Postpartum Haemorrhage

Quick Answer

One-liner: Postpartum haemorrhage (PPH) is blood loss ≥500mL (vaginal) or ≥1000mL (caesarean) after delivery, requiring immediate resuscitation, identification of cause (4Ts: Tone, Tissue, Trauma, Thrombin), and escalating interventions from uterotonics to surgical management.

PPH affects 10-15% of deliveries and remains a leading cause of maternal mortality globally. The most common cause is uterine atony (70%). Emergency management follows simultaneous resuscitation and definitive treatment: call for help (activate obstetric emergency team), assess ABCD, secure large-bore IV access, initiate oxytocin (5-10U IM then 20-40U infusion), perform bimanual uterine compression, give tranexamic acid 1g IV within 3 hours, commence massive transfusion protocol if loss greater than 1500mL, and escalate to balloon tamponade, surgical interventions (B-Lynch suture), or hysterectomy if refractory. Maternal mortality is below 1 per 100,000 in high-income countries but Aboriginal and Torres Strait Islander women face 3-fold higher maternal mortality.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Uterine blood supply (uterine arteries from internal iliacs, 500-700mL/min at term), placental site anatomy, myometrial layers (contraction mechanism), pelvic vascular anatomy for surgical ligation
• Physiology: Haemostasis at placental site (myometrial contraction = "living ligatures"), pregnancy-induced hypercoagulability, increased cardiac output at term (50% above baseline), plasma volume expansion (40-50%), physiological anaemia of pregnancy
• Pharmacology: Oxytocin (G-protein coupled receptor → myometrial contraction), ergometrine (alpha-adrenergic + serotonergic vasoconstriction), prostaglandins (carboprost PGF2α, misoprostol PGE1), tranexamic acid (antifibrinolytic via lysine binding)

Fellowship Exam Relevance

• Written: High-yield SAQ topics include immediate management algorithm, massive transfusion protocol activation, 4Ts differential diagnosis, surgical escalation ladder, complications of emergency hysterectomy, tranexamic acid evidence (WOMAN trial), viscoelastic testing interpretation (FIBTEM below 7mm triggers fibrinogen replacement)
• OSCE: Likely scenarios include PPH resuscitation station (team leadership, closed-loop communication, activation of emergency team), communication station (counselling about hysterectomy, informed consent under duress), procedure station (bimanual compression technique, balloon tamponade insertion), post-resuscitation debrief with multidisciplinary team
• Key domains tested: Medical Expert (systematic approach to PPH, knowledge of escalation ladder), Communicator (clear handover, family communication during crisis), Collaborator (coordinating with obstetrics, anaesthetics, haematology), Leader (team coordination during resuscitation, activating MTP, knowing when to call for senior help)

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Key Points

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Epidemiology

Australian/NZ Specific

• Australia: PPH rates have increased from 6.9% (2001) to 9.6% (2016) in some states, attributed to improved recognition and lower thresholds for diagnosis rather than true increase in severe cases [8]
• Aboriginal and Torres Strait Islander women: 3-fold higher maternal mortality (20.2 vs 5.5 per 100,000), with PPH contributing significantly; barriers include remote location, delayed recognition, limited access to specialist obstetric care [9,10]
• Māori women (NZ): 2-fold higher risk of severe maternal morbidity including PPH, associated with later presentation to antenatal care and socioeconomic disparities [11]
• Rural/remote: Increased risk of poor outcomes due to distance from tertiary obstetric services, lack of on-site blood products, delayed activation of retrieval services [12]

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Pathophysiology

Mechanism

Normal Haemostasis After Delivery: After placental separation, the placental site (15-20cm diameter) has exposed maternal spiral arteries and venous sinuses. Normal haemostasis depends on:

1. Myometrial contraction ("living ligatures"): Interlacing myometrial fibres compress blood vessels, reducing blood flow from 500-700mL/min to near-zero
2. Mechanical compression: Retraction of uterine muscle physically kinks and compresses vessels
3. Coagulation cascade: Local thrombosis at vessel ends (enhanced by pregnancy hypercoagulability)

Failure of Haemostasis = Postpartum Haemorrhage via:

1. Uterine Atony (70-80%):

• Myometrium fails to contract adequately
• Spiral arteries remain patent → 500-700mL/min blood loss
• Risk factors: Overdistension (twins, polyhydramnios, macrosomia), prolonged labour (greater than 12 hours), rapid labour (below 3 hours), multiparity (greater than 5 births), tocolytic use, general anaesthesia, chorioamnionitis, uterine abnormalities (fibroids)

2. Retained Tissue (10%):

• Retained placenta (complete or partial)
• Placenta accreta spectrum (increta, percreta): abnormal placental invasion through decidua into myometrium or beyond, associated with previous caesarean section (risk 3% after 1 CS, 40% after 3+ CS with placenta praevia)
• Retained membranes or blood clots prevent effective contraction

