National Womens Health Clinical Guideline / Recommended Best Practice

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POSTPARTUM HAEMORRHAGE
Associated Documents Primary Postpartum Haemorrhage
Definitions & Management

Ongoing Monitoring Appendix 1: Primary PPH Further

Detail Including Risk Factors

Primary PPH Flowchart Management

from Labour & Birthing Unit (modified from PROMPT course) Immediate Management from Labour & Birthing Assess Replace Arrest Bleeding

Appendix 2: Uterine / Vaginal

Tamponade

Appendix 3: Laparotomy for Further

Surgical Measures, Including BLynch Appendix 4: Recombinant Factor VIIA Appendix 5: Secondary Postpartum Haemorrhage References

Associated Documents
Type Board Clinical Document Titles Blood Components & Blood Products Administration Surgical Safety Checklist ( under development) Group & Screen Requirements - Inpatients Intrapartum Care - Normal Labour & Birth Intra-Operative Cell Salvage (IOCS) - Obstetrics ADHB Blood Resource http://www.nzblood.co.nz/dhb/auckland/index.htm

National Womens Clinical NZBS

Primary Postpartum Haemorrhage Definitions & Management

Term Primary Secondary Postpartum Haemorrhage Major Postpartum Haemorrhage Definition Within 24 hours of delivery After 24 hours post partum Blood loss >=500ml Blood loss >=1000ml and/or unstable

Management
Identify PPH Get help Assess, arrest and replace bleeding simultaneously see flowchart

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Primary PPH Flowchart Management from Labour & Birthing Unit (modified from PROMPT course)

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Immediate Management from Labour & Birthing

Call for Help early Call Clinical Charge Midwife and Registrar for all PPH If > 500ml and clinical concerns push emergency bell and dial 777 and state Obstetric emergency, room . Send for blood 1000-1500 mls: Call in Obstetric Consultant, notify Anaesthetist > 2000 ml: Call in 2nd Obstetric Consultant and Anaesthetist > 2000 ml: notify Blood Bank If pre-eclampsia or significant medical history, notify Obstetric Physician

Delegate Tasks Identify Team Leader IV lines (2X 14/16 gauge cannulae Running total of blood loss Vital signs and communication with woman Fluid replacement Runner to organise theatre /blood/extra help Documentation Communicate with family

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Assess
Rapid Evaluation Shock this is a late sign Blood pressure, pulse, respirations, peripheral perfusion, colour, cerebral function Estimate blood loss and keep ongoing record Document blood and blood products as requested and actually transfused, laboratory coagulation results Use automated BP and SpO2 monitoring every 3 minutes
DEGREE OF SHOCK (see 30) COMPENSATION MILD MODERATE SHOCK SHOCK 500 1000ml 1000 1500ml 1500 2000ml 10 15% 15 25% 25 35% none Slight fall Marked fall (90 100 mmHg) (70-80 mmHg) SEVERE SHOCK 2000 3000ml 35 45% Profound fall (50-70 mmHg)

Blood loss Blood pressure change (systolic pressure) Signs and symptoms

palpitations dizziness tachycardia

weakness sweating tachycardia

restlessness pallor oliguria

collapse air hunger anuria

Four Ts: Tone: Uterine Massage Tissue: Check placenta complete Trauma: Examine perineum , cervix, vagina, uterine scar Thrombin: Think Coagulation

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Replace

Administer oxygen by mask 6L/min Keep the patient warm Act : resuscitation Insert two 14/16 gauge cannulas Draw blood for group and Ab screen, send to Blood Bank- URGENT STICKER Draw blood for FBC & coagulation, send to Haematology- URGENT STICKER PHONE Blood Bank and Haematology to process urgently Plasmalyte first line Infuse one litre rapidly, ASSESS response as above Infuse 2nd or 3rd litre if indicated WARMED FOR ALL ONGOING FLUIDS Use pressure infusers where available If further fluid required give BLOOD, but can use colloid while waiting Act: give blood ( see 28) Use a blood giving set Blood should be used as soon as possible > 1500ml with ongoing bleeding and/or if haemodynamically unstable i.e. if systolic BP < = 90 mmHg or significant fall from baseline If no ongoing bleeding then Hb can be used to guide transfusion requirements Note :Group and Ab screen takes 40 minutes but then if negative Ab screen, compatible blood can be issued quickly Phone Blood Bank, request blood, specify amount and timeframe, advise them of active bleeding and need for ongoing support. If compatible blood is not available after a blood loss of 2000mls or haemodynamically unstable then uncrossmatched blood (desperate blood or emergency blood) must be given. Phone blood bank and give Drs name, no of units, and send sticker down the tube. State We need blood NOW Further products e.g. FFP, platelets, cryoprecipitate, will be required if massive transfusion or coagulopathy, request early, seek advice from senior colleague Transfusion Medicine Specialist available for consultation 24/7 ( via Blood Bank) Obstetric Physicians on call 24/7

