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Chapter 4: HaemorrhageChapter 4: HaemorrhageJ Norman (on behalf of the Centre for Maternal and Child Enquiries)University of Edinburgh Centre for Reproductive Biology, The Queens Medical Research Institute, Edinburgh, UKCorrespondence: Professor Jane Norman, Chair of Maternal and Fetal Health, University of Edinburgh Centre for Reproductive Biology, TheQueens Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK. Email: jane.norman@ed.ac.uk. Keywords obstetric haemorrhage, Confidential Enquiry, maternal,mortality.Obstetric haemorrhage: specific recommendation• Despite the decline in numbers this triennium, obstetric haemorrhage remains an important cause of maternal death.All units should have protocols in place for its identification and management, and all clinicians responsible for thecare of pregnant women, antenatally, postnatally and intrapartum, including those practicing in the community,should carry out regular skills training for such scenarios.• Early senior multidisciplinary team involvement is essential in the management of major obstetric haemorrhage.• All clinicians should be aware of the guidelines for management of women who refuse blood transfusion.• The welcome absence of deaths in relation to elective caesarean section for placenta praevia in this Report endorsesthe recommendations in earlier Reports that senior staff should be involved in these deliveries.• The recommendation in the previous Report that ‘All women who have had a previous caesarean section must havetheir placental site determined. If there is any doubt, magnetic resonance imaging (MRI) can be used along with ultrasoundscanning in determining if the placenta is accreta or percreta’ needs to be restated, as scans for placental localisationsite in women with previous caesarean sections are still sometimes not being performed.• Women delivered by caesarean section should have regular observations of pulse and blood pressure for the first24 hours after delivery recorded on a Modified Early Obstetric Warning score (MEOWS) chart. Abnormal scores onMEOWS should be investigated and acted upon immediately.• The Royal College of Obstetricians and Gynaecologists (RCOG) recommend that women with major placenta praeviawho have previously bled should be admitted and managed as inpatients from 34 weeks of gestation. Those withmajor placenta praevia who remain asymptomatic, having never bled, require careful counselling before contemplatingoutpatient care. Women with major placenta praevia who elect to remain at home should have the risks explained tothem and ideally require close proximity with the hospital.Obstetric haemorrhage: learningpointsAnaemia magnifies the effects of obstetric haemorrhage.Antenatal anaemia should be diagnosed and treatedeffectively: parenteral iron therapy should be consideredantenatally for women with iron deficiency anaemiawho do not respond to oral iron.Moderate or excessive traction on the cord before placentalseparation is inappropriate. The appropriate initialmanagement of uterine inversion is attemptedreplacement.Any decision to give women blood should be madecarefully, and all clinicians involved in blood transfusionshould be aware of the potential adverse effects of transfusionand signs and symptoms of transfusion-relatedcomplications.Women known to be at risk of major haemorrhage, e.g.those with placenta accreta and those who decline bloodand blood products, should be delivered in maternityunits with access to critical care, interventional radiologyand cell salvage.ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 71