3. Trauma (19%):

• Cervical lacerations (especially instrumental delivery)
• Vaginal sidewall lacerations (especially precipitate delivery)
• Perineal trauma (3rd/4th degree tears)
• Uterine rupture (previous caesarean scar, obstructed labour, excessive oxytocin)
• Uterine inversion (rare below 1:2500, excessive cord traction)

4. Thrombin (Coagulopathy) (below 1%):

• Pre-existing: Von Willebrand disease, haemophilia carriers, ITP, anticoagulation
• Acquired: DIC (from placental abruption, amniotic fluid embolism, sepsis), dilutional coagulopathy (massive transfusion), HELLP syndrome

Pathological Progression

Placental delivery → Inadequate haemostasis (4Ts) → Blood loss 500-1500mL
→ Compensatory tachycardia, peripheral vasoconstriction (Class I-II shock)
→ Blood loss greater than 1500mL → Decompensation (Class III shock: tachycardia greater than 120, SBP below 90, altered consciousness)
→ Lethal triad: Hypothermia (below 35°C) + Acidosis (pH below 7.2) + Coagulopathy (INR greater than 1.5)
→ Refractory shock, multi-organ failure, cardiac arrest

Why It Matters Clinically

Understanding pathophysiology guides treatment:

• Atony: Requires mechanical stimulation (bimanual compression, uterine massage) + pharmacological contraction (uterotonics)
• Retained tissue: Requires removal (manual extraction, curettage under ultrasound guidance)
• Trauma: Requires direct repair (suturing lacerations) or surgical control (pelvic packing)
• Coagulopathy: Requires targeted replacement (fibrinogen concentrate, cryoprecipitate) guided by viscoelastic testing (ROTEM/TEG), NOT just FFP

The "lethal triad" develops rapidly in PPH: hypothermia from exposure + massive transfusion, acidosis from hypoperfusion, coagulopathy from consumption + dilution. Prevention requires early aggressive warming, permissive hypotension (SBP 80-90 until bleeding controlled), and balanced blood product replacement (1:1:1 ratio PRBC:FFP:Platelets).

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Clinical Approach

Recognition

How to Recognise PPH:

1. Measured blood loss: Use calibrated under-buttocks drape or weigh blood-soaked materials (1g = 1mL blood)
2. Visual estimation: Notoriously inaccurate (underestimates by 30-50%), BUT if it "looks like a lot" → treat as PPH
3. Haemodynamic signs: Tachycardia greater than 100, SBP below 90, pallor, altered consciousness, oliguria
4. Shock Index: HR/SBP greater than 0.9 suggests significant blood loss (normal pregnancy 0.7-0.8)

Key Triggers:

• "Boggy" uterus on abdominal palpation (suggests atony)
• Failure of placenta to deliver within 30 minutes (retained placenta)
• Visible bleeding with contracted uterus (suggests trauma or coagulopathy)
• Previous PPH, caesarean section, or placenta praevia (high-risk for placenta accreta)

Initial Assessment

Primary Survey (ABCDE)

A - Airway:

• Usually patent unless obtunded from severe shock
• Prepare for intubation if GCS below 8 or anticipated theatre/hysterectomy

B - Breathing:

• Respiratory rate: Tachypnoea (greater than 20) suggests compensatory response to metabolic acidosis
• Oxygen: Apply high-flow 15L via non-rebreather mask to optimise oxygen delivery
• Consider early intubation and mechanical ventilation if ongoing massive haemorrhage (improves oxygen delivery, reduces work of breathing, facilitates damage control surgery)

C - Circulation:

• Heart rate: Tachycardia greater than 100 suggests blood loss greater than 500mL; greater than 120 suggests greater than 1500mL (Class III shock)
• Blood pressure: Hypotension is a late sign in young pregnant women (compensatory mechanisms maintain BP until 30-40% blood volume lost)
• Shock Index: HR/SBP greater than 0.9 indicates significant bleeding
• Capillary refill: greater than 2 seconds suggests poor perfusion
• IV access: Two large-bore (14-16G) cannulae immediately
• Blood loss quantification: Use calibrated drape, weigh swabs (1g = 1mL), visual estimation (unreliable)
• Uterine palpation: Assess fundal height and tone (boggy = atony; firm = consider trauma/coagulopathy)

D - Disability:

• GCS: Altered consciousness suggests severe hypovolaemia (Class III-IV shock)
• Confusion, agitation: Early signs of cerebral hypoperfusion

E - Exposure:

• Visualise bleeding source: Perineal inspection for lacerations, vaginal examination for cervical tears
• Prevent hypothermia: Remove wet linen, use forced-air warming (Bair Hugger), warm IV fluids, warm ambient temperature to 26-28°C
• Look for bruising/petechiae: Suggests coagulopathy

History

Key Questions (if time permits - usually obtained simultaneously with resuscitation)

