DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
- Rare but potentially fatal neonatal event
- Can occur in the following situations:
- damage to cord before clamping
- massive placental abruption
- massive acute feto-maternal haemorrhage
- subgaleal haemorrhage
- unintended scalpel injury during caesarean section
DEFINITION
- Actual/suspected blood loss with haemodynamic instability or
- Blood loss 2–3 mL/kg/hr
SYMPTOMS AND SIGNS
Hypovolaemia
- High/increasing heart rate (>160 bpm)
- Low/falling Hb or haematocrit
- Poor peripheral perfusion with slow central capillary refill (>3 sec)
- Low or falling blood pressure [mean blood pressure (MBP) <40 mmHg in a term baby]
- Presence of, or worsening, metabolic acidosis
- Echocardiography (if available) to assess volume status
- small systemic veins and low ventricular filling volumes can indicate hypovolaemia
INVESTIGATIONS
- Crossmatch
- FBC
- PT
- APTT
- Fibrinogen
- U&E
- Ionised calcium
- Blood gases
- If feto-maternal haemorrhage suspected, request maternal Kleihauer test
Hb can be normal due to lack of dilutional effect – do not view as reassuring
IMMEDIATE TREATMENT
Major haemorrhage pathway (MHP)
Group O RhD negative blood can be used whilst awaiting massive haemorrhage protocol blood products –
ALWAYS available on labour suite/obstetric theatres
ALWAYS available on labour suite/obstetric theatres
Table 1: Products
Product | Unit |
RBC (20 mL/kg) |
Paediatric (<100 mL) |
Plasma (20 mL/kg) |
Neonatal fresh frozen plasma (100 mL) |
Platelets (20 mL/kg) |
Paediatric platelets (50 mL) |
Cryoprecipitate (10 mL/kg) |
Single donor (40 mL) |
Table 2: Paediatric major haemorrhage pack contents
Pack 1 | Pack 2 | |
Packed red cells | ✓ | ✓ |
FFP | ✓ | ✓ |
Platelets | ✓ | |
Cryoprecipitate | ✓ |
- Note: Pack contents –these are not packs that actually exist, but provide a way of thinking through what should be needed in suitable ratios. Many centres will need to design and implement a local protocol between haematology and neonatal teams to plan for this eventuality, based on this structure and flowchart
SUBSEQUENT MANAGEMENT
- The following may be necessary, discuss with neonatologist:
- elective intubation and ventilation (following resuscitative blood and blood product replacement)
- inotropic support
DISCHARGE AND FOLLOW-UP
- Neurodevelopment follow-up for long-term neurological outcome