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Arrest Bleeding
Tone
Massage the uterus firmly, expel any clots First line drug therapy Syntometrine one ampoule IM (if not already given and no history of hypertension) Syntocinon 5 units IV IV infusion Syntocinon (20units in 1000mls Plasmalyte at 250mls/hour). If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment should be instituted rather than increasing the dose or rate of syntocinon: Second line drugs Misoprostol (Cytotec) 800mgs PR Carboprost (Haemabate) IM 250mcg Q15min up to 8 doses further Syntometrine IM /ergometrine IV slowly - only one more dose (see appendix 1 for doses and maximums) Insert Indwelling Catheter Internal Bimanual Compression

Tissue
Retained placenta with postpartum haemorrhage Urgent transfer to theatre for manual removal: Acuity One if >=1000ml, actively bleeding or unstable Consider possibility of placenta accreta

Trauma
Repair the Tear Apply pressure as initial measure. Stabilise the mother and Repair the tear/lacerations as soon as possible (theatre may be required) Ensure that swab and instrument counts are correct in all cases.

Thrombin
Check coagulation results: O&G staff to consult asap if initial results show: PR > 1.5 ; APTT > 40 ; fibrinogen < 1.5 ; platelets < 100 ; Hb < 80 See Blood Components & Blood Products Administration / Massive Transfusion Protocol for treatment of coagulopathy

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Ongoing Monitoring
After a significant PPH the following are recommended for ongoing monitoring: NIBP monitoring Pulse oximetry ECG Strict fluid balance with hourly urine measures

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Appendix 1: Primary PPH Further Detail Including Risk Factors

Background
Postpartum haemorrhage continues to be a significant contributor world-wide to the 500,000 maternal pregnancy related deaths each year accounting for 11% of the total number. (see 7) It is, also, a potent cause of postnatal iron deficiency in women. The case fatality is approximately 1 in 600 to 1 in 800 cases of obstetric bleeding. ( CEMACH)

Definitions
Until recent times, Primary Postpartum Haemorrhage (PPH) was defined as a blood loss of > = 500 ml from the genital tract in first 24 hours post delivery (see 7). This definition, however, is based on subjective observations, making accurate assessment of excessive blood loss difficult. Recent research indicates that clinical estimates of blood loss frequently fall below the actual amount and the incidence of PPH is being under reported by 30-50%. On the basis of these findings, more objective assessment parameters have been advocated for the diagnosis of major PPH - viz: The patient: Is haemodynamically unstable Has a blood loss of >1000ml from genital tract Has a >10% change in her haematocrit between admission and the post partum period.(see 8) or Requires a transfusion of red blood cells (see 8)

Based on these definitions the incidence of postpartum haemorrhage for a vaginal delivery has been estimated at 3.9% (see 9) and 6.4% (see 11) for a caesarean delivery. Continued on next page

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Appendix 1: Primary PPH Further Detail Including Risk Factors, Continued

Aetiology and Risk Factors (modified from NSW framework)
CAUSE Abnormalities of uterine contraction (Tone)

ETIOLOGY PROCESS atonic uterus

70%

over distended uterus

uterine muscle exhaustion

intra-amniotic infection

drug induced hypotonia

Genital tract trauma (Trauma)