Red Flag History

Examination

General Inspection

• Pallor: Conjunctival pallor, pale palms suggest significant anaemia
• Work of breathing: Tachypnoea suggests metabolic acidosis from shock
• Conscious state: Confusion, agitation, obtundation = severe hypovolaemia
• Visible bleeding: Continuous vs intermittent, volume estimation
• Uterine palpation: Fundal height (should be at umbilicus immediately post-delivery), uterine tone (firm vs "boggy")

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound (POCUS)

POCUS Applications in PPH:

1. IVC assessment: IVC diameter below 1cm with greater than 50% collapse suggests hypovolaemia; helps guide fluid resuscitation
2. Intrauterine evaluation: Identify retained placental tissue (appears as heterogeneous echogenic material within uterine cavity)
3. Free fluid: Intraperitoneal free fluid suggests uterine rupture or broad ligament haematoma (rare)
4. Cardiac function: Assess for hyperdynamic state (early shock) vs reduced contractility (late shock, myocardial dysfunction from massive transfusion)

Limitations:

• Should NOT delay immediate resuscitation or definitive management
• Operator-dependent
• Limited sensitivity for small retained placental fragments

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Management

Immediate Management (First 10 Minutes)

SIMULTANEOUS ACTIONS (do not perform sequentially):

1. CALL FOR HELP (0-1 min)
   - Activate obstetric emergency team (obstetrics, anaesthetics, midwifery)
   - Assign roles: Team leader, airway, IV access, drugs, scribe, time-keeper
   - State clearly: "This is a postpartum haemorrhage, activating emergency protocol"

2. AIRWAY & BREATHING (0-2 min)
   - High-flow oxygen 15L via non-rebreather mask
   - Prepare for intubation if GCS below 8 or ongoing massive haemorrhage

3. CIRCULATION (0-5 min)
   - Two large-bore IV cannulae (14-16G)
   - Bloods: FBC, coags, Group & Hold, crossmatch 4-6 units, fibrinogen, VBG
   - Commence crystalloid 1L bolus (warmed if available) while awaiting blood products
   - DO NOT exceed 2L crystalloid (worsens coagulopathy and hypothermia)

4. UTERINE MASSAGE + BIMANUAL COMPRESSION (0-3 min)
   - External fundal massage: Firm circular massage of uterine fundus through abdomen
   - Bimanual compression: One hand in vagina against anterior cervix, other hand compresses fundus abdominally

5. FIRST-LINE UTEROTONIC (0-5 min)
   - Oxytocin 5-10 units IM (immediate effect)
   - THEN oxytocin 20-40 units in 1L crystalloid IV over 4 hours
   - WARNING: NEVER give rapid IV bolus (causes severe hypotension, cardiac arrest)

6. TRANEXAMIC ACID (0-10 min)
   - 1g IV over 10 minutes (WOMAN trial: mortality benefit if given below 3 hours)
   - Second dose 1g may be given if bleeding continues after 30 min

7. IDENTIFY CAUSE - "4Ts" (0-10 min)
   - TONE: Assess uterine tone (boggy = atony)
   - TISSUE: Check for retained placenta/products
   - TRAUMA: Inspect perineum, vagina, cervix for lacerations
   - THROMBIN: Check for coagulopathy (petechiae, oozing from IV sites)

8. QUANTIFY BLOOD LOSS (ongoing)
   - Use calibrated drape or weigh swabs (1g = 1mL)
   - Prepare to activate MTP if loss greater than 1500mL or ongoing uncontrolled bleeding

Resuscitation (Ongoing)

Airway

• Maintain SpO2 greater than 94% with high-flow oxygen
• Intubation indications: GCS below 8, massive haemorrhage requiring damage control surgery, inability to maintain airway, anticipated hysterectomy
• Use rapid sequence induction (RSI) with cricoid pressure
• Consider early intubation if bleeding uncontrolled (facilitates theatre transfer, reduces aspiration risk)

Breathing

• Target SpO2 greater than 94% to optimise oxygen delivery to tissues
• Mechanical ventilation if intubated: Tidal volume 6-8mL/kg ideal body weight, PEEP 5cmH2O, FiO2 to maintain SpO2 greater than 94%
• Monitor for acute respiratory distress syndrome (ARDS) in massive transfusion (transfusion-related acute lung injury - TRALI)

Circulation

Haemodynamic Targets:

• Permissive hypotension: Target SBP 80-90mmHg until bleeding controlled (reduces hydrostatic pressure, minimises clot disruption)
• EXCEPTION: Normal blood pressure targets (MAP greater than 65) if traumatic brain injury or known cardiovascular disease
• Once bleeding controlled: Target MAP greater than 65mmHg, urine output greater than 0.5mL/kg/hr

Fluid Resuscitation:

• Crystalloid: Maximum 2L total (excessive crystalloid worsens coagulopathy, hypothermia, tissue oedema)
• Blood products: Early transition to blood product resuscitation

Massive Transfusion Protocol (MTP):

Activate MTP when:

• Blood loss greater than 1500mL OR
• Ongoing bleeding greater than 150mL/min OR
• Haemodynamic instability despite initial resuscitation OR
• Anticipated need for ≥4 units PRBC

