OBSTETRICS AND GYNECOLOGY FOR PRACTITIONERS
MANAGEMENT OF POSTPARTUM HAEMORRHAGIE

1. Call additional personnel (nurses, junior nurses, hospital attendants) and anesthesiologist.

2. Make an order to perform connection to a vein and begin infusion of saline (0,9% sodium chloride)
         In case of massive bleeding, perform connections to more than one vein and begin infusion of saline

3. Perform sequentially following     manipulations: Drain urinary bladder Perform outer massage of the uterus Perform manual inspection of the uterine cavity and outer-inner massage of the uterus Put ice pack on lower part of the abdomen Perform examination of maternal passages and suture ligation of all ruptures Place a tampon with ether into rear fornix of vagina or put fenestrated clamps on the parametrium (by Baksheev) or put a suture on the cervix (by Lositskaya) In case of massive bleeding perform pressing of abdominal aorta (it can be performed immediately after manual examination of uterine cavity)

3. Immediately after manual examination of uterine cavity     make an order to inject intravenously: Uterotonic medications (oxytocin 5 IU, methylergobrevine 0.2 mg, misoprostol), Injections of oxytocin and methylergobrevine may be repeated each 15-30 min. Misoprostol may be given sublingually or per rectum up to 800 micrograms. All these medications have different mechanisms of action. Therefore all of them can be used if one has no effect Calcium chloride or gluconate 10% 10 ml singly: by bolus intravenous injection or dissolved into 100 ml of saline by continuous intravenous infusion Fibrinolytics inhibitors (Aprotinin: Gordox, Contrycal, Trasylol) by bolus intravenous injections, first injection is performed with 2 ampules (20000 KIU), and it can be repeated each 5-10 min until bleeding is stopped. Drugs stimulating primary haemostasis: Ethamsylate 12.5% - 4-6 ml by bolus intravenous injection, a dose can be repeated after 30 min Eptacog alpha (NovoSeven; recombinant coagulation factor 7а) inject in dependence on severity of haemorrhagie from 1 (60 KIU) to 3 (180 KIU) doses, it may be repeated after 2 hours, then intervals between injections can be expanded from 3 up to 8-12 hours Tranexamic acid 0.25-0.5 g intravenously by bolus injection (maximal daily dose is 2 g) FEIBA (from 50 to 100 KIU per kg of body mass; do not exceed a single dose 100 KIU per kg and daily dose 200 KIU per kg) intravenously by bolus injection

4. Continue intravenous infusion of saline and begin to infusion plasma-substituting solutions (solutions of hydroxyethyl starch), fresh frozen plasma, erythrocyte mass or blood

5. Glucocorticoids (prednisolone 30-60 mg, dexamethasone 4-8 mg) for shock prophylaxis

6. In case of decrease of arterial blood pressure below 70 millimeters of mercury, dose of glucocorticoids should be augmented.
         If arterial blood pressure did not rise up to 80-90 millimeters of mercury begin intravenous infusion of dopamine. Arterial blood pressure should be maintained at least at 80-90 millimeters of mercury

Estimate constantly:

• Skin, mucous (pale, cyanotic - shock)
• Arterial blood pressure (falling - shock)
• Pulse (tachycardia, arrhythmia, cardiac arrest)
• Lungs status (shortness of breath, wheezes?, bronchial sounds, lung edema)

Mount catheter in the bladder and examine urination (oliguria, anuria, acute renal failure) until patient is transferred to postpartum department

Drain uterine cavity from blood cloths by outer massage of the uterus (periodically) or by vacuum aspiration (single), especially in patients after planned cesarean section

If volume of bloodless reach 1 liter, you have to think about preparation of operation room and passing to surgical approaches of treatment

Surgical approaches:

• Selective embolization of arteries of small pelvis or uterine arteries
• Ligation of uterine arteries (uterine edge at the level of inner uterine mouth is sutured by absorbable thread through vessels-free area of broad ligament of the uterus; to check before tie a knot that the ureter is not in the suture; do not cut sutured uterine vessels)
• Ligation of inner iliac arteries (cut uterine round ligament and open lateral wall of the pelvis; move the ureter medially and find the bifurcation of common iliac artery by separating of the peritoneum with surrounding tissue. Try does not touch surrounding inner iliac vein, very carefully take inner iliac artery before dividing into anterior and posterior branches with curved clamps and then suture it with two non-absorbable threads)
• Amputation or extirpation of the uterus

To note! This protocol is based on real practice performing in maternity hospitals of our city (Cheboksary, Russia).
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