parameters than for laboratory parameters, have three components: (1) the underlying disease, (2) clinical symptoms, and (3) laboratory findings. It is justified that it is appropriate to initiate therapy for DIC when the obstetrical DIC score reaches 8 points or more before obtaining the results of coagulation tests. Management: (1) Control of the underlying disease: because prolongation of exposure to the triggering factors worsens DIC, it is important to eliminate the etiologic factors as rapidly as possible. Elimination of the cause of DIC can be easily performed in obstetrics, for example, by cesarean section. (2) Antithrombin (AT) therapy: AT monotherapy (1,500 to 3,000 units/day, 2 days) is preferably employed instead of heparin monotherapy or heparin-AT therapy because of the hemorrhagic side effects of heparin. (3) Synthetic serine protease inhibitors: continuous infusion ofgabexate mesilate (FOY) or nafamostat mesilate (FUT) is effective for DIC. Controlled multicenter trials showed a significant improvement not only in clinical response but also in platelet counts and prothrombin time (PT) in the AT group compared with the FOY group. (4) Activated protein C (APC) can inhibit thrombin generation and accelerate fibrinolytic activity. APC (5,000 to 10,000 units) is administered for 2 days in patients with placental abruption complicated by DIC. APC is a very safe, effective, and useful agent for the treatment of DIC.

OBJECTIVES: A double blind randomized controlled trial was performed at the tertiary hospital in Harare, Zimbabwe to compare oral misoprostol with intramuscular oxytocin in the management of third stage of labor.
METHODS: A total of 499 women were randomized to receive either 400 microg misoprostol orally or 10 IU oxytocin intramuscularly. The incidences of postpartum hemorrhage and side effects were examined.
RESULTS: The demographic and labor characteristics were comparable. Postpartum hemorrhage occurred in 15.2% of women given misoprostol and in 13.3% of those given oxytocin (P=0.534). Measured blood loss of more than 1000 ml occurred in 3.7% of the misoprostol group compared with 2% in the oxytocin group (P=0.237). There was no significant difference in the need for additional oxytocic drugs or blood transfusion in women given misoprostol (P values 0.137 and 0.600, respectively). Significant side effects of misoprostol were shivering [RR=1.32 (95% CI 1.11-1.58); P=0.002) and a rise in temperature [RR=2.02 (95% CI 1.75-2.33); P<0.001].
CONCLUSIONS: Oral misoprostol is as effective as intramuscular oxytocin in the prevention of PPH. Shivering and transient pyrexia were specific side effects of misoprostol. Misoprostol has potential in reducing the high incidence of PPH in developing countries.

Postpartum hemorrhage (PPH) is the main cause of maternal mortality. Yet, even though solutions have been identified, governments and donor countries have been slow to implement programs to contain the problem. While poverty and low educational level remain the underlying cause of PPH, the current literature suggests that active management of the third stage of labor can prevent it. The International Confederation of Midwives (ICM) and the International Federation of Gynecology and Obstetrics (FIGO) are attempting to address the chronic PPH crisis by educating their members on best practices and on troubleshooting where resources are inadequate. Some studies found oxytocin to be preferable to misoprostol in settings where active management is the norm. However, secondary clinical effects may prove more troublesome with oxytocin than with misoprostol, and misoprostol may prove to be more practical and equally effective in low-resource settings. Two new interventions are also proposed, the anti-shock garment and the balloon tamponade.

BACKGROUND: Excessive bleeding is one of the major threats to women at childbirth. The aim of this study was to validate estimation of blood loss during delivery.
METHODS: Bleeding was estimated after 29 elective cesarean sections and 26 vaginal deliveries and compared to blood loss measured by extraction of hemoglobin using the alkaline hematin method, according to Newton.
RESULTS: Inter-individual agreement of estimation showed good results. Estimated loss in comparison with measured loss resulted in an over-estimation. In vaginally delivered women, there was no correlation between estimated and measured blood loss (r2=0.13), and in women delivered by elective cesarean section, the correlation was moderate (r2=0.55). Agreement, according to Bland and Altman, indicated that measured blood loss could vary from 570 ml less to 342 ml more than estimated blood loss.
CONCLUSIONS: The standard procedure of estimation of obstetric bleeding was found to be unreliable. In this study, blood loss was over-estimated in cesareans. In vaginal deliveries, there seemed to be no correlation. Estimated blood loss as a quality indicator or as a variable in studies comparing complications must be used with caution. For clinical purposes, estimation of blood loss and measurement of post partum hemoglobin is of low value and may lead to the wrong conclusions.

Healthy pregnancy is accompanied by changes in the haemostatic system which convert it into a hypercoagulable state vulnerable to a spectrum of disorders ranging from venous thromboembolism to disseminated intravascular coagulation (DIC). This latter is always a secondary phenomenon triggered by specific disorders such as abruptio placentae and amniotic fluid embolism due to release of thromboplastin intravascularly or endothelial damage resulting from pre-eclampsia and sepsis. In modern obstetric practice the most common cause is haemorrhagic shock with delay in resuscitation leading to endothelial damage. The initial management of massive obstetric haemorrhage is the same whether associated with coagulopathy initially or not. Low-grade DIC, associated with pre-eclampsia, is monitored haematologically by serial platelet counts and serum fibrin degradation products (FDPs). Supportive measures and removal of the triggering mechanism are the key to successful management. Outcome depends primarily on our ability to deal with the trigger and not on direct attempts to correct the coagulation deficit

OBJECTIVE: Because postpartum hemorrhage may result from factors related to obstetrical practice patterns, we examined the variability of postpartum hemorrhage and related risk factors (obstetrical trauma, chorioamnionitis, and protracted labor) across hospital types and hospitals in California.
METHODS: Linked birth certificate and hospital discharge data from 507,410 births in California in 1997 were analyzed. Cases were identified using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes. Comparisons were made across hospital types and individual hospitals. Risk adjustments were made using 1) sample restriction to a subset of 324,671 low-risk women, and 2) Bayesian hierarchical logistic regression model to simultaneously quantify the effects of patient-level and hospital-level risk factors.
RESULTS: Postpartum hemorrhage complicated 2.4% of live births. The incidence ranged from 1.6% for corporate hospitals to 4.9% for university hospitals in the full sample, and from 1.4% for corporate hospitals to 3.9% for university hospitals in the low-risk sample. Low-risk women who delivered at government, HMO and university hospitals had two- to threefold increased odds (odds ratios 1.98 to 2.71; 95% confidence sets ranged from 1.52 to 4.62) of having postpartum hemorrhage compared to women who delivered at corporate hospitals, irrespective of patient-level characteristics. They also had significantly higher rates of obstetrical trauma and chorioamnionitis. Greater variations were observed across individual hospitals.
CONCLUSION: The incidence of postpartum hemorrhage and related risk factors varied substantially across hospital types and hospitals in California. Further studies using primary data sources are needed to determine whether these variations are related to the processes of care.

In pregnancy and puerperium disseminated intravascular coagulopathy may accompany abruptio placenta, intrauterine fetal demise with retained dead fetus, amniotic fluid embolism, endotoxin sepsis, preecalampsia with HELLP and massive transfusion. Clinical signs and symptoms of DIC can include oozing from venipuncture sites and/or mucous membranes, red cell lysis from activation of the complement system, hemorrhage from coagulopathy and possible uterine atony, hypotension from hemorrhage and/or bradykinin release, and oliguria from end-organ insult and hypovolemia/hypotension. Treatment of DIC consists of replacement of volume, blood products, and coagulation components and cardiovascular and respiratory support with elimination of underlying triggering mechanism.

BACKGROUND: Postpartum hemorrhage can become rapidly catastrophic. If medical management fails, then, according to recent reports, the use of an intrauterine inflated Foley catheter balloon for tamponade gives excellent results and can help avoid invasive procedures.
CASE: We present one case of profuse hemorrhage following evacuation of the fetus after intrauterine fetal death at 17 weeks' gestation controlled with intrauterine balloon tamponade and two cases of severe postpartum hemorrhage (one immediate and one late) following normal vaginal deliveries, both controlled with Foley catheters. In either case the patient required no blood transfusions, and major surgery was avoided.
CONCLUSION: Intrauterine balloon tamponade is highly effective. The catheter is readily available, is not expensive, does not require special training for insertion and, extremely important, can avoid major surgery.

OBJECTIVE: To develop a simulation-based curricular unit for labor and delivery teams involved in obstetric emergencies to detect and address common mistakes.
METHODS: A simulation-based curricular unit for hands-on training of four obstetric emergency scenarios was developed using high-tech mannequins and low-tech simulators. The scenarios were eclamptic seizure, postpartum hemorrhage, shoulder dystocia, and breech extraction. The obstetric teams consisted of at least one resident and two midwives. Checklists of actions expected from the teams were handed out to the course's tutors who observed the "event." All sessions were videotaped and then reviewed and analyzed by the trainees themselves, who were guided by two experienced tutors. We identified the most commonly occurring mistakes by summing up checklists and by watching the recorded sessions.
RESULTS: Between February 2004 and April 2006, 60 residents in obstetrics and gynecology and 88 midwives underwent the simulation-based course. Forty-two labor and delivery teams completed all four sessions. The most common management errors were delay in transporting the bleeding patient to the operating room (82%), unfamiliarity with prostaglandin administration to reverse uterine atony (82%), poor cardiopulmonary resuscitation techniques (80%), inadequate documentation of shoulder dystocia (80%), delayed administration of blood products to reverse consumption coagulopathy (66%), and inappropriate avoidance of episiotomy in shoulder dystocia and breech extraction (32%). Eighteen trainees were invited for repeated sessions at least 6 months after the first training day, and their scores were significantly higher in the latter sessions (79.4+/-4.3 versus 70+/-5.3 for the second and first simulated eclampsia sessions).
CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.