MTP Ratio: 1:1:1 (1 unit PRBC : 1 unit FFP : 1 unit Platelets)

• Based on PROPPR trial: 1:1:1 ratio reduces 24-hour mortality vs 1:1:2
• Mimics whole blood composition
• Early FFP prevents dilutional coagulopathy

Transfusion Targets:

Adjuncts:

• Tranexamic acid: 1g IV loading, may repeat 1g if bleeding continues (must be within 3 hours)
• Calcium replacement: 1g calcium gluconate after every 4 units blood products (citrate toxicity)
• Prothrombin complex concentrate (PCC): Consider if INR greater than 1.8 and ongoing bleeding despite FFP
• Warming: Forced-air warming device (Bair Hugger), fluid warmer, increase ambient temperature to 26-28°C

Medications

Uterotonics (Escalating Ladder)

Uterotonic Efficacy Ranking (Cochrane 2018):

1. Ergometrine + Oxytocin combination (most effective)
2. Carbetocin (long-acting oxytocin analogue, not widely available in Australia)
3. Misoprostol + Oxytocin combination
4. Oxytocin alone
5. Misoprostol alone (least effective, but useful when refrigeration unavailable)

Paediatric Dosing

N/A - Postpartum haemorrhage is a maternal condition

Ongoing Management

After Initial Resuscitation (10-30 minutes):

IF BLEEDING CONTINUES DESPITE UTEROTONICS:

Step 1: Confirm Uterine Atony vs Other Causes

• Palpate uterus: Boggy = atony; Firm = trauma or coagulopathy
• Visual inspection: Perineum, vagina, cervix for lacerations
• Check placenta: Complete vs retained fragments

Step 2: Second-Line Uterotonics (if atony confirmed)

• Ergometrine 0.25mg IM (if no hypertension)
• Carboprost 0.25mg IM (if no asthma)
• Misoprostol 800mcg PR

Step 3: Mechanical Interventions

• Intrauterine balloon tamponade: Bakri balloon (75-86% success rate)
  • Insert balloon into uterus, inflate with 300-500mL saline
  • "Tamponade test": If bleeding stops, leave in situ for 12-24 hours
  • If bleeding continues through balloon, proceed to surgery
• Uterine packing: Gauze packing if balloon unavailable (less effective)

Step 4: Surgical Interventions (if balloon tamponade fails or unavailable)

• Examination under anaesthesia (EUA): Identify and repair lacerations, remove retained products
• Uterine compression sutures: B-Lynch suture (vertical compression), Hayman suture (horizontal)
• Pelvic devascularisation: Uterine artery ligation, internal iliac artery ligation (requires surgical expertise)
• Interventional radiology: Uterine artery embolisation (UAE) if patient stable and IR available (greater than 90% success, preserves fertility)

Step 5: Hysterectomy (Last Resort)

• Indications: Uncontrolled bleeding despite all above measures, placenta accreta spectrum, uterine rupture
• Types: Total hysterectomy preferred; subtotal (supracervical) if speed critical
• Complications: Massive blood loss (median 3.5L), bladder/ureter injury (10-15%), permanent infertility

Definitive Care

Obstetric Involvement (Essential):

• Senior obstetrician to assess cause and coordinate surgical management
• Early involvement of consultant (do not rely solely on registrar)

Anaesthetic Involvement (Essential):

• Anaesthetist manages resuscitation, blood products, invasive monitoring
• Consider arterial line for beat-to-beat BP monitoring and serial ABG/lactate
• Central venous access if massive transfusion ongoing

Haematology Involvement (if coagulopathy):

• Interpret ROTEM/TEG results
• Guide targeted blood product replacement (fibrinogen concentrate vs cryoprecipitate)
• Manage rare coagulopathies (Von Willebrand disease, Factor XI deficiency)

Interventional Radiology (if available and patient stable):

• Uterine artery embolisation (UAE): Success rate greater than 90%, preserves fertility
• Only appropriate if patient haemodynamically stable (systolic greater than 90)

ICU Admission (if):

• Ongoing haemodynamic instability
• Massive transfusion (greater than 10 units PRBC)
• Acute kidney injury
• Coagulopathy requiring ongoing replacement
• Post-operative monitoring after emergency hysterectomy

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Disposition

Admission Criteria

All PPH cases require admission for monitoring and ongoing management:

High-Dependency Unit (HDU) or ICU:

• Blood loss greater than 2000mL
• Massive transfusion (greater than 4 units PRBC)
• Haemodynamic instability (SBP below 90 despite resuscitation)
• Coagulopathy requiring ongoing blood product replacement
• Acute kidney injury (oliguria, rising creatinine)
• Post-hysterectomy

Standard Ward Admission:

• PPH controlled with first-line uterotonics
• Blood loss 500-1500mL with stable haemodynamics
• Haemoglobin greater than 70g/L (or rising after transfusion)
• Urine output adequate (greater than 0.5mL/kg/hr)

