ESTIMATION OF BLOOD LOSS

1. Visual assessment
- is “notoriously” inaccurate and clinicians can underestimate blood loss by 50%.
Standard definitions of postpartum haemorrhage, that is, >500 ml after vaginal
delivery and >1000 ml after cesarean section, do not adequately reflect the clinical
response of the patient.

2. Hematocrit
- immediate Hct will not reflect the actual blood loss. Even a blood loss of 1000 ml
will reflect a fall in Hct of only 3% in the 1st hr.
3. Urine output
- being sensitive to changes in blood volume, can give an early indication of changes
in renal perfusion and hence perfusion of other organs.

4. Pulse oximetry
- an imperfect tool in the haemodynamically unstable patient.

INDICATIONS OF BLOOD TRANSFUSION IN OBSTETRICS

a. Severe anemia
 Blood transfusion is life-saving for severely anemic patients presenting in the
last 4 weeks of pregnancy to combat hemorrhage that may complicate delivery. It is
important to ensure that the total blood volume is not increased as this may precipitate
cardiac failure/pulmonary edema. To avoid any added strain on the heart, packed cells
are transfused very slowly with simultaneous administration of a diuretic such as
furosemide, which helps to maintain a negative fluid balance. This patient is kept in
propped up position and oxygen inhalation is given if required.

b. Obstetric hemorrhage

 Antepartum hemorrhage
Management would depend on the type and severity of the
hemorrhage. Initial management involves rapid assessment of maternal
hemodynamic status and the rate of continuing blood loss, followed by a fetal
assessment. Patients should have a large bore (14–16 gauge) intravenous line
established and depending on the amount of blood loss, fluid replacement
should commence. With continued bleeding at least four units of blood should
be cross matched. Baseline hemoglobin and hematocrit levels should be
obtained.

 Postpartum hemorrhage
The incidence of postpartum anemia necessitating red blood cell
transfusion is less than 1% after vaginal delivery and 1–7% after cesarean
section. Red cell transfusion is indicated when the blood loss exceeds 30% or
more of blood volume. A Hb level of at least 8g/dl is recommended after
transfusion. It should be remembered that patients with acute hemorrhage can
have normal or hematocrit values until the plasma volume is restored. The
clinical evaluation in such situations is extremely important.

c. Surgeries  where  significant  blood  loss  is   expected