Over a 14-year period, the obstetric outcome of Jehovah's Witnesses in an inner city hospital was reviewed and the effect of refusal of blood on morbidity and mortality evaluated. Ninety women had 116 deliveries and of these, 24% were delivered by caesarean section, 10% had instrumental deliveries and 66% were normal vaginal deliveries. Postpartum haemorrhage of >1,000 mls occurred in 6% and postpartum anaemia was the commonest complication. The mean postdelivery haemoglobin (11.10 +/- 1.15 g/dl) was not significantly less from the mean predelivery haemoglobin level (11.81 +/- 1.62 g/dl) (P > 0.05, paired t test). The single maternal death occurred after caesarean hysterectomy, which when extrapolated, resulted in a 65-fold increased risk of maternal death compared to the national rate. The optimum management of pregnant women who decline transfusion is discussed.

Postpartum hemorrhage is a significant cause of maternal morbidity and mortality. Most postpartum hemorrhages are caused by uterine atony and occur in the immediate postpartum period. Expectant or physiologic management of the third stage of labor has been compared with active management in several studies. Active management involves administration of uterotonic medication after the delivery of the baby, early cord clamping and cutting, and controlled traction of the umbilical cord while awaiting placental separation and delivery. Good evidence shows that active management of the third stage of labor provides a better balance of benefits and harms and should be practiced routinely to decrease the risk of postpartum hemorrhage. Oxytocin, ergot alkaloids, and prostaglandins have been compared, as have timing and route of administration of these uterotonic medications. Oxytocin is the uterotonic agent of choice; it can be administered as 10 units intramuscularly or as 20 units diluted in 500 mL normal saline as an intravenous bolus, and can safely and effectively be given to the mother with the delivery of the baby or after the delivery of the placenta.

Management of the third stage of labor has been an issue of discussion, concern, and continued debate for the past two decades. Despite the many strategies employed and the divergent approaches to care and philosophies espoused, there has not been a significant, consistent reduction in the postpartum hemorrhage rates reported in industrialized countries in recent times. This article explores the strategies that have been and are currently being used in an effort to reduce the risk of postpartum hemorrhage.

Postpartum haemorrhage remains an important cause of maternal death in the developed and especially in the developing world. An appreciation of the physiological changes of pregnancy that predispose to rapid development of severe haemorrhage and DIC help maintain a level of vigilance. Although routine antenatal assessment can identify women with factors associated with an increased risk of severe postpartum haemorrhage, a significant proportion of women will develop intrapartum complications that cause severe haemorrhage. Prompt recognition and treatment of women with severe ongoing blood loss is essential to prevent morbidity and mortality. In addition to surgical correction of bleeding, replacement of plasma components to reverse coagulopathy and red cells to maintain tissues oxygenation are the basic aims of management. The haemostatic agent, recombinant Factor VIIa is a potentially useful addition to management of massive, life-threatening obstetric haemorrhage but its safety and efficacy remains untested in clinical trials.

BACKGROUND AND OBJECTIVE: Massive post-partum haemorrhage continues to be one of the world's leading causes of maternal morbidity and mortality. Any new treatment that potentially helps at risk parturients should be thoroughly investigated. Recombinant factor VIIa (rVIIa) is increasingly being used in the treatment of massive haemorrhage. We performed a case-matched analysis of its use since 2003 in the treatment of massive post-partum haemorrhage at our hospital.
METHODS: Twenty-eight cases of massive post-partum haemorrhage were identified over a 3-yr period since 2003. In six of these cases, rVIIa was used as part of their management. Six case-matched controls were sought. The six women with the greatest requirement for packed red cell transfusion who also had a deranged prothrombin time were included. The groups were then compared for differences. The worst prothrombin time in each group was noted as was the best prothrombin time within 6 h, this was used as our measure of response to treatment.
RESULTS: There was no statistical difference in age, gestation, parity, transfusion requirements, mode of delivery or the severity of the coagulopathy between the two groups. In both groups the prothrombin time improved with management. There was no significant difference in either the magnitude of the improvement in the value of the prothrombin time or the absolute value of the best prothrombin time (P = 0.09). Five out of the six women in the rFVIIa group had normal or low prothrombin times within 6 h yet only one woman who did not receive rFVIIa had a normal prothrombin time within 6 h though this was not significant (P = 0.08).
CONCLUSIONS: This case-matched analysis supports the management of massive post-partum haemorrhage with appropriate resuscitation, surgical intervention and use of blood and blood products. This study does not support the routine use of rFVIIa in the management of massive obstetric haemorrhage. rFVIIa may have a role to play in this management but further studies and analyses will be required

Major obstetric hemorrhage remains the leading cause of maternal mortality and morbidity worldwide, and is associated with a high rate of substandard care. A well-defined and multidisciplinary approach that aims to act quickly and avoid omissions or conflicting strategies is key. The most common etiologies of hemorrhage are abruptio placenta, placenta previa/accreta, uterine rupture in the antepartum period and retained placenta, uterine atony, and genital-tract trauma in the postpartum period. Basic treatment of postpartum hemorrhage relies on manual removal of the placenta or manual exploration of the uterus plus bladder emptying and oxytocin administration. If this does not arrest bleeding, or if there is any suspicion of genital-tract trauma, examination of the vagina and cervix with appropriate valves and analgesia/anesthesia must follow quickly. Postpartum uterine atony resistant to oxytocin must be treated with prostaglandin within 15 to 30 minutes; uterine balloon tamponade can be also useful at this stage. Aggressive transfusion therapy and resuscitation are mandatory in major obstetric hemorrhage. Specific invasive treatment must be considered within no more than 30 to 60 minutes, if previous measures have failed-and even earlier in some particular etiologies. The two main options are radiologic embolization and surgical artery ligations. Recombinant factor VIIa may also be considered, but should not delay the performance of a life-saving procedure such as embolization or surgery. Hysterectomy must be implemented when all other interventions have failed.

OBJECTIVE: To compare the effect of non-pneumatic anti-shock garment (NASG) on blood loss from obstetric haemorrhage with standard management of obstetric haemorrhage.
DESIGN: Observational study of consecutive obstetric haemorrhage cases before and after introduction of the NASG.
SETTING: Four tertiary care maternity facilities in Egypt.
SAMPLE: The sample consisted of women with obstetric haemorrhage and signs of shock and the entry criteria were: >750 mL of blood loss and either pulse of >100 beats per minute or systolic blood pressure of <100 mmHg. A total of 158 women were in the preintervention group and 206 in the postintervention group.
METHODS: All the women with haemorrhage meeting the eligibility criteria were treated according to the standard protocol for 4 months (May-August 2004); blood loss was measured and recorded. The NASG was then introduced, and all the women meeting the eligibility criteria were treated according to the standard haemorrhage protocol plus the NASG for 4 months (September-December 2004).
MAIN OUTCOME MEASURES: Measured blood loss collected in a closed-end, graduated, plastic, under buttocks collection drape.
RESULTS: Median measured blood loss in the drape following study entry was 50% lower in those treated with the NASG (250 versus 500 mL, P < 0.001). There was also a non-statistically significant decrease in morbidity and mortality.
CONCLUSIONS: This is the first comparative study of the NASG with a standard obstetric haemorrhage treatment protocol. The NASG shows promise for management of obstetric haemorrhage, particularly in lower resource settings. Larger studies will be needed to determine if the NASG contributes to statistically significant decreases in morbidity and mortality.

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

Annually, over 500,000 women die from complications of pregnancy and childbirth; the majority die from hemorrhage and shock. Obstetrical hemorrhage of all etiologies, such as uterine atony, ruptured uterus, and ruptured ectopic, can cause massive blood loss resulting in severe shock. Unless women can access fluid replacement, blood transfusions, and, often, surgery, the shock leads to organ failure and death. Therefore, the majority of maternal hemorrhage deaths occur in developing countries. The non-pneumatic anti-shock garment (NASG) is a light-weight, reusable, neoprene and Velcro compression device that can be rapidly applied to a hemorrhaging woman to shunt blood from the lower extremities to the core organs, heart, lung and brain, and to decrease blood loss. We review literature on the history, mechanisms of action, and use of Anti-Shock Garments (ASGs) in emergency medicine, focusing on the use of inflatable or Pneumatic ASGs (PASGs) for obstetrical, gynecological, and urological hemorrhage. We describe similarities and differences between the PASG and the newer NASG. We then review recent studies on the NASG for obstetrical hemorrhage in Pakistan, Nigeria, and Egypt, and conclude with recommendations for the types of research necessary to bring the NASG into wider use.

Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure b100 mm Hg or pulse N100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5± 93.9 mL, compared with 340.4±248.2 mL pre- intervention (Pb0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.

Obstetric haemorrhage is one of the leading causes of maternal mortality. In many lowresource settings, delays in transport to referral facilities and in obtaining lifesaving treatment, contribute to maternal deaths. The non-pneumatic anti-shock garment (NASG) is a low-technology pressure device that decreases blood loss, restores vital signs, and has the potential to improve adverse outcomes by helping women survive delays in receiving adequate emergency obstetric care. With brief training, even individuals without medical backgrounds can apply this first-aid device. In this secondary analysis of hospital data from a pre-post intervention study in Egypt (N
/364 women with obstetric haemorrhage and shock), 158 received standard care, while 206 received standard care plus the NASG. The NASG significantly reduced blood loss, time to recovery from shock, and, for those with postpartum haemorrhage due to uterine atony who received oxytocin, the NASG had a significant effect on blood loss independent of oxytocin. These results indicate that the NASG may be a valuable innovation for reducing maternal mortality in low-resource settings. Testing at community and household levels will be necessary in order to determine whether the NASG can help women survive the longest delays.

BACKGROUND: Primary postpartum haemorrhage (PPH) is one of the top five causes of maternal mortality in both developed and developing countries.
OBJECTIVES: To assess the effectiveness and safety of pharmacological, surgical and radiological interventions used for the treatment of primary PPH.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2006).
SELECTION CRITERIA: Randomised controlled trials comparing pharmacological, surgical techniques and radiological interventions for the treatment of PPH.
DATA COLLECTION AND ANALYSIS: We assessed studies for eligibility and quality, and extracted data, independently. We contacted authors of the included studies for more information.
MAIN RESULTS: Three studies (462 participants) were included. Two placebo-controlled randomised trials compared misoprostol (dose 600 to 1000 mcg) with placebo and showed that misoprostol use was not associated with any significant reduction of maternal mortality (two trials, 398 women; relative risk (RR) 7.24, 95% confidence interval (CI) 0.38 to 138.6), hysterectomy (two trials, 398 women; RR 1.24, 95% CI 0.04 to 40.78), the additional use of uterotonics (two trials, 398 women; RR 0.98, 95% CI 0.78 to 1.24), blood transfusion (two trials, 394 women; RR 1.33, 95% CI 0.81 to 2.18), or evacuation of retained products (one trial, 238 women; RR 5.17, 95% CI 0.25 to 107). Misoprostol use was associated with a significant increase of maternal pyrexia (two trials, 392 women; RR 6.40, 95% CI 1.71 to 23.96) and shivering (two trials, 394 women; RR 2.31, 95% CI 1.68 to 3.18).One unblinded trial showed better clinical response to rectal misoprostol compared with a combination of syntometrine and oxytocin. We did not identify any trial dealing with surgical techniques, radiological interventions or haemostatic drugs for women with primary PPH unresponsive to uterotonics. AUTHORS'
CONCLUSIONS: There is insufficient evidence to show that the addition of misoprostol is superior to the combination of oxytocin and ergometrine alone for the treatment of primary PPH. Large multi-centre, double-blind, randomised controlled trials are required to identify the best drug combinations, route, and dose of uterotonics for the treatment of primary PPH. Further work is required to assess the best way of managing women who fail to respond to uterotonics therapy.

Postpartum haemorrhage remains in the top five causes of maternal deaths in both developed and developing countries. Persistent blood loss of more than 1000 ml should prompt predetermined measures to achieve resuscitation and haemostasis. A protocol including guidelines is given and volume replacement is discussed. The range of medical and surgical interventions that may be considered for the modern management of major haemorrhage unresponsive to oxytocin and ergometrine are presented. The review discusses in depth the use of misoprostol, recombinant activated factor VII, the uterine tamponade procedures, artery ligation, and uterine haemostatic suturing techniques. It also evaluates the place of interventional radiology and hysterectomy in modern obstetrics.

Every year, about 210 million women become pregnant. Postpartum hemorrhage (PPH) is one of the major complications of pregnancy, accounting for 14 million cases annually. Of these, it is estimated that around 140,000 women die, resulting in a case fatality rate of 1%. PPH is defined by WHO as a blood loss > or = 500 mls. Most instances of PPH occur suddenly and without warning even in women without any of the known risks for this condition. If women do not receive timely medical treatment, as is often the case in many parts of the world, death can occur within two hours. The chance of receiving a safe blood transfusion as part of the therapy for PPH varies enormously from country to country, depending on whether a safe blood transfusion program has been set up as a part of the national health policy. The increasing realization of the potential deleterious effects of blood transfusion, including exposure to HIV and other viral agents, has changed the practices that were previously acceptable for the transfusion of blood, as has the recent recognition of specific patients who will benefit from a single unit of blood. In countries with limited resources, where a majority of women have anemia at the onset of their pregnancies, the slightest deviation from normality during labor and/or delivery leading to excessive hemorrhage can put a women's life at risk. In these instances, the patient needs urgent resuscitation, stabilization and transfer to a nearby center. Available blood, preferably typed cross matched and screened for infections, should be given until the patient receives specific treatment. This is especially true in bled- out obstetrics patients, where one unit may make the difference between a near death state and the possibility of slow recovery and survival.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of a combination of surgical interventions for control of postpartum hemorrhage.
STUDY DESIGN: At cesarean delivery, patients with persistent bleeding from uterine atony after the administration of oxytonics were treated with the placement of a B-Lynch suture. When the B-Lynch failed, subsequent placement of an intrauterine Bakri balloon followed. This combination is termed the uterine sandwich.
RESULTS: The uterine sandwich was successful for all 5 patients undergoing this approach. The median nadir hematocrit was 21.1% (range 20.1% to 28%). The balloon was in place for a median duration of 11 hours (range 10-24 hours). The median volume infused into the balloon was 100 mL (range 60-250 mL). No complications were observed.
CONCLUSION: Placing an intrauterine Bakri balloon in conjunction with the B-Lynch uterine compression suture was successful in treating uterine atony.

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery.
METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures.
RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (-5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).
CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement.
CLINICAL TRIAL REGISTRATION: (www.ClinicalTrials.gov), NCT00381056
LEVEL OF EVIDENCE: I.

Our objective was to compare oral misoprostol with intramuscular oxytocin in the prevention of postpartum haemorrhage. Four hundred and ninety-six women were randomised to receive either 600 microg misoprostol orally or 10 IU oxytocin intramuscularly after delivery. There were no significant differences between the misoprostol and oxytocin groups with regard to the incidence of postpartum haemorrhage (1% vs. 0% respectively, relative risk (RR) 3.02, 95% confidence interval (CI) 0.32-28.88) or drop in haemoglobin concentration (0.71 g/dl vs. 0.68 g/dl, respectively, P = 0.699). The length of the third stage of labour and the percentage of women requiring manual removal of placenta, further oxytocics or blood transfusion were also similar. Shivering was significantly higher with misoprostol (57% vs. 14%; RR 4.06, CI 2.93-5.62), but there were no differences in other side effects. We conclude that oral misoprostol can replace intramuscular oxytocin in reducing postpartum haemorrhage in low-risk women, in developing countries, especially as it is administered orally and it is thermostable in tropical conditions.

CONTEXT: The US Food and Drug Administration (FDA) licensed recombinant human coagulation factor VIIa (rFVIIa) on March 25, 1999, for bleeding in patients with hemophilia A or B and inhibitors to factors VIII or IX. Use in patients without hemophilia has been increasing since licensure.
OBJECTIVE: To review serious thromboembolic adverse events (AEs) reported to the FDA's Adverse Event Reporting System (AERS). DESIGN, SETTING,
AND PATIENTS: The AERS database was reviewed from March 25, 1999, through December 31, 2004, for thromboembolic AE reports with rFVIIa. The AERS database includes US and non-US spontaneous AE reports from both approved (specific indications for patients with hemophilia) and unlabeled uses. It also includes serious AEs in patients enrolled in postlicensure clinical trials who received rFVIIa. Manufacturer reporting to FDA is mandatory, but primary notification from clinicians and others to FDA or manufacturers is voluntary for spontaneous reports; therefore, AERS underrepresents actual event occurrences.
MAIN OUTCOME MEASURE: Reported thromboembolic events occurring in patients administered rFVIIa.
RESULTS: A total of 431 AE reports for rFVIIa were found, of which 168 reports described 185 thromboembolic events. Seventeen events occurred in patients with hemophilia and 59 occurred in patients enrolled in postlicensure trials. Unlabeled indications accounted for 151 of the reports, most with active bleeding (n = 115). Reported AEs were thromboembolic cerebrovascular accident (n = 39), acute myocardial infarction (n = 34), other arterial thromboses (n = 26), pulmonary embolism (n = 32), other venous thromboses (including deep vein thrombosis) (n = 42), and clotted devices (n = 10). In 36 (72%) of 50 reported deaths, the probable cause of death was the thromboembolic event. In 144 patients with timing information, 73 events (52%) occurred in the first 24 hours after the last dose (30 events within 2 hours). Sixty-four reports (38%) noted concomitant use of hemostatic agents. Most reports lacked sufficient information to evaluate potential dosage associations.
CONCLUSIONS: Most reported thromboembolic AEs followed the use of rFVIIa for unlabeled indications and occurred in arterial and venous systems, often resulting in serious morbidity and mortality. Analysis of the relationship between AEs and rFVIIa is hindered by concomitant medications, preexisting medical conditions, confounding by indication, and inherent limitations of passive surveillance. Randomized controlled trials are needed to establish the safety and efficacy of rFVIIa in patients without hemophilia.