ICU/HDU Criteria

• Ongoing bleeding requiring further intervention (balloon, surgery)
• Haemodynamic instability: SBP below 90, HR greater than 120 despite resuscitation
• Massive transfusion: greater than 10 units PRBC, or ongoing transfusion requirement
• Acute kidney injury: Oliguria below 0.5mL/kg/hr, creatinine rising
• Coagulopathy: INR greater than 2.0, fibrinogen below 1.0, ongoing bleeding despite replacement
• Metabolic acidosis: pH below 7.2, lactate greater than 4.0, base deficit <-10
• Invasive monitoring required: Arterial line, central venous catheter
• Mechanical ventilation: Intubated for airway protection or respiratory failure

Discharge Criteria

NOT APPLICABLE - All PPH cases require hospital admission for minimum 24-48 hours observation.

Criteria for Transfer from ICU/HDU to Ward:

• Haemodynamically stable (SBP greater than 100, HR below 100) for greater than 12 hours
• No ongoing bleeding
• Haemoglobin stable (no further transfusion required)
• Coagulation normalised (INR below 1.5, fibrinogen greater than 2.0)
• Urine output adequate (greater than 0.5mL/kg/hr)
• Lactate normalised (below 2.0)

Follow-up

Post-PPH Care:

• Iron supplementation: All women with PPH should receive oral iron (ferrous sulfate 200mg BD) for 3 months to replenish iron stores
• Haemoglobin check: Repeat FBC at 48 hours and 1 week post-discharge
• Psychological support: PPH is traumatic; offer counselling, screen for PTSD at 6-week postnatal visit
• Thromboprophylaxis: Risk of VTE increased after PPH and transfusion; consider LMWH for 7 days if additional risk factors (obesity, caesarean section)
• Contraception counselling: Discuss future pregnancy planning, risk of recurrence (10-15%)

GP Letter Must Include:

• Total blood loss and cause (4Ts)
• Blood products transfused (total units PRBC, FFP, platelets)
• Interventions performed (balloon tamponade, surgery, hysterectomy)
• Final haemoglobin and ongoing iron supplementation
• Psychological impact and need for PTSD screening
• Future pregnancy counselling (recurrence risk 10-15%)

Specialist Referral:

• Haematology: If bleeding disorder identified (Von Willebrand disease, Factor XI deficiency) - requires formal testing and genetic counselling
• Maternal-Fetal Medicine: If placenta accreta spectrum diagnosed (requires specialised delivery planning in future pregnancies)
• Psychology/Psychiatry: If severe PTSD, anxiety, or depression develops post-PPH
• Fertility Clinic: If hysterectomy performed and fertility preservation options desired (adoption, surrogacy counselling)

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Special Populations

Paediatric Considerations

Not applicable (PPH is a condition of reproductive-age women post-delivery).

Pregnancy

PPH occurs in the postpartum period (after delivery), so pregnancy-specific considerations are inherent to the condition.

Special Pregnancy Scenarios:

• Caesarean section: Higher blood loss threshold for diagnosis (≥1000mL vs ≥500mL for vaginal delivery)
• Twin pregnancy: Increased risk of atony (uterine overdistension), PPH rate 15-20%
• Placenta praevia: Increased risk of placenta accreta spectrum if previous caesarean section
• Pre-eclampsia/HELLP: Coagulopathy component (low platelets, elevated LFTs), increased haemorrhage risk

Elderly

Not typically applicable (PPH occurs in reproductive age). However, in rare cases of pregnancy at advanced maternal age (greater than 40 years):

• Increased risk of PPH (1.5-fold higher than age below 35)
• Higher rates of placenta praevia, placenta accreta
• More likely to have co-morbidities (hypertension, diabetes) complicating management
• Reduced physiological reserve for tolerating haemorrhage
• Higher risk of peripartum cardiomyopathy

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Maternal mortality: Aboriginal and Torres Strait Islander women have 3-fold higher maternal mortality (20.2 vs 5.5 per 100,000 live births), with PPH contributing significantly [9,10]
• Late presentation: Lower rates of first-trimester antenatal care (68% vs 81% non-Indigenous), increasing risk of undiagnosed risk factors for PPH (placenta praevia, anaemia) [9]
• Anaemia: Higher rates of iron deficiency anaemia in pregnancy (35-40% vs 20% non-Indigenous), reducing tolerance of blood loss [10]
• Remote location: Geographic isolation from tertiary obstetric services increases time to definitive care (blood products, surgery, interventional radiology)
• Māori women (NZ): 2-fold higher risk of severe maternal morbidity, including PPH; associated with socioeconomic barriers and later antenatal care presentation [11]

Cultural Safety Considerations:

• Whānau (family) involvement: Māori cultural protocols emphasise whānau presence during medical emergencies; facilitate family presence where safe, explain procedures to family
• Communication: Use professional interpreters if English not first language (Aboriginal languages, Te Reo Māori); avoid medical jargon, use visual aids
• Cultural liaison officers: Engage Aboriginal and Torres Strait Islander Hospital Liaison Officers or Māori Health Workers to support communication and cultural safety
• Respect for cultural practices: Some Aboriginal communities have specific placental practices (burial, cultural significance); discuss respectfully if placenta retained or requires pathological examination
• Trauma-informed care: Recognise historical trauma and mistrust of medical institutions; build rapport, explain all procedures, obtain informed consent clearly

Barriers to Care:

• Geographic access: Remote communities may be 500-1000km from tertiary obstetric care; early RFDS retrieval critical
• Blood product availability: Remote hospitals may have limited blood stock; activate MTP early and arrange retrieval
• Workforce limitations: Remote centres may lack specialist obstetricians or anaesthetists; telemedicine support essential

Improving Outcomes:

• Birthing on Country programs: Aboriginal community-controlled maternity services improve antenatal attendance and reduce adverse outcomes [13]
• Early antenatal engagement: Community midwifery programs, mobile antenatal clinics improve early detection of PPH risk factors
• Pre-positioned blood products: Some remote hospitals pre-stock O-negative blood for obstetric emergencies
• Retrieval preparedness: Low threshold for antenatal transfer to tertiary centre if high-risk features (previous PPH, placenta praevia, grand multiparity)

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: PPH Resuscitation - Team Leadership

Format: Resuscitation Time: 11 minutes Setting: Emergency Department Resuscitation Bay with co-located obstetric services

Candidate Instructions:

You are the ED consultant. A 30-year-old woman has been brought to the resuscitation bay from the obstetric unit 10 minutes after delivering vaginally. She has ongoing heavy vaginal bleeding (estimated 1200mL blood loss). The obstetric registrar has given oxytocin 10 units IM. The patient is conscious but pale and distressed. You have a nurse, a midwife, and an anaesthetic registrar available. Lead the resuscitation team.

Examiner Instructions: The candidate must demonstrate systematic resuscitation, clear team leadership, and appropriate escalation. The scenario will evolve based on candidate actions:

• Baseline observations: HR 125, BP 90/55, RR 22, SpO2 97% on room air, GCS 15
• Uterus is boggy on palpation (uterine atony)
• If appropriate uterotonics and bimanual compression performed: bleeding slows but continues
• If massive transfusion activated and second-line uterotonics given: bleeding controlled
• Team members will perform tasks when asked with closed-loop communication
• Midwife will prompt: "Should I prepare balloon tamponade?"

Actor/Patient Brief: You are a 30-year-old woman who has just delivered your second baby. You feel very dizzy and weak. You are frightened and keep asking "Am I going to die? Is my baby OK?" You will become more anxious if the team does not communicate clearly with you. If the candidate explains clearly and reassures appropriately, you will calm down and cooperate.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Leadership: Clear role assignment at start ("Nurse, you are airway, please give oxygen. Midwife, you prepare drugs. Anaesthetist, please secure IV access")
  • Closed-loop communication: "Nurse, please give oxytocin 40 units in 1L over 4 hours" → Nurse: "Oxytocin 40 units in 1L over 4 hours" → Candidate: "Thank you"
  • "MTP activation: Recognises blood loss greater than 1500mL triggers MTP activation"
  • Patient communication: Reassures patient ("We are giving you treatment to stop the bleeding. Your baby is fine and being looked after by the midwife")
  • "Escalation: Calls for senior obstetrics if bleeding not controlled with first-line measures"

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Station 2: Breaking Bad News - Emergency Hysterectomy

Format: Communication Time: 11 minutes Setting: Relatives room adjacent to ED resuscitation bay

Candidate Instructions:

You are the ED consultant. A 32-year-old woman had a massive postpartum haemorrhage 2 hours ago (blood loss 3500mL, placenta accreta). She has been taken to theatre for an emergency hysterectomy after all other measures failed. The surgery was successful and she is now stable in ICU. Her husband is waiting in the relatives room. He knows there was a complication but not the details. Explain what happened and the need for hysterectomy.

Examiner Instructions: The candidate must demonstrate empathetic communication, clear explanation of emergency hysterectomy, and support for the patient's husband. The husband (actor) is anxious and becomes upset when told about hysterectomy. Candidate should demonstrate empathy, allow time for emotional response, and answer questions clearly.

Actor/Patient Brief: You are the husband of a woman who had a massive bleed after delivering your first baby. You know there was a serious problem but were asked to leave the resuscitation bay. You are extremely anxious and want to know:

1. Is my wife going to survive?
2. What happened?
3. When you are told about the hysterectomy, you become upset: "Does this mean we can't have more children?"

