1. Life Support in Haemorrhage and Fluid Loss H.Gee MD, FRCOG

2. TRIAGE Priority 1 Requires emergency treatment and resuscitation soon or she will die. Priority 2 Care may be delayed a few hours. Priority 3 Condition permits significant delay.

3. Life support in haemorrhage and fluid loss Recognise circulatory collapse (SHOCK) and treat: ABC Call for help. CAUSES: Haemorrhage Sepsis. Life-threatening – needs immediate and intensive treatment - PRIORITY 1 Inadequate perfusion of organs and cells with oxygenated blood.

4. Recognising circulatory collapse (SHOCK) Main signs and symptomsOther signs and symptoms Pulse weak and fast (>110 beats/minute) Pallor BP low (systolic <90 mmHg) (late sign) Sweatiness or cold and clammy skin Rapid breathing Anxious, confused Unconscious Fetal distress

5. Classification of circulatory volume loss ClassCirculating volume lostSigns 115% or less (not much more than 700ml) You may notice only a mild rise in pulse rate If the woman is otherwise healthy and if not anaemic she will not require a blood transfusion 215-30% (over 1.5L)Symptoms will include rising pulse rate and rising breathing frequency Use crystalloids to replace fluid loss 330-40% (over 2L)It is only at this stage that the blood pressure falls Remember a drop in BP is a later sign of hypovolaemia Patient will need a blood transfusion in addition to crystalloids 4>40%This is immediately life threatening Blood transfusion is required immediately NB: A pregnant woman has a circulation volume of about 100 ml/kg (for a woman of 60kg this is 6 litres).

6. Action Call for help Position woman on her left side with legs higher than her chest Remember – in the pregnant woman any shock is made worse by aorta-caval compression Insert at least one IV line – give fluids at rapid rate Cover patient to keep warm Assess condition of mother and child If at Health Centre, once initial treatment commenced, refer to hospital Management of haemorrhage or sepsis.

7. Fluid Management Insert IV line and give fluids: Clean woman’s skin with spirit at site for IV line Insert an IV line using 16-18 gauge needle Infuse Ringer lactate or normal saline. Give fluids at rapid rate if systolic blood pressure (BP) less than 90 mmHg, pulse faster than 110 beats/minute or heavy vaginal bleeding Infuse 1L in 15-20 minutes (as rapid as you can) After that, infuse 1L in 30 minutes at 30 ml/minute Repeat if necessary.

8. Fluid Management...continued... Monitor every 15 minutes for: Pulse and BP Shortness of breath or puffiness. Reduce the infusion rate: To 3 ml/minute (1L in 6-8 hours) when pulse slows to less than 100 beats/minute, systolic BP increases to 100 mmHg or higher To 0.5 ml/minute(1L in 18-24 hours) if breathing difficulty or puffiness develops.

9. Reassessment and further management Reassess the woman’s response to IV fluids within 30 minutes for signs of improvement Stabilising pulse (90 beats/minute or less) Increasing systolic blood pressure (100 mmHg or more Improving mental status (less confusion or anxiety) Increasing urine output (30 ml/hour or more). If condition improves: Adjust rate of IV infusion to 1L in 6 hours Continue to manage underlying cause of circulatory collapse.

10. CAUTIONS Give fluids at moderate rate (1L in 2-3 hours) in: Severe abdominal pain Obstructed labour Fever and dehydration. Give fluids at slow rate (1L in 6-8 hours) in: Severe anaemia Pre-eclampsia Eclampsia. ALWAYS Monitor urine output – insert catheter if available Use fluid balance sheet to record time and amount of fluids.

11. No IV access Oral rehydration solution if able to drink 500 ml/hour or by NG tube Venous cut-down.

12. Procedure for venous cut-down The saphenous vein is about one finger anterior and superior to the medial malleolus (on inner side of the ankle).

13. Coagulation Defects Abruption Large Transfusions

14. Transfusion > 4 Units (Stored Blood) Consider: Platelets Fresh Frozen Plasma (clotting factors) Cryo-precipitate (fibrinogen) Calcium Gluconate