OBJECTIVE: To compare the effect of prophylactic use of oxytocin and ergometrine in management of the third stage of labor.
METHODS: A prospective randomized study of 600 women assigned to receive either oxytocin or ergometrine in the third stage of labor. Outcome measures were the predelivery and 48-hour postdelivery hematocrit, duration of the third stage, specific side effects, and incidence of postpartum hemorrhage. Statistical analyses were done using the t test for continuous variables and chi(2) test for categorical variables. The level of significance was set at P<0.05.
RESULTS: There were no significant differences between the 2 groups in maternal age, gestational age, duration of third stage, birth weights, risk for retained placenta, manual removal of placenta, or need for additional oxytocics. Patients in the ergometrine group were at significant risk for nausea, vomiting, headaches, and elevated blood pressure (P=0.0001).
CONCLUSION: Oxytocin is as effective as ergometrine at reducing the incidence of postpartum hemorrhage, but without the undesirable side effects of nausea, vomiting, and elevated blood pressure associated with ergometrine.

OBJECTIVE: To determine the long-term sequelae of pelvic embolization for postpartum hemorrhage and to study the effect on fertility and menses.
METHODS: Twenty-eight consecutive patients who underwent pelvic embolization for postpartum hemorrhage between the years 1977 and 2002 were included in the study. Chart review and telephone interviews were conducted to gather data regarding the type of delivery, causative factors of the bleeding, preembolization treatments, total blood loss, length of time between delivery and embolization, complications, long-term side effects, and subsequent pregnancies.
RESULTS: The average (+/- standard deviation) time to follow-up was 11.7 +/- 6.9 years. The most common causes of hemorrhage were vaginal/cervical laceration, placenta accreta, and placenta previa. In only one case was the embolization unsuccessful, during which there was an accidental perforation of an internal iliac artery resulting in a retroperitoneal hematoma and subsequent total abdominal hysterectomy. All of the interviewed patients that desired to get pregnant after embolization were able to do so. Six patients reported a total of six uncomplicated pregnancies and deliveries in the years after their embolization. Of the remaining patients interviewed, none made subsequent attempts to get pregnant. The most commonly reported long-term side effects were transient buttock numbness (n = 2) and urinary frequency (n = 2). In no patients were the side effects severe enough to seek further medical attention.
CONCLUSION: Pelvic arterial embolization is a safe and effective procedure and offers patients a fertility-preserving alternative to hysterectomy for treatment of intractable postpartum hemorrhage.

Bilateral iliac artery ligation is an effective second-line procedure to control massive obstetric and gynaecological haemorrhage, it is life-saving in certain cases and has the advantage that it preserves fertility, which is particularly important in young women of low parity. Bilateral ligation of internal iliac arteries is a life-saving procedure in cases of massive obstetric haemorrhage. It has the advantage of preserving fertility compared with the commonly performed emergency obstetric hysterectomy. It has also proved effective in cases of secondary pelvic haemorrhage in gynaecological operations. We report here a case series of 11 women who had bilateral internal iliac artery ligation for severe pelvic haemorrhage in a period of 10 years in our department. Ten of them were obstetric cases and one was a case of haemorrhage following vaginal hysterectomy. The outcome was favourable in 10 out of the 11 cases and there was only one case of massive postpartum haemorrhage where the procedure failed and required an emergency hysterectomy

OBJECTIVE: To compare (1) visual estimation of postpartum blood loss with estimation using a specifically designed blood collection drape and (2) the drape estimate with a measurement of blood loss by photospectrometry.
METHODS: A randomized controlled study was performed with 123 women delivered at the District Hospital, Belgaum, India. The women were randomized to visual or drape estimation of blood loss. A subsample of 10 drape estimates was compared with photospectrometry results.
RESULTS: The visual estimate of blood loss was 33% less than the drape estimate. The interclass correlation of the drape estimate to photospectrometry measurement was 0.92.
CONCLUSION: Drape estimation of blood loss is more accurate than visual estimation and may have particular utility in the developing world. Prompt detection of postpartum hemorrhage may reduce maternal morbidity and mortality in low-resource settings.

available soon...

Most maternal deaths occur to women who are not attended by trained health professionals. Postpartum hemorrhage is the single most common cause of maternal death. The delivery of large haemochorial placenta in our species predisposes to heavy bleeding and can be dealt with only by using effective uterotonics. The 1987 Safe Motherhood Initiative has failed to reduce maternal mortality significantly, and shortages of trained personnel will not be remedied in the foreseeable future. Bold new policies are imperative and need to be derived from an appropriate evidence base. It is suggested that these should include the low-cost shock garments in primary health facilities and making misoprostol easily accessible in both the public and private sector.

OBJECTIVE: To compare current practices for the active management of the third stage of labor (AMTSL) with the use of 600 mug of oral misoprostol.
METHODS: An operations research study was designed to compare blood loss with current AMTSL practices and misoprostol use.
RESULTS: Women in the misoprostol group were less likely to bleed 500 ml or more (adjusted odds ratio, 0.30; 95% confidence interval, 0.16-0.56) compared with those in the current practices group. In the current practices group 73% women required interventions because of postpartum hemorrhage, compared with 11% in the misoprostol group.
CONCLUSION: In situations where oxytocin and or ergometrine are not consistently and appropriately used during third stage of labor, misoprostol should be considered for inclusion in the AMTSL protocol.

BACKGROUND: Expectant management of the third stage of labour involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. Active management involves administration of a prophylactic oxytocic before delivery of the placenta, and usually early cord clamping and cutting, and controlled cord traction of the umbilical cord.
OBJECTIVES: The objective of this review was to assess the effects of active versus expectant management on blood loss, post partum haemorrhage and other maternal and perinatal complications of the third stage of labour.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register.
SELECTION CRITERIA: Randomised trials comparing active and expectant management of the third stage of labour in women who were expecting a vaginal delivery.
DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by the reviewers.
MAIN RESULTS: Five studies were included. Four of the trials were of good quality. Compared to expectant management, active management (in the setting of a maternity hospital) was associated with the following reduced risks: maternal blood loss (weighted mean difference -79.33 millilitres, 95% confidence interval -94.29 to -64.37); post partum haemorrhage of more than 500 millilitres (relative risk 0.38, 95% confidence interval 0.32 to 0.46); prolonged third stage of labour (weighted mean difference -9.77 minutes, 95% confidence interval -10.00 to -9. 53). Active management was associated with an increased risk of maternal nausea (relative risk 1.95, 95% confidence interval 1.58 to 2.42), vomiting and raised blood pressure (probably due to the use of ergometrine). No advantages or disadvantages were apparent for the baby.
CONCLUSIONS: Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).

Ongoing bleeding from patients who have an acquired coagulopathy post-surgery is a common problem. Strategies that are available to combat this problem revolve around the replacement of coagulation factors, platelets, and red blood cells as necessary. These strategies are not always successful and a more direct approach to activating the coagulation system can be more effective and in some instances life saving. We describe the use of recombinant factor VIIa in a patient with ongoing post partum bleeding.

BACKGROUND: Amniotic fluid embolism (AFE) is a rare syndrome that can complicate pregnancy and labor. It often has debilitating and lethal consequences. One serious sequela of AFE is disseminated intravascular coagulation (DIC).
CASE: This report describes an atypical presentation of AFE manifested by sudden fetal bradycardia and complicated by maternal DIC. The DIC was eventually successfully treated with the use of recombinant activated factor VIIa.
CONCLUSION: The use of recombinant activated factor VIIa in cases of massive hemorrhage, such as in our patient, is controversial but has been shown, in some cases, to reverse DIC and be successful. The use of recombinant activated factor VIIa should be considered in patients with massive obstetric hemorrhage in whom standard measures of stabilization are unsuccessful.

Jehovah's Witnesses are primarily known to physicians for their refusal of blood transfusions. Conflict arises at times with the medical staff concerning how best to manage their care. This article will begin with a brief description of the beliefs of Jehovah's Witnesses and will then recommend specific clinical strategies highlighting newer potential therapies according to the principles of bloodless medicine. The scenarios of bleeding and acute and chronic anemia will be discussed in detail for the care of these patients refusing red blood cell transfusions. An update in the use of blood substitutes will be mentioned as well as the surgical advances used today that can minimize blood loss for all patients. The experience of organ transplantation in Jehovah's Witnesses will be detailed. Further resources for physicians with questions in the care of these patients will be listed. Stressed throughout the article will be the need for a team approach and good communication between physicians to successfully care for their patients who are Jehovah's Witnesses.