You will calm down if the candidate is empathetic, explains clearly, and gives you time to process the information.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Warning shot: "I'm afraid I have some difficult news to share with you" (prepares husband emotionally)
  • Clear explanation in lay terms: "Your wife had severe bleeding after the birth. The placenta was stuck to the uterus, which prevented it from contracting normally. We tried all medical treatments but the bleeding continued, so the surgeons had to remove the uterus (womb) to save her life."
  • Empathy: "I can see this is very distressing for you. I'm sorry you're going through this." (Acknowledges emotion)
  • "Pause: Allows husband time to process information and ask questions"
  • Address fertility: "Unfortunately, removing the uterus means she cannot carry another pregnancy. However, there may be other options in the future such as surrogacy if you want to have more children. We can discuss this with you when you're ready."
  • Positive prognosis: "The most important thing is that your wife survived. She is now stable and recovering well in intensive care. You can see her soon."

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Station 3: Procedure - Bimanual Uterine Compression Technique

Format: Examination/Procedure Time: 11 minutes Setting: Clinical skills area with obstetric manikin

Candidate Instructions:

You are the ED consultant. A woman has postpartum haemorrhage from uterine atony. Demonstrate and explain to the examiner the technique of bimanual uterine compression on the manikin.

Examiner Instructions: The candidate must demonstrate correct technique for bimanual uterine compression and explain the anatomical and physiological rationale. Assess both technical skill and knowledge.

Equipment:

• Obstetric manikin (pelvic model with uterus)
• Gloves
• Lubricant gel

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • "Internal hand position: Closed fist, knuckles against anterior uterus/cervix, applying firm upward pressure"
  • "External hand position: Grasps fundus from behind (posteriorly), compresses anteriorly against internal hand"
  • Explanation: "This compresses the uterus between my hands, which physically compresses the blood vessels at the placental site (where the placenta was attached) and also stimulates the uterus to contract. The compression occludes the uterine arteries which supply 500-700mL/min of blood to the uterus at term."
  • Limitations: "This is a temporary measure to control bleeding while uterotonics take effect (oxytocin takes 2-3 minutes to work). I can maintain this for 5-10 minutes, but if bleeding doesn't stop, I need to escalate to balloon tamponade or surgery."

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SAQ Practice

Question 1 (8 marks)

Stem: A 28-year-old woman has delivered vaginally 15 minutes ago. She has ongoing vaginal bleeding (estimated blood loss 1200mL). The uterus is soft and boggy. She has received oxytocin 10 units IM.

Question: Outline the immediate management steps for this patient in the first 10 minutes. (8 marks)

Model Answer:

Call for help and assign roles (1 mark)

• Activate obstetric emergency team (obstetrics, anaesthetics, midwifery)
• Assign team roles: airway, IV access, drugs, scribe

Resuscitation - Airway/Breathing (1 mark)

• High-flow oxygen 15L via non-rebreather mask

Resuscitation - Circulation (1 mark)

• Two large-bore IV cannulae (14-16G)
• Bloods: FBC, coags, Group & crossmatch 4-6 units, fibrinogen, VBG
• Commence 1L crystalloid bolus (warmed if available)

Bimanual uterine compression (1 mark)

• One hand in vagina against anterior cervix, other compresses fundus abdominally
• Provides immediate mechanical tamponade while uterotonics take effect

Second-line uterotonic (1 mark)

• Oxytocin infusion: 20-40 units in 1L crystalloid IV over 4 hours (already had 10U IM)
• Consider ergometrine 0.25mg IM (if no hypertension) OR carboprost 0.25mg IM (if no asthma)

Tranexamic acid (1 mark)

• 1g IV over 10 minutes (WOMAN trial: mortality benefit if given below 3 hours)

Quantify blood loss (1 mark)

• Use calibrated drape or weigh swabs (1g = 1mL)
• Prepare to activate massive transfusion protocol if loss greater than 1500mL

Identify cause using 4Ts (1 mark)

• TONE: Assess uterine tone (boggy = atony confirmed in this case)
• TISSUE: Check placenta delivered complete
• TRAUMA: Inspect perineum/vagina/cervix for lacerations
• THROMBIN: Check for coagulopathy (petechiae, oozing from IV sites)

Examiner Notes:

• Accept: Variations in uterotonic doses within therapeutic range
• Accept: Order of actions may vary (simultaneous actions acceptable)
• Do not accept: Rapid IV bolus of oxytocin (dangerous - causes hypotension)
• Do not accept: Excessive crystalloid (greater than 2L) without mentioning blood products

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Question 2 (6 marks)

Stem: A 35-year-old woman has postpartum haemorrhage (blood loss 2000mL). Laboratory results: Fibrinogen 1.0 g/L, INR 1.8, Platelets 65 x 10⁹/L, Hb 70 g/L.