20%

functional or anatomic distortion of the uterus episiotomy or lacerations (cervix, vagina or perineum)

extensions, lacerations at caesarean section uterine rupture uterine inversion

CLINICAL RISK FACTORS physiological management of third stage prolonged 3rd stage (> 30 min) polyhydramnios multiple gestation macrosomia rapid or incoordinate labour prolonged labour (1st or 2nd stage) labour dystocia high parity labour augmented with syntocinon pyrexia prolonged ROM (more than 24 hours) magnesium sulphate, nifedipine, salbutamol general anaesthetic fibroid uterus uterine anomalies labour induced labour augmented with syntocinon labour dystocia malposition precipitous delivery operative delivery (vacuum or forceps) malposition deep engagement previous uterine surgery strong cord traction in 3rd stage, especially with fundal placenta short umbilical cord high parity relaxed uterus, lower segment and cervix placenta accreta, especially fundal congential uterine weakness or anomalies antepartum use of magnesium sulphate or oxytocin Continued on next page

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Appendix 1: Primary PPH Further Detail Including Risk Factors, Continued

CAUSE Retained products of conception (Tissue)

10%
Abnormalities of coagulation (Thrombin)

ETIOLOGY PROCESS retained products abnormal placenta retained cotyledon or succenturiate lobe

1%

retained blood clots coagulation disorders acquired in pregnancy Idiopathic Thrombocytopenic Purpura (ITP) Von Willebrands disease Haemophilia or carrier Thrombocytopenia with pre-eclampsia Disseminated Intravascular Coagulopathy (DIC) pre-eclampsia dead fetus in utero severe infection abruption amniotic fluid embolus therapeutic anticoagulation

CLINICAL RISK FACTORS incomplete placenta at delivery placenta accreta or percreta previous caesarean or other uterine surgery high parity abnormal placenta on U/S atonic uterus bruising elevated BP, HELLP fetal death pyrexia, WBC antepartum haemorrhage (current or previous) sudden collapse

history of blood clot

Continued on next page

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Appendix 1: Primary PPH Further Detail Including Risk Factors, Continued

Epidemiological Risk factors (see 12) OR = odds ratio
Previous PPH Maternal Obesity (CEMACH) Hypertensive disorders OR 1.7 LGA OR 1.9 Antepartum haemorrhage including abruption Placenta praevia, with risk of accreta increasing with each previous CS Induction of labour OR 1.4 Augmented labour OR 1.4 Prolonged second stage OR 3.4 Operative vaginal delivery OR 2.3 Lacerations OR 2.4 Retained placenta OR 3.5 Placenta accreta OR 3.3

Caesarean section is strongly associated with peripartum hysterectomy. (see 13)

Prevention
There is high quality evidence that active management of the third stage reduces the incidence of PPH for all women. (see 14) Refer to the policy Intrapartum Care - Normal Labour & Birth / Management of third stage for a full description of active management of third stage. For women with risk factors for PPH the following is recommended: Insert an IV line (preferably 14g cannula) Take blood for group and antibody screen - this takes 40 minutes and FBC Chase result of antibody screen and if positive request crossmatching to begin early in order to avoid delays in the event of an emergency ; suggest 4 - 6 units ; this takes about an hour Active management of the third stage of labour with syntometrine if not contraindicated For women who have stated a wish not to receive blood products: ( CEMACH) Ensure specific wishes are documented Obtain informed consent for red blood cell salvage and infusion Review by Consultant Obstetrician and Anaesthetist at the onset of labour

Continued on next page

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Appendix 1: Primary PPH Further Detail Including Risk Factors, Continued