OBJECTIVE: To analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion.
POPULATION AND METHODS: Retrospective cohort study from a database in one high-risk obstetric unit over a 7-year period.
RESULTS: In a cohort of 19,204 deliveries, 44 patients were transfused of whom five were given frozen fresh plasma only. Of the 39 who received red blood cells, 35 received at least three units. Multivariate analysis of postpartum hemorrhage risk factors revealed a significant role of placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease. Nevertheless 28% of women transfused had none of these risk factors.
CONCLUSION: The percentage of patients transfused has probably decreased markedly with improved prevention, surveillance and treatment. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion justifies special obstetrical and anesthetic management.

BACKGROUND: Placenta accreta is a rare event in pregnancy and may cause life-threatening hemorrhage. This obstetric complication is a diagnostic and management challenge. When the condition is diagnosed, medical management is usually employed first for hemostasis. If the bleeding cannot be controlled, conservative surgical management is attempted, but hysterectomy is often required for definitive care.
CASE: The diagnosis of placenta accreta was made intraoperatively at cesarean section undertaken for breech presentation. The placenta was densely adherent to the anterior lower uterus. Severe hemorrhage, which resulted from attempts to manually remove it, was treated with oxytocin, carboprost tromethamine and methylergonovine without success. The uterus was everted to provide access to the placental site, which was excised; the myometrial defect was sutured closed. Three Foley balloons were used to provide uterine tamponade. Methotrexate was administered prophylactically. These measures effectively controlled the hemorrhage.
CONCLUSION: Because placenta accreta might not be diagnosed antepartum or during labor, especially when no risk factors are present, adequate preparations cannot be made. If it is diagnosed at the time of cesarean section, a combined conservative approach may prove helpful in controlling bleeding and avoid hysterectomy and hypovolemia.

We reviewed all cases of massive primary postpartum haemorrhage greater than 1000 mL over a six month period in 1999 to establish the incidence, identify aetiological factors and implement change. Fifty-four cases (1.7%) were identified. We classified four as 'near-miss' maternal mortality. Over 60% were delivered by caesarean section. Seventy-six percent were due to uterine atony, 9% due to genital tract trauma and 15% were associated with significant antepartum haemorrhage from placenta praevia or abruption. No obvious labour or delivery risk factors were identified but deviation from hospital guidelines was common. Following revision of the guidelines, dissemination to staff and use of practice drills, we repeated the study on a prospective basis over the same time period in 2002. There was a significant reduction in the incidence of massive postpartum haemorrhage to 0.45%, and 100% adherence to the guidelines which resulted in a significant reduction in maternal morbidity. We believe that this approach can be replicated in other units.

We reviewed all cases of massive primary postpartum haemorrhage greater than 1000 mL over a six month period in 1999 to establish the incidence, identify aetiological factors and implement change. Fifty-four cases (1.7%) were identified. We classified four as ‘near-miss’ maternal mortality. Over 60% were delivered by caesarean section. Seventy-six percent were due to uterine atony, 9% due to genital tract trauma and 15% were associated with significant antepartum haemorrhage from placenta praevia or abruption. No obvious labour or delivery risk factors were identified but deviation from hospital guidelines was common. Following revision of the guidelines, dissemination to staff and use of practice drills, we repeated the study on a prospective basis over the same time period in 2002. There was a significant reduction in the incidence of massive postpartum haemorrhage to 0.45%, and 100% adherence to the guidelines which resulted in a significant reduction in maternal morbidity. We believe that this approach can be replicated in other units.

OBJECTIVE: To assess the validity of obstetric complications, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Core Measure on perineal lacerations, in the California Patient Discharge Data Set.
METHODS: We randomly sampled 1,611 deliveries from 52 of the 267 hospitals that performed more than 678 eligible deliveries in California in 1992-1993. We compared hospital-reported complications against our recoding of the same records.
RESULTS: Third- and fourth-degree perineal lacerations were reported accurately, with estimated sensitivities exceeding 90% and positive predictive values exceeding 65% (weighted to account for the stratified sampling design) or 85% (unweighted). Based on in-depth review of discrepant cases, we estimate the actual positive predictive value at over 90%. Most coding discrepancies were between no injury and first degree, or between first and second degree. Most postpartum complications, including urinary tract and wound infections, endometritis, anesthesia complications, and postpartum hemorrhage were reported with less than 70% sensitivity, but at least 80% positive predictive value. Composite measures from HealthGrades and Solucient, which include these complication codes, also suffer from high false-negative rates.
CONCLUSION: Third- and fourth-degree perineal lacerations are accurately reported on hospital discharge abstracts, confirming the validity of related quality indicators sponsored by the Agency for Healthcare Research and Quality and JCAHO. Administrative data seem less useful for monitoring other in-hospital postpartum complications.

OBJECTIVE: To evaluate risks for intraoperative or postoperative packed red blood cell transfusion in women who underwent cesarean delivery.
METHODS: This was a 19-university prospective observational study. All primary cesarean deliveries from January 1, 1999, to December 31, 2000, and all repeat cesareans from January 1, 1999, to December 31, 2002, were included. Trained, certified research nurses performed systematic data abstraction. Primary and repeat cesarean deliveries were analyzed separately. Univariable analyses were used to inform multivariable analyses.
RESULTS: A total of 23,486 women underwent primary cesarean delivery, of whom 762 (3.2%) were transfused (median 2 units, 25th% to 75th% 2-3 units). A total of 33,683 women underwent repeat [corrected] cesarean delivery, and 735 (2.2%) were transfused (median 2 units, 25th% to 75th% 2-4 units). Among primary cesareans, general anesthesia (odds ratio [OR] 4.2, 95% confidence interval [CI] 3.5-5.0), placenta previa (OR 4.8, CI 3.5-6.5) and severe (hematocrit less than 25%) preoperative anemia (OR 17.0, CI 12.4-23.3) increased the odds of transfusion. Among repeat cesareans, the risk was increased by general anesthesia (OR 7.2, CI 5.9-8.7), a history of five or more prior cesareans (OR 7.6, CI 4.0-14.3), placenta previa (OR 15.9, CI 12.0-21.0), and severe preoperative anemia (OR 19.9, CI 14.5-27.2).
CONCLUSION: Overall, the risk of transfusion in association with cesarean is low. However, both severe preoperative maternal anemia and placenta previa are associated with markedly increased risks. The former argues for optimizing maternal antenatal iron status to avoid severe anemia and the latter for careful perioperative planning when previa complicates cesarean.
LEVEL OF EVIDENCE: II-2

Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits.
TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians Learning.
OBJECTIVES: After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

Recombinant activated factor VII (rFVIIa, NovoSeven) was used in three patients with massive obstetric hemorrhage due to placenta previa accreta, rupture of the uterus and pre-eclampsia with HELLP. Administration of the drug markedly decreased the bleeding and enabled control of the hemorrhage. rFVIIa seems to be an adjunctive hemostatic measure for the treatment of severe obstetric hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions.
METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage.
RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization.
CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates.

OBJECTIVE: To review practice of massive primary postpartum haemorrhage management and develop a protocol.
METHODS: Cross-sectional study conducted at the Department of Obstetrics and Gynaecology at Aga Khan University Hospital, Karachi between January 1, 2003 and July 31, 2004. Women with primary postpartum haemorrhage and had blood loss > or = 1000ml were included in the study. Medical record files of these women were reviewed for maternal mortality and morbidities which included mode of delivery, possible cause of postpartum haemorrhage, supportive, medical and surgical interventions.
RESULTS: Approximately 3% (140/4881) of women had primary postpartum haemorrhage. 'Near miss' cases with blood loss > or = 1500ml was encountered in 14.37% (20/140) of these cases. Fifty-six percent (18/32) of the women who had massive postpartum haemorrhage delivered vaginally. Uterine-atony was found to be the most common cause, while care in High Dependency Unit (HDU) was required in 87.5% (28/32) of women. In very few cases balloon tamponade (2-cases) and compression sutures (2-cases) were used. Hysterectomy was performed in 4-cases and all of them encountered complications. Blood transfusions were required in 56% of women who had massive postpartum haemorrhage.
CONCLUSION: This study highlights the existence variable practices for the management of postpartum haemorrhage. Interventions to evaluate and control bleeding were relatively aggressive; newer and less invasive options were underutilized. Introduction of an evidence-based management model can potentially reduce the practice variability and improve the quality of care.

