MOH and PPH

Selected Guideline Examples Date
ROTEM Protocol  October 2019
Obs Cymru PPH Checklist
October 2019
RPH Management of Massive Obstetric Haemorrhage March 2017
Lancashire Guideline
What We Liked
  • Clear pathway to escalate 
  • Estimated time taken to crossmatch blood and where to find O negative blood
  • Highlights need to avoid hypothermia and consideration of thromboprophylaxis
  • Mentions use of IOCS
What We Didn't Like
  • Resuscitation only, ie immediate management
  • Delayed administration of tranexamic acid
  • No mention of potential need for invasive monitoring 
  • No discussion of RA vs GA in MOH
Not Sure
  • 1:1 ratio of PRC:FFP; not in line with ObsCymru research
Yorkshire Guideline
What We Liked
  • Highlight underestimation of blood loss and concealed haemorrhage
  • Summary of causes including sepsis
  • Need for situational awareness and good communication between team members
  • Mention of increased haematocrit of PRC so can use more crystalloid to resuscitate
  • Discussion of optimal modes of anaesthesia – RA vs GA
  • Advise temperature measurement; target Hb, plt count etc
  • Mention management of Jehovah’s Witness patient
What We Didn't Like
  • No mention of point of care testing (although may not be available in this unit)
  • No mention of antibiotic therapy
UHCW Guideline
What We Liked
  • Contemporaneous documentation by dedicated member of staff (suggest midwife)
  • Team leader to ensure protocol followed
  • Complications of resuscitation including pulmonary oedema and coagulopathy
  • Anticipation and prediction of bleeding
  • Surgical management and interventional radiology mentioned
What We Didn't Like
  • A lot of information, more like a textbook than a guideline, including details of insertion of intraosseous needle and mechanism of action of drugs – would not be easy to use in emergency
  • Need to stress that all women who decline blood products should be seen by consultant obstetrician and anaesthetist antenatally
Not sure
  • Consultant obstetrician and anaesthetist to do all cases if increased risk of bleeding
    Other Comments
    • Note there were different definitions of MOH and triggers for protocols between units (1-2 litres)
    • All mention POC testing including Haemocue, TEG/ROTEM if available on their unit
    • All mention warming patient including using warm fluids and blood products
    • Should encourage use of 4:4:1 replacement in line with current evidence
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