Life Support in Haemorrhage
and Fluid Loss
H.Gee MD, FRCOG
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.
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.
Recognising circulatory
collapse (SHOCK)
Main signs and symptoms
Other 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
Classification of circulatory
volume loss
NB: A pregnant woman has a circulation volume of about 100 ml/kg (for a woman of 60kg
this is 6 litres).
Class
Circulating volume lost
Signs
1
15% 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
2
15-30% (over 1.5L)
Symptoms will include rising pulse rate and
rising breathing frequency
Use crystalloids to replace fluid loss
3
30-40% (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
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.
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.
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.
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.
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.
No IV access
• Oral rehydration solution if able to drink 500
ml/hour or by NG tube
• Venous cut-down.
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).
Coagulation Defects
• Abruption
• Large Transfusions
Transfusion > 4 Units
(Stored Blood)
Consider:
• Platelets
• Fresh Frozen Plasma (clotting factors)
• Cryo-precipitate (fibrinogen)
• Calcium Gluconate