M7Major obstetric haemorrhage, transfusion and coagulopathy

Clinical overview

Major obstetric haemorrhage is a race between source control and the spiral of hypoperfusion, dilution, hypothermia, hypocalcaemia, acidosis and coagulopathy. The patient can lose blood into the room, uterus, broad ligament, retroperitoneum or peritoneum. Visual loss may underestimate severity; initial haemoglobin may remain deceptively close to baseline. Treat the clinical trajectory and measured cumulative loss, not a late laboratory confirmation.

Postpartum haemorrhage (PPH) is the best-studied obstetric bleeding syndrome, but critical-care principles also apply to placental abruption, placenta praevia/accreta spectrum, ruptured ectopic pregnancy, uterine rupture, surgical trauma and bleeding with anticoagulation or inherited/acquired haemostatic disease. Tranexamic acid (TXA) is established treatment for PPH. It can also be useful in selected major antepartum or perioperative obstetric haemorrhage when the local major-haemorrhage protocol and specialist team support antifibrinolytic treatment; that use must not be misrepresented as direct WOMAN-trial evidence for every APH presentation.

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Figure M7.1 — Major obstetric haemorrhage is a race: identify the source through tone, trauma, tissue and thrombin while simultaneous source control and haemostatic resuscitation interrupt the self-amplifying spiral of hypoperfusion and coagulopathy.

Core knowledge

Recognition and activation

The 2026 South African Adult Hospital STG defines PPH as blood loss above 500 mL after birth or any loss causing haemodynamic instability. WHO’s 2025 consolidated guidance promotes earlier objective recognition: measured loss of at least 300 mL with abnormal haemodynamic signs, or at least 500 mL, whichever occurs first. These are complementary safety ideas but not identical operational definitions. The unit should use its approved national/local trigger and visibly document the discrepancy rather than blending thresholds silently.

Activate a major obstetric haemorrhage response for rapid ongoing loss, haemodynamic impairment, suspected concealed bleeding, evolving coagulopathy or likely need for massive transfusion/procedure. Activation mobilises obstetrics, anaesthesia/critical care, theatre, blood bank, laboratory, porters and neonatal support; it is not merely an order for a fixed product pack.

Stop the bleeding

Organise cause by tone, trauma, tissue and thrombin, while remembering antepartum and intra-abdominal sources.

• Tone: uterine massage/bimanual compression, appropriate uterotonics and escalation to tamponade or surgery.
• Trauma: inspect and repair genital tract; identify uterine rupture, extension, broad-ligament or surgical bleeding.
• Tissue: remove retained placenta/products and manage placenta accreta spectrum without forced placental separation.
• Thrombin: recognise DIC, severe thrombocytopenia, anticoagulants, inherited disorders and thrombotic microangiopathy.

Temporary measures buy time; definitive control may require uterine balloon tamponade, compression sutures, vessel ligation, interventional radiology or hysterectomy. Do not allow repeated medical steps to delay surgery in an exsanguinating patient.