OBJECTIVE: The study was aimed to identify obstetric risk factors for early postpartum hemorrhage (PPH) in singleton gestations and to evaluate pregnancy outcome.
STUDY DESIGN: A comparison between consecutive singleton deliveries with and without early PPH was performed. Deliveries occurred during the years 1988-2002 in a tertiary medical center. A multivariate logistic regression model was constructed in order to define independent risk factors for PPH.
RESULTS: Postpartum hemorrhage complicated 0.4% (n = 666) of all deliveries enrolled in the study (n = 154 311). Significant risk factors for PPH, identified using a multivariable analysis, were: retained placenta (OR 3.5, 95%CI 2.1-5.8), failure to progress during the second stage of labor (OR 3.4, 95%CI 2.4-4.7), placenta accreta (OR 3.3, 95%CI 1.7-6.4), lacerations (OR 2.4, 95%CI 2.0-2.8), instrumental delivery (OR 2.3, 95%CI 1.6-3.4), large for gestational age (LGA) newborn (OR 1.9, 95%CI 1.6-2.4), hypertensive disorders (OR 1.7, 95%CI 1.2-2.1), induction of labor (OR 1.4, 95%CI 1.1-1.7) and augmentation of labor with oxytocin (OR 1.4, 95%CI 1.2-1.7). Women were assigned into three different groups according to the assessed severity of PPH, assuming that the severe cases were handled by revision of the birth canal under anesthesia, and the most severe cases required in addition treatment with blood products. A significant linear association was found between the severity of bleeding and the following factors: vacuum extraction, oxytocin augmentation, hypertensive disorders as well as perinatal mortality, uterine rupture, peripartum hysterectomy and uterine or internal iliac artery ligation (p < 0.001 for all variables).
CONCLUSION: Hypertensive disorder, failure to progress during the second stage of labor, oxytocin augmentation, vacuum extraction and LGA were found to be major risk factors for severe PPH. Special attention should be given after birth to hypertensive patients, and to patients who underwent induction of labor or instrumental delivery, as well as to those delivering LGA newborns.

OBJECTIVE: The purpose of this study was to determine the rates of obstetric hemorrhage and maternal mortality in women who are Jehovah's Witnesses and to evaluate a protocol that uses erythropoietin to optimize the red blood cell mass before delivery.
STUDY DESIGN: Obstetric outcomes were described for all of the women who were Jehovah's Witnesses and who delivered at Mount Sinai Medical Center during an 11-year period. The risk of maternal death was compared with our general obstetric population during this interval.
RESULTS: A total of 332 women who were Jehovah's Witnesses had 391 deliveries. An obstetric hemorrhage was experienced in 6% of this population. There were 2 maternal deaths among the women who were Jehovah's Witnesses, for a rate of 512 maternal deaths per 100,000 live births versus 12 maternal deaths per 100,000 live births (risk ratio, 44; 95% CI, 9-211). Erythropoietin was associated with a nonsignificant increase in hematocrit level.
CONCLUSION: Women who are Jehovah's Witnesses are at a 44-fold increased risk of maternal death, which is due to obstetric hemorrhage. Patients should be counseled about this risk of death, and obstetric hemorrhage should be aggressively treated, including a rapid decision to proceed to hysterectomy when indicated.

OBJECTIVE: When 2 maternal deaths due to hemorrhage occurred at New York Hospital Queens in 2000-2001, a multidisciplinary team implemented systemic change. Our objective was to improve outcomes of episodes of major obstetric hemorrhage.
METHODS: We report outcomes before (2000-2001) and after (2002-2005) the introduction of a patient safety program aimed at improving the care of women with major obstetric hemorrhage. Process changes were instituted in late 2001 at the direction of a multidisciplinary patient safety team. A rapid response team was formulated using the cardiac arrest team as a model. Protocols for early diagnosis, assessment, and management of patients at high risk for major obstetric hemorrhage were developed and communicated to staff.
RESULTS: There were significant increases in cesarean births (P < .001), repeat cesarean births (P = .002), and cases of major obstetric hemorrhage (P = .02) between the periods of 2000-2001 and 2002-2005. There was a significant improvement in mortality due to hemorrhage (P = .036), lowest pH (P = .004), and lowest temperature (P < .001) when comparing 2000-2001 with 2002-2005. There were no differences in measures of severity of obstetric hemorrhage between the 2 periods, including Acute Physiology and Chronic Health Evaluation II scores, occurrence of placenta accreta and estimated blood loss.
CONCLUSION: Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.

OBJECTIVE: To assess the use of B-Lynch type uterine compression sutures as an alternative to hysterectomy for severe postpartum hemorrhage (PPH) due to uterine atony.
METHODS: The use of uterine compression sutures for severe postpartum hemorrhage was reviewed over a 30-month period (January 2000 June 2002) in a tertiary obstetric unit.
RESULTS: In 7 cases of uterine atony at the time of Caesarean section, which were unresponsive to all oxytocic agents, a B-Lynch type compression suture was used before resorting to hysterectomy. In 6 of the 7 women, the bleeding was controlled with the suture, while the other required hysterectomy.
CONCLUSION: At the time of writing there were 6 reports in the literature involving a total of 20 women who were successfully treated with this type of compression suture for severe atonic PPH. Our review adds 7 cases and found that the B-Lynch compression suture is easy to apply and should be considered in cases of severe atonic PPH when oxytocic agents fail, and before resorting to hysterectomy.

Objective: the primary objective of these guidelines is to review the clinical aspects of Postpartum Haemorrhage (PPH) and provide guidelines to help clinicians prevent and manage excessive bleeding postpartum. Options: prevention, appropriate intervention, keys to minimiz- ing its impact. Outcomes: establish practices to facilitate the identification of women who may be at particularly high risk of PPH and to allow prompt intervention should excessive bleeding occur Evidence: follows the Qualify of Evidence of The Canadian Task Force on the Periodic Health Examination. Values: developed by experts in the field of obstetrics. Benefits, harms and costs: the use of uterotonic drugs and other active management techniques have been evaluated based on their convenience, accuracy, availability and safety Recommendations: the 12 recommendations listed in the guidelines have been graded according to the level of evi- dence on which they are based Validation: Medline references were sought using the MeSH heading postpartum haemorrhage.The Cochrane Library was searched for relevant studies.The ALARM course Manual was consulted. Sponsors: developed and reviewed by the Clinical Practice Obstetrics Committee and approved by the Council of the SOGC.

This article describes the need for mock emergency drills in perinatal emergencies such as shoulder dystocia, maternal hemorrhage, and emergency cesarean section. Effective drills are a patient safety initiative to reduce medical errors and adverse events during the antepartum, intrapartum, and postpartum periods. Successful strategies are identified from other fields of practice to improve patient outcomes. Realistic, institutional specific scenarios for mock emergency drills result in improved team behaviors leading to better outcomes for mothers and infants.

The management of acute massive blood loss is considered and a template guideline is formulated, supported by a review of the key literature and current evidence. It is emphasized that, if avoidable deaths are to be prevented, surgeons, anaesthetists, haematologists and blood-bank staff need to communicate closely in order to achieve the goals of secure haemostasis, restoration of circulating volume, and effective management of blood component replacement.

BACKGROUND: Postpartum haemorrhage (PPH) is one of the major contributors to maternal mortality and morbidity worldwide. Active management of the third stage of labour has been proven to be effective in the prevention of PPH. Syntometrine is more effective than oxytocin but is associated with more side-effects. Carbetocin, a long-acting oxytocin agonist appears to be a promising agent for the prevention of PPH.
OBJECTIVES: To determine if the use of oxytocin agonist is as effective as conventional uterotonic agents for the prevention of PPH, and assess the best routes of administration and optimal doses of oxytocin agonist.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 2), MEDLINE (1966 to June 2006) and EMBASE (1974 to June 2006). We checked references of articles and communicated with authors and pharmaceutical industry.
SELECTION CRITERIA: Randomised controlled trials which compared oxytocin agonist (carbetocin) with other uterotonic agents or with placebo or no treatment for the prevention of PPH.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality.
MAIN RESULTS: Four studies (1037 women) were included in the review (three studies on caesarean delivery and one on vaginal delivery). The risk of PPH was similar in both oxytocin and carbetocin arms for participants who underwent caesarean delivery as well as participants, with risk factor(s) for PPH, who underwent vaginal delivery. Use of carbetocin resulted in a statistically significant reduction in the need for therapeutic uterotonic agent (relative risk (RR) 0.44, 95% confidence interval (CI) 0.25 to 0.78) compared to oxytocin for those who underwent caesarean section, but not for vaginal delivery. Carbetocin is also associated with a reduced need for uterine massage in both caesarean and vaginal deliveries (RR 0.38, 95% CI 0.18 to 0.80; RR 0.70, 95% CI 0.51 to 0.94) respectively. However, this outcome measure was only documented in one study on caesarean delivery and in the only study on vaginal delivery. Pooled data from the trials did not reveal any statistically significant differences in terms of the adverse effects between carbetocin and oxytocin. AUTHORS'
CONCLUSIONS: There is insufficient evidence that 100 micrograms of intravenous carbetocin is as effective as oxytocin to prevent PPH. In comparison to oxytocin, carbetocin was associated with reduced need for additional uterotonic agents, and uterine massage. There was limited comparative evidence on adverse events.

ABSTRACT Background: Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health (CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population. Methods: We performed an Obstetric Anaesthetists’ Association (OAA) approved postal survey of all UK consultant-led obstetric anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and invited comments and samples of systems already in use. Results: The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed and implemented a system locally and submitted it to the OAA for consideration. Conclusions: The survey results support CEMACH recommendations for a nationally agreed obstetric EWS. c 2009 Elsevier Ltd. All rights reserved. Keywords: Obstetric Early Warning Systems

Life-threatening post-partum haemorrhage (PPH) occurs with a frequency of 1 per 1000 deliveries in the developed world. In the 1994-1996 Triennial Confidential Enquiry into Maternal Deaths in the United Kingdom primary PPH was responsible for five deaths. In this chapter we discuss briefly the assessment and initial medical management of the patient with primary PPH but concentrate on the surgical management where medical treatment has failed. The surgical management discussed includes both traditional or long-established management strategies together with newer, less radical surgical options, such as embolization techniques, uterine compression sutures and methods involving uterine tamponade, which are less hazardous to perform and have the advantage of preserving reproductive function. The recommendations of the reports from the Confidential Enquiries into Maternal Deaths in the UK are summarized at the end of the chapter. Copyright 2002 Elsevier Science Ltd.