Fluids & drugs
Fluids Warmed buffered crystalloid solution ie Plasmalyte is preferred for first line resuscitation. For fluid other than blood, replace blood loss with 3 to 4 times the EBL. Pentastarch ( Starquin) causes fewer severe allergic reactions and exerts its intravascular effect longer than Gelofusine Warmed fluids reduce the risk of coagulopathy. Resuscitation must commence early regardless of the availability of an anaesthetist If an anaesthetist is not available ensure there is an appropriate person in charge of fluid and/or blood resuscitation at all times with close attention to total blood loss. Delivery of any drugs to the uterus, especially IM, will be compromised by poor circulation therefore fluid resuscitation must be effective. Be cautious with use of syntocinon in the presence of hypovolaemia If the Syntocinon infusion fails to achieve uterine contraction additional medical treatment should be instituted rather than increasing the dose or rate of syntocinon: Syntometrine one ampoule intramuscular if not already administered. This contains 500 micrograms of ergometrine. If ergometrine has already been administered (as Ergometrine or Syntometrine) a second dose of 250 micrograms may be given, but beware of the hypertensive woman who may develop extreme hypertension following the administration of ergometrine. A second dose of ergometrine should only be used after consultation with the on-call obstetrician. The total dose of ergometrine in 24 hours must not exceed 1000 micrograms. Ergometrine is contraindicated with a history of maternal hypertension or preeclampsia regardless of actual BP readings during PPH. Ref Ng S.Y., Ithnin F., Sia A.T.H., Ng C.C.M. Ergometrine administration for postpartum haemorrhage in an undiagnosed preeclamptic. Anaesthesia and Intensive Care. 36 (1) ( pp 113 115), 2008 Misoprostol 800mcg PR. This has been shown in one small trial (see 15) to be subjectively more effective than syntometrine but the numbers are too small to draw conclusions regarding outcomes such as hysterectomy or maternal mortality. It is however quick to administer rectally and has fewer side effects than Syntometrine. It avoids the use of IM injection (which may be less effective in the presence of shock or morbid obesity, and poses risk of haematoma in the presence of coagulopathy) Carboprost (Haemabate) has a high success rate (95% used with other ecbolics (see 16) but is third line due to side effects. Give 1 ampoule (250 mcg) IM Q15 minutes up to 8 doses. May be given intramyometrially with caution, this is best done in theatre.

Interventional Radiology
This technique needs discussion with the radiologist on-call, and is best undertaken whilst the patients condition is stable, since it usually involves transfer to the Interventional Radiology Suite. It may be more suitable for recurrent primary or secondary PPH where uterine conservation is desired or hysterectomy is too risky due to maternal medical condition. If embolisation is expected to be required then femoral catheters with balloons can be electively placed prior to Caesarean Section which can provide temporary control prior to formal embolisation and/or hysterectomy. Continued on next page

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Appendix 1: Primary PPH Further Detail Including Risk Factors, Continued

Management in the Operating Room Initial Measures
Continue bi-manual compression and/or firm pressure on perineum. Consider applying aortal compression via pressure through the abdominal wall. (This may be helpful as a temporary measure if the patient is in shock or during CPR. (see 2) Take a few minutes for multidisciplinary plan Request Blood Bank to send blood to OR immediately patient arrives in theatre Examination under anaesthetic to remove retained placenta/tissue and repair any tear. Beware uterine inversion and previously undiagnosed placenta accreta.

Further measures
Consider: Inserting a central line and/or arterial line earlier rather than later Administering fresh frozen plasma, cryoprecipitate and platelet concentrates The need for antibiotic cover Use of a cell saver Give further ecbolics as required IM syntometrine (maximum 2 ampoules/24hr) IM Carboprost (1 ampoule = 250 mcg q15min up to 8 doses i.e. 2mg) Intramyometrial prostaglandin in the presence of the Obstetric Consultant and appropriate Anaesthetic staff may be used. Caution must be exercised to avoid intravascular injection which can cause collapse. Give 125mcg in 20ml normal saline via 22G spinal needle into 3 or 4 more myometrial sites, can be repeated if necessary, total dose 2mg) Uterine/Vaginal Tamponade with balloon or gauze packing (appendix 2) Laparotomy for further surgical measures including B Lynch suture (appendix 3) Factor VII a ( appendix 4)

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Appendix 2: Uterine / Vaginal Tamponade

(consider this may mask ongoing bleeding)
Possible options include: Pack the uterus using a Rusch balloon. Balloon may be inflated with up to 1500ml of saline, less will be required but tailor to the size of the uterus, usually about 300ml. Hydrostatic Catheter (Cat. Ref.: 7015) Intended Purpose: For bladder distention Product Description: 1. Portfolio: Standard 2. Size: 16Fr 3. Balloon: 10ml and 1500ml 4. Eye configuration: One pair opposed eyes 5. Tip Configuration: Standard round tip with hydrostatic balloon over tip 6. Funnel: Main funnel and inflation Hydrostatic Catheter funnel 7. End of inflation funnel is fitted with a plastic valve held securely by a coloured rubber sleeve. 8. Coating: Silicone treated. 9. Sterility: Shipped sterile Alternatively for gauze packing tie 3-4 gauze rolls together, soak in an iodine solution, and pack uterus and vagina. Remove 24 hours later. (see 10)

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Appendix 3: Laparotomy for Further Surgical Measures, Including BLynch

