[Anesthesiologists at the initial stage of postpartum hemorrhage]

Abstract

Objectives: To describe the best practices for management of postpartum hemorrhage (PPH) after vaginal delivery at its initial stage by anesthesiologists.

Methods: Medline, the Cochrane Library, and international guidelines have been exhaustively analyzed, graded, and discussed by the members of the scientific committee.

Results: Early recognition of PPH relies on either a perceived or a quantified blood loss of 500mL and over (using a collecting bag), or the presence of clinical signs of shock (hypotension, tachycardia, tachypnea, altered mental status) (professional consensus). Precise timing of the diagnosis of PPH must be annotated (professional consensus). Once the diagnosis is established, appropriate senior professionals, including the anesthesiologist at the early stage, must be called in. The cornerstones of initial resuscitation are restoration of blood volume and oxygen carrying capacity, achieved, with adequate intravenous access, initially with crystalloids, associated with oxygen by facemask (professional consensus). Initial resuscitation is performed, and its efficiency is assessed by continuous monitoring and hemoglobin bedside tests (Hemocue(®)). Adequate anesthetic technique must be performed to enable the obstetricians to perform a diagnostic procedure (manual removal of placenta, uterine revision), and to most frequently obtain the cessation of bleeding. Hemodynamic stability is required for loco-regional anesthesia, while on the other hand, general anesthesia with rapid sequence induction and intubation is recommended (professional consensus). Anesthesiologists must anticipate in case of failure of initial measures, including in alerting the blood transfusion service and calling for additional help (professional consensus).

Conclusions: Adequate management of postpartum hemorrhage (PPH) requires multidisciplinary combined and simultaneous actions. After early recognition, five components are undertaken simultaneously: communication, resuscitation, monitoring, investigating the cause of bleeding, and controlling or stopping the bleeding. Bleeding is usually stopped within 30min in 70 to 80% of cases.

Keywords: Anesthesia; Anesthésie; Hypovolemia; Hypovolémie; Hémorragies du post-partum; Monitorage; Monitoring; Postpartum haemorrhage; Remplissage vasculaire; Volume replacement.