This review describes disseminated intravascular coagulation (DIC) as a syndrome in which hemostatic factors are activated. The syndrome ranges in severity from a decompensated coagulopathy (overt-DIC) to the subclinical compensated activation of hemostatic factors (nonovert DIC). The first part of this review emphasizes two points. First, activation of the hemostatic system is controlled by a vast network of capillaries and venules through anticoagulant and anti-inflammatory regulatory factors that operate from the endothelium (e.g., protein C and thrombomodulin, tissue factor pathway inhibitor). These hemostatic regulators can be overridden by procoagulant disorders such as amniotic fluid embolism or degraded by proinflammatory disorders such as sepsis. Second, because this link between the microvascular endothelium and circulating hemostatic factors is so close, even a relatively mild disturbance of the microvasculature targeted by the inflammatory process may be reflected systemically by changes in molecular biomarkers of hemostatic activity. Therefore, application of criteria for the diagnosis of nonovert DIC should be of value in detecting a compensated response to inflammatory stress of the microvasculature in patients who are at risk before they develop an uncompensated over DIC response and organ failure. The second part of this review covers the recent experience investigators have had in diagnosing and following the response of patients to treatment with biomarkers.

Placenta percreta is a rare but potentially life-threatening condition associated with high maternal mortality and morbidity rates, usually arising from severe obstetric haemorrhage. Due to rising caesarean section rates, an increase in the incidence of morbidly adherent placentas (accreta, increta and percreta) has been observed. Various treatment strategies have been employed in different centres, ranging from performing a caesarean hysterectomy at the time of delivery to leaving the placenta in situ, with or without adjuvant internal iliac and uterine arterial embolisation and/or methotrexate therapy. In the case of placenta percreta, irrespective of the treatment method employed, women are still at high risk of life-threatening haemorrhage and morbidity secondary to placental invasion beyond the confines of the uterine serosa into surrounding organs, most commonly the bladder. We describe an unusual case of a partially adherent placenta percreta in which partial separation of the normally implanted placenta led to torrential haemorrhage on the third postoperative day after the placenta was left in situ at the time of delivery. We therefore advise caution in following a conservative approach in the treatment of cases of placenta percreta in which the percreta feature is only partial and will discuss the merits and disadvantages of alternative options.

To test the hypotheses that: (1) standard definitions of common obstetric terms exist and (2) frontline workers in daily obstetric practice have common understandings of these terms, we undertook (a) a review of definitions for nine common terms from latest editions of standard texts and resources, and (b) an exploratory questionnaire survey of these definitions applied in a work setting among four groups; trainee and consultant obstetricians, student and qualified midwives (five of each). Definitions for nine selected obstetric terms in common use (labour, parity, precipitate labour, primary postpartum haemorrhage, primiparity, PROM, secondary postpartum haemorrhage, term and viability) were inconsistent in standard texts. Obstetric staff had no agreed perception of the precise definitions. There is a potentially hazardous lack of clarity about obstetric terms, and a need to develop standard definitions. This would benefit students, practitioners, information technology experts and, most importantly, patients.

BACKGROUND: Visual blood loss estimation often underestimates blood loss. In this study we sought to determine the effect of calibrated drape markings on blood loss estimation in a simulated vaginal delivery.
METHODS: Subjects were randomized to estimate simulated blood loss (300, 500, 1000, and 2000 mL) in calibrated or noncalibrated vaginal delivery drapes and then crossover.
RESULTS: Visual blood loss estimation with noncalibrated drapes underestimated blood loss, with worsening accuracy at larger volumes (16% error at 300 mL to 41% at 2000 mL). The calibrated drape error was <15% at all volumes.
CONCLUSIONS: Calibrated vaginal delivery drapes improve blood loss estimation.

BACKGROUND: Visual blood loss estimation often underestimates blood loss. In this study we sought to determine the effect of calibrated drape markings on blood loss estimation in a simulated vaginal delivery.
METHODS: Subjects were randomized to estimate simulated blood loss (300, 500, 1000, and 2000 mL) in calibrated or noncalibrated vaginal delivery drapes and then crossover.
RESULTS: Visual blood loss estimation with noncalibrated drapes underestimated blood loss, with worsening accuracy at larger volumes (16% error at 300 mL to 41% at 2000 mL). The calibrated drape error was <15% at all volumes.
CONCLUSIONS: Calibrated vaginal delivery drapes improve blood loss estimation.

OBJECTIVE: Depending on the country and the publications, post-partum hemorrhage (PPH) is either the first or second cause of maternal death in the world, including in developed countries. It remains a significant source of morbidity, severe anemia, blood transfusion, transfusion complications, acquired coagulation disorders and hemostasis hysterectomy. Visual assessment underestimates the amount of blood loss in around 45% of cases. Emergency treatment is therefore sometimes undertaken with some delay, giving time for Disseminated Intravascular Coagulation (DIC) to occur, which worsens the prognosis. A collecting plastic bag put under the pelvis of the mother just after delivery is a quantitative and objective method of measuring blood loss. The objective was to assess sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), studying correlation between bag's volume and hemoglobin and hematocrit variation.
MATERIALS AND METHODS: Included outpatients were women with unique pregnancy at term. Breech presentations were excluded. We measured serum hemoglobin and hematocrit just after admission for labor. A collecting bag, placed under the pelvis of each woman just after birth, was weighted after delivery. Serum hemoglobin and hematocrit were again assessed at three days. Post-partum hemorrhage was defined by a fall of hematocrit more than 10 points (delta Ht), or by a fall of hemoglobin more than 3g/dL (delta Hb).
RESULTS: From January 2003 to May 2003, 272 patients were included. 8.9% of the results were unuseful (n=24). The mean volume of blood loss was 190 ml (5th p=29 ml, 10th p=48 ml, 90th p=610 ml, 95th p=824 ml). The mean delta Ht was 2.7 +/- 4 pts (16.5 / -4.8). The mean delta Hb was 1.2 +/- 1.4 g/dL (5.9 / -1.5). For a delta Ht=10 the calculated bag volume was 564 ml. With this cut off we noted 5.5% PPH (n=15) prevalence=0.06. Sensitivity=34.21%. Specificity=99%. PPV=86%. NPV=90.38%. For a delta Hb=3 the calculated bag volume was 486 ml. With this cut off we noted 10.7% PPH (n=24) prevalence of PPH=0.1. Sensitivity=38.77%. Specificity=95.96%, PPV=67. 85%. NPV=87.7%.
CONCLUSION: The collecting pelvis bag is a rapid and precise procedure to diagnose PPH in the delivery room. It also enables a visual and quantitative non-subjective estimation of blood loss. Because of its simplicity and very low cost, the collecting pelvis bag should be used widely as a routine preventive measure. [Article in French]

The B-Lynch surgical technique for the management of massive postpartum hemorrhage (PPH) has been used successfully since 1989 in cases where bleeding was secondary to uterine atony with failed conservative management. It allows for conservation of the uterus for subsequent menstrual function and pregnancies. In this report, we present a follow up of a case with successful pregnancy ten years after PPH was managed with the B-Lynch uterine compression suture to demonstrate the long-term anatomical consequences of this operation. This case represents the longest follow up after the application of the B-Lynch suture (brace suture) technique for the control of massive PPH as an alternative to hysterectomy. Published data have confirmed that on the balance of probability, the B-Lynch surgical technique is safe, effective and free of short- and long-term complication.

OBJECTIVE: To determine the risk of maternal mortality and serious maternal morbidity because of major obstetric haemorrhage in Jehovah's witnesses in The Netherlands.
DESIGN: A retrospective study of case notes.
SETTING: All tertiary care centres, general teaching hospitals and other general hospitals in The Netherlands.
SAMPLE: All cases of maternal mortality in The Netherlands between 1983 and 2006 and all cases of serious maternal morbidity in The Netherlands between 2004 and 2006.
METHODS: Study of case notes using two different nationwide enquiries over two different time periods.
MAIN OUTCOME MEASURES: Maternal mortality ratio (MMR) and risk of serious maternal mortality.
RESULTS: The MMR for Jehovah's witnesses was 68 per 100,000 live births. We found a risk of 14 per 1000 for Jehovah's witnesses to experience serious maternal morbidity because of obstetric haemorrhage while the risk for the total pregnant population was 4.5 per 1000.
CONCLUSIONS: Women who are Jehovah's witnesses are at a six times increased risk for maternal death, at a 130 times increased risk for maternal death because of major obstetric haemorrhage and at a 3.1 times increased risk for serious maternal morbidity because of obstetric haemorrhage, compared to the general Dutch population.