Consider calling for extra surgical assistance (eg. Senior gynaecologist, gynaecological oncologist, vascular surgeon or general surgeon). It is a mistake to leave these steps until the patient is in extremis. Prompt resuscitation including correction of coagulopathy must occur to support early recourse to surgery but coagulation factors do not of themselves stop surgical bleeding. Consider applying aortal compression or clamp at laparotomy. see 2) B-Lynch stitch (see 3) Uterine artery ligation (OLeary stitch) (see 4) Bilateral internal iliac artery ligation (see 5) Ovarian artery ligation Uterine devascularisation (see 6) Hysterectomy is the definitive treatment and must be proceeded with if bleeding is not controlled quickly with other measures and blood loss is > 2000ml Continued on next page

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Appendix 3: Laparotomy for Further Surgical Measures, Including BLynch, Continued

Original B-Lynch Suture ( above)

Modified B-Lynch stitch (70mm round- bodied needle with 2 Chromic catgut suture)

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Appendix 4: Recombinant Factor VIIA

European consensus guidelines confirm the role of rFVIIA as an adjunct to surgery for massive bleeding in certain situations. An American review group evaluated the literature for a number of indications including a small number of obstetric cases, and concluded that its use for PPH is appropriate only after attempted significant clotting factor replacement. There are only a small number of cases (n = 65) where rFVIIA has been used for PPH and there are no randomised studies therefore the evidence base is limited. Cost is significant but cost neutrality is maintained if given relatively early ie after a 14 unit red cell transfusion. The use of rFVIIA should be in conjunction with local massive transfusion guidelines (currently under development at ADHB) and considered only as a lifesaving (or fertility saving) measure for PPH resistant to standard therapy. (see 29) See also N:\GROUPS\EVERYONE\POLICY\Master file of Intranet\Clinical Practice\National Womens\SSM\non-document controlled attachments\PDF Guidelines VIIa Mar06.pdf

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Appendix 5: Secondary Postpartum Haemorrhage

Definition
Secondary postpartum haemorrhage is defined as excessive blood loss from the genital tract occurring more than 24 hrs to 6 weeks after delivery.

Aetiology
Retained products of conception Infection (often secondary to retained products) Lacerations, including episiotomy Others (rare): Blood dyscrasias, Trophoblastic disease, Carcinoma of cervix, submucous fibroids(causing subinvolution), Placental site causing subinvolution

Management Details
There are no randomised controlled trials to inform the management of secondary PPH. (see 25) The following is based on expert opinion. Assess patient: The diagnosis and management of a secondary postpartum haemorrhage primarily relies on a clinical assessment. Ultrasound, looking for retained products of conception, should play a minor secondary role, as it has high false positive rate (low specificity) which may lead to unnecessarily aggressive intervention with a significant risk of serious consequences. Ultrasound does not easily differentiate between retained products and blood clot. Estimate the total blood loss and measure HB Vital signs : temperature, pulse, and blood pressure Resuscitation as required as per primary PPH guidelines Assess uterine size Check status of cervical os and take endocervical swab Consider B subunit HCG testing to exclude trophoblastic disease Treat the cause General principles of treatment: Bed rest and antibiotics therapy are the mainstays of treatment Curettage is not performed routinely (risk of uterine perforation or Ashermans Syndrome). Evidence of retained products is suggested by subinvolution of the uterus, an open cervical os or ultrasound findings. Oxytocics (eg. Oral Ergometrine) have almost no part in the management. If vaginal bleeding continues following treatment for secondary post partum haemorrhage, then consider the need for a pelvic trans-vaginal ultrasound scan. Retained products of conception Bleeding in the first few days after delivery is probably due to retained products of conception. Gentle digital evacuation of the uterus under general anesthesia should be performed. Antibiotic therapy is indicated prior to the procedure to reduce the risk of Ashermans syndrome. Uterine infection Bleeding occurring later in the puerperium may be due to infection of the uterus, for which antibiotics should be prescribed. If bleeding continues despite antibiotics exploration of the uterus is indicated.