OBJECTIVE: To assess the effects of prophylactic misoprostol use in the third stage of labor compared with injectable uterotonics or placebo or no treatment.
DATA SOURCES: The Cochrane Pregnancy and Childbirth Group trials register; the Cochrane Library, including databases such as the database of systematic reviews and the Cochrane Controlled Trials Register; and MEDLINE were searched. Researchers in the field were also contacted. The date of the latest search was March 1, 2002.
METHODS OF STUDY SELECTION: Randomized trials comparing misoprostol with injectable oxytocin or oxytocin-ergot preparations to prevent postpartum hemorrhage or placebo/no treatment as active management of the third stage of labor were eligible for inclusion. Eligibility and trial quality were assessed following selected criteria. Data were extracted and analyzed using RevMan software. TABULATION, INTEGRATION,
AND RESULTS: Sixteen randomized trials with a total of 28,138 women were considered. Data were available for 27,498 women. Oral misoprostol (600 microg) is less effective than injectable uterotonics in reducing blood loss at least 1000 mL (relative risk [RR] 1.36, 95% confidence interval [CI] 1.17, 1.58) and increases the use of additional uterotonics. Shivering and pyrexia (temperature greater than 38C) are the main side effects of misoprostol and are dose related. Compared with injectable uterotonics, the RR of "any shivering" with misoprostol (600 microg) is 3.27 (95% CI 3.01, 3.56) and pyrexia is 6.96 (95% CI 5.65, 8.57). The RR of blood loss of 500 mL or more is 1.11 (95% CI 0.87, 1.43) and the RR of use of additional uterotonics is 1.80 (1.13, 2.85) in the three trials (1441 women) comparing rectal misoprostol (400 microg) with injectable uterotonics.
CONCLUSION: Injectable oxytocin or oxytocin-ergot preparations are more effective than misoprostol as part of the active management of the third stage of labor.

OBJECTIVE: To compare the efficacy and side effects of sublingual misoprostol and intravenous methylergometrine for active management of third stage of labor.
METHOD: One hundred twenty low risk pregnant women at term with spontaneous onset of labor were included in the study. The women were randomized to receive either two tablets of misoprostol (200 microg/tablet) sublingually or 1 ml of methylergometrine (200 microg) intravenous injection, after the delivery of the anterior shoulder of the baby. The main outcome measures were: need for additional oxytocic drugs, blood loss >or=500 ml, change in hemoglobin levels and side effects.
RESULTS: Postpartum hemorrhage as defined by hemorrhage >or=500 ml occurred in 3.1% of the women in the sublingual misoprostol group but none of the women in the methylergometrine group (P > 0.05). There was a need for additional oxytocic drugs in 5.0% and 8.3% after methylergometrine and misoprostol, respectively (P > 0.05). The change in hemoglobin levels at 24 h postpartum were 0.8 and 0.7 gm% in methylergometrine and misoprostol group, respectively(P > 0.05). In the misoprostol group, 6.6% women developed fever >or=38 degrees C and 21.6% had shivering while in methylergometrine group none experienced these side effects. However, the incidence of other side effects like nausea, vomiting, headache and giddiness were similar in both groups.
CONCLUSION: Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.

Recombinant activated coagulation factor VII (rFVIIa) was developed initially for treatment of patients with hemophilia and neutralizing antibodies ("inhibitors") to coagulation factors VIII or IX. Owing to the unique and selective mechanism of action of rFVIIa and encouraged by clinical experience with other circumstances of inadequate hemostasis, a broad development program has been pursued to test potential efficacy and evaluate safety of this biologic for indications other than hemophilia. This review summarizes the current development of rFVIIa, focusing on results of prospective, randomized clinical trials.

BACKGROUND: The European Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.
OBJECTIVES: The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth.
DESIGN: Survey of policies.
SETTING: The project was a European collaboration, with participants in 14 European countries.
SAMPLE: All maternity units in 12 countries and in selected regions of two countries in Europe.
METHODS: A postal questionnaire was sent to all or a defined sample of maternity units in each participating country.
MAIN OUTCOME MEASURES: Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage.
RESULTS: Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable.
CONCLUSIONS: Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

PURPOSE OF REVIEW: Haemorrhage remains a cause of significant maternal morbidity and mortality. This review summarizes the prevention, management and treatment of obstetric haemorrhage and highlights recent advances and developments.
RECENT FINDINGS: Postpartum haemorrhage is the most common cause of major obstetric haemorrhage and is usually due to uterine atony. Pharmacological treatment has not altered much in recent years with oxytocin and ergometrine remaining first-line options. Although controversy surrounds its advantages over other uterotonics, the use of misoprostol has been increasing, especially in resource-poor countries. Placenta accreta is becoming more common, a sequelae to the rising caesarean section rate. Interventional radiology may reduce blood loss in these cases. Uterine compression sutures, intrauterine tamponade balloons and cell salvage have all made their debut in the last decade.
SUMMARY: Accurate diagnosis and appropriate management of obstetric haemorrhage can reduce maternal morbidity and mortality. This review outlines the current evidence.

OBJECTIVE: To report an 8-year institutional experience in the use of the B-Lynch Suture for the management of postpartum hemorrhage (PPH).
STUDY DESIGN: Cases with B-Lynch suture utilization for severe postpartum hemorrhage were identified, from March 1997 to March 2005, at White Memorial Medical Center. Case charts were reviewed, and postoperative follow-up after hospital discharge was conducted by telephone interview and outpatient clinic chart review. Historical characteristics and outcome of these patients are described.
RESULTS: B-Lynch suture was performed on 22 patients, between March 1997 and March 2005, to control intractable PPH at cesarean section that did not respond to uterotonic agents. In 12 instances, the B-Lynch suture was the only intervention, whereas in 10 it was combined with vessel ligation. The procedure resulted in control of bleeding with uterine preservation in 77% of the cases. In those cases where the etiology of PPH was uterine atony, the B-Lynch suture was successful in 85% of the cases. Hysterectomy was avoided in 17/22 cases.
CONCLUSION: The B-Lynch suture is an alternative surgical procedure for uterine preservation that may be used to control postpartum hemorrhage from uterine atony.

OBJECTIVE: To describe the incidence of three conditions of acute severe maternal morbidity in selected regions in nine European countries.
DESIGN: A population-based questionnaire survey.
SETTING: Eleven regions in nine countries of Europe.
POPULATION: All the pregnant women in each region who had delivered during the period covered by the study.
METHODS: Standard definitions of three severe obstetric conditions, pre-eclampsia, postpartum haemorrhage and sepsis were established by a steering committee. A common questionnaire was used in each participating country. The incidence of the three obstetric conditions and characteristics of the study women were compared.
MAIN OUTCOME MEASURES: Incidence of three severe obstetric conditions: pre-eclampsia, postpartum haemorrhage and sepsis.
RESULTS: The study identified 1734 women with at least one of the three conditions, with 847 experiencing severe haemorrhage, 793 experiencing severe pre-eclampsia and 142 experiencing severe sepsis. There were wide variations in incidence of three conditions combined, ranging from 14.7 per thousand deliveries in Brussels, Belgium to 6.0 per thousand deliveries in Upper Austria.
CONCLUSIONS: This study sets a simple and straightforward approach to the definition of three severe obstetric conditions and allows population-based comparisons between developed countries in Europe, even though difficulties may have been present with applying the definition across countries. The reported incidence of these severe obstetric conditions in general and severe haemorrhage varied significantly between countries. Overall, severe haemorrhage in particular was the most common of the three conditions, followed closely by severe pre-eclampsia.

The most common causes of maternal death are pregnancy induced hypertension (PIH), embolism, and obstetrical hemorrhage. Obstetrical hemorrhage is known as the most preventable cause of maternal mortality. Hemorrhage accounted for 15.25% of all reported maternal mortalities in New York State between 2003 and 2005. Ninety seven percent (97%) of all hemorrhage deaths occurred while women were hospitalized. These deaths spanned all socioeconomic classes and, in addition to the deaths, an even larger number of "near misses", women who had severe hemorrhages but survived, were reported. Because most of the deaths from hemorrhage occur in the hospital, and because it is a highly preventable cause of death, New York State and New York City Health Departments, in collaboration with American College of Obstetricians and Gynecologists (ACOG), District II/NY, have sent clinical recommendations and a poster for labor/delivery or surgical suite staff to all hospitals with obstetric services in the state. Access to educational slide sets on prevention of maternal death through improved management of hemorrhage is available at this site.

This is the website for the Wisconsin Association for Perinatal Care and the Perinatal Foundation, and is an information source for perinatal health care professionals and consumers alike. The specific link provides resources related to protocols and management of postpartum hemorrhage, including case studies, case-scenario drills, drill checklists, B-Lynch suture diagrams and more.

A reasonable trigger tool for nursing charting on L&D. From: Appendix to Saving Mother's Lives (2007); also published in: International Journal of Obstetric Anesthesia (2006) 15, S1-S43 Abstracts of free papers presented at the annual meeting of the Obstetric Anaesthetists? Association, Glasgow 11-12 May, 2006. “Early-warning scoring in obstetrics”. P Harrison, C Hawe, F McIlveney. Department of Anaesthesia, Stirling Royal Infirmary, Stirling, UK.