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References
1. Druzin ML. 1989. Packing of lower uterine segment for control of post cesarean bleeding in instances of placenta previa. Surg Gynecol Obstet 169: 543-45. 2. Riley DP. Burgess RW. 1995. External abdominal aortic compression: A study of a resuscitation manoeuver for postpartum hemorrhage. Obstet Gynecol Surv 50: 426-7. 3. B-Lynch C. Coker A. Lawal AH. Abu J. Cowen MJ. 1997. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. British Journal of Obstetrics & Gynaecology. 104:3: 372-5. 4. O'Leary JA, SO. 1986. Hemorrhage with uterine artery ligation. Contemp Ob/Gyn Update Surg 27: 13-16. 5. Allahbadia G. 1993. Hypogastric artery ligation: A new perspective. Obstet Gynecol Surv 48: 613-15. 6. AbdRabbo SA. 1994. Stepwise uterine devascularization: A novel technique for management of uncontrollable postpartum hemorrhage with preservation of the uterus. Am J Obstet Gynecol 171: 694-700. 7. AbouZahr C. 2003. Global burden of maternal death. In British Medical Bulletin. Pregnancy: Reducing maternal death and disability. British Council. Oxford University Press, 2003. 1-13. 8. Pritchard JA. Baldwin RM. Dickey JC. Wiggins KM. 1962. Blood volume changes in pregnancy and the puerperium. II. Red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy. Am J Obstet Gynecol 84: 1271-1282. 9. Combs CA. Murphy EL, LRJ. 1991. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 77: 69-76. 10. American College of Obstetricians and Gynecologists. 1998. Postpartum hemorrhage. ACOG Educational Bulletin Number 243. In 2001 Compendium of Selected Publications, Washington DC: ACOG. 11. Combs CA. Murphy EL. Laros RK Jr. 1991. Factors associated with postpartum hemorrhage in cesarean birth. Obstet Gynecol 77: :1: 77-82. 12. Sheiner E, Sarid L, Levy A, et al. Obstetric risk factors and outcome of pregnancies complicated with postpartum haemorrhage : a population-based study. J Matern Fetal Neonatal Med. Sep 2005 ; 18 ( 3) : 149-54 13. Stanco LM. Schrimmer DB. Paul RH. Mishell DR Jr. 1993. Emergency peripartum hysterectomy and associated risk factors. Am J Obstet Gynecol. 168: 879-883. 14. Prendiville WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour. Cochrane Database Syst Rev. 2000 ; (2) :CD000007Guidelines for red cell transfusions and volume replacement in adults. 2008 UpToDate 15. Lokugamage AU et al. 2001. A randomized study comparing rectally administered misoprostol versus syntometrine combined with an oxytocin infusion for the cessation of primary post partum haemorrhage. Acta Obstetrica et Gyanecologica Scandinavica 2001 ; 80( 9) : 8359 16. Oleen MA, Mariano JP. Controlling refractory atonic postpartum haemorrhage. International Journal of Gynecology & Obstetrics 2003 ; 80 : 67-8 17. Mousa HA. & Walkinshaw S. 2001. Major postpartum haemorrhage. Current Opinion in Obstetrics & Gynaecology 13: 595-603. Continued on next page

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References, Continued
18. WHO Policy 19. Ultrasound O&G 2001 20. Ultrasound O&G 2001 18 p49 21. Ultrasound O&G 2000 16 p640 22. American Journal O&G 1970 107 p565 23. BJOG 2001 p108-927 24. High Risk Pregnancy Management options, Chapter 79 pages 1615 16178. 25. Cochrane review 2008 Treatments for secondary postpartum haemorrhage 26. Confidential Enquiry into Maternal and Child Health (CEMACH) December 2007: Saving Mothers Lives 2003 2005 Report : A Report of the UK confidential Enquiries into maternal deaths 27. Postpartum haemorrhage (PPH) Framework for Prevention, Early Recognition & Management: 27 Jan 2005 : NSW Health Policy Directive : http: // www.nsw.gov.au/policies/PD/2005/PD23005_264.html 28. Murphy, MF, et al. 2001. British Committee for Standards in Haematology, Blood Transfusion Task Force. Br J Haematol 2001 ; 113:24 29. Welsh A., McLintock C., Gatt S., Somerset D., Popham P., Ogle R., Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage. Australian and New Zealand Journal of Obstetrics and Gynaecology. 48 ( 1) ( pp 12-16). 2008 30. SOGC. Prevention and management of Postpartum Haemorrhage : SOGC Clinical Practice Guidelines No 88. J Soc Obstet Gynaecol Can 2000 ; 22(4) : 271 - 81

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