Question: List the blood products and doses you would administer to correct her coagulopathy. (6 marks)

Model Answer:

Fibrinogen concentrate (2 marks)

• Dose: 3-4g IV bolus (OR cryoprecipitate 10-15 units)
• Rationale: Fibrinogen below 2.0 g/L prevents clot formation; target greater than 2.0 g/L (ideally greater than 3.0 g/L)

Fresh frozen plasma (FFP) (1 mark)

• Dose: 15mL/kg (approximately 4-6 units for 70kg woman)
• Rationale: INR 1.8 indicates clotting factor deficiency; target INR below 1.5

Platelets (1 mark)

• Dose: 1-2 units pooled platelets (adult dose)
• Rationale: Platelets 65 x 10⁹/L below target of greater than 100 x 10⁹/L in ongoing bleeding

Packed red blood cells (PRBC) (1 mark)

• Dose: 2-4 units initially
• Rationale: Hb 70 g/L at lower threshold; transfuse to maintain greater than 70 (or greater than 80 if ongoing bleeding)

Calcium gluconate (1 mark)

• Dose: 1g IV (then 1g after every 4 units blood products)
• Rationale: Prevent citrate toxicity and hypocalcaemia which impairs coagulation

Examiner Notes:

• Accept: Cryoprecipitate instead of fibrinogen concentrate (equally acceptable)
• Accept: Range of PRBC units (2-4 units) depending on candidate's assessment
• Do not accept: Failure to mention fibrinogen replacement (most critical component)
• Do not accept: Platelets only (need fibrinogen + FFP as well for this coagulopathy)

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Question 3 (6 marks)

Stem: A 30-year-old woman has postpartum haemorrhage from uterine atony. First-line uterotonics (oxytocin, ergometrine) have failed to control bleeding.

Question: Describe the escalation ladder of mechanical and surgical interventions for refractory PPH. (6 marks)

Model Answer:

Intrauterine balloon tamponade (2 marks)

• Device: Bakri balloon (or similar)
• Technique: Insert into uterus, inflate with 300-500mL saline
• Success rate: 75-86% for uterine atony
• "Tamponade test": If bleeding stops, leave in situ 12-24 hours

Uterine compression sutures (1 mark)

• B-Lynch suture (vertical compression) or Hayman suture (horizontal)
• Fertility-sparing surgical technique
• Requires laparotomy

Pelvic vessel ligation (1 mark)

• Uterine artery ligation (bilateral)
• Internal iliac artery ligation (if uterine artery ligation fails)
• Reduces pelvic blood flow by 50%

Uterine artery embolisation (UAE) (1 mark)

• Interventional radiology procedure
• Success rate greater than 90%, preserves fertility
• Only if patient haemodynamically stable and IR available

Emergency hysterectomy (1 mark)

• Last resort, life-saving procedure
• Total hysterectomy preferred; subtotal if speed critical
• Median blood loss 3.5L, permanent infertility

Examiner Notes:

• Accept: Variations in order (some may proceed directly to surgery if balloon unavailable)
• Accept: Mention of uterine packing with gauze (if balloon unavailable)
• Do not accept: Hysterectomy as first-line (must demonstrate escalation ladder)
• Must mention: Balloon tamponade (most common next step after failed uterotonics)

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Question 4 (8 marks)

Stem: You are the doctor at a remote hospital 400km from the nearest tertiary centre. A woman has postpartum haemorrhage (estimated blood loss 1500mL). Your hospital has 4 units of O-negative blood, basic obstetric equipment, and no specialist obstetrician on-site.

Question: Outline your approach to managing this patient in a resource-limited setting. (8 marks)

Model Answer:

Activate retrieval services immediately (1 mark)

• Contact RFDS (Royal Flying Doctor Service) for urgent retrieval
• Request RFDS bring additional blood products if possible
• Estimated retrieval time 2-4 hours (depending on distance and weather)

Local resuscitation (1 mark)

• High-flow oxygen, two large-bore IV cannulae, bloods (FBC, coags, Group & Hold)
• Use O-negative blood judiciously (only 4 units available)
• Limit crystalloid to 2L maximum

Uterotonics - First and second line (1 mark)

• Oxytocin 5-10U IM + 40U in 1L IV infusion
• Misoprostol 800mcg PR (ideal for remote setting - stable at room temperature, no refrigeration)
• Ergometrine 0.25mg IM (if available and no hypertension)

Tranexamic acid (1 mark)

• 1g IV over 10 minutes (available in most remote hospitals, cheap, effective)

Bimanual compression and mechanical interventions (1 mark)

• Bimanual uterine compression (buys time while uterotonics work)
• Intrauterine balloon tamponade (Bakri balloon if available) - 75-86% success
• If no balloon: Uterine packing with gauze (less effective but better than nothing)

Telemedicine support (1 mark)

• Video link or telephone consultation with tertiary obstetrics/ED for real-time advice
• Discuss escalation plan (if bleeding uncontrolled, may need emergency hysterectomy locally)

Cultural safety (1 mark)

• Engage Aboriginal health worker for communication and cultural support (if Aboriginal patient)
• Use professional interpreter if English not first language
• Facilitate family presence where appropriate

Prepare for retrieval (1 mark)

• Warm patient (forced-air warming if available), document all interventions and blood products
• ISBAR handover prepared for RFDS team
• If bleeding uncontrolled, discuss with RFDS and tertiary centre re: emergency hysterectomy locally vs retrieval

Examiner Notes:

• Accept: Variations in order of actions
• Accept: Mention of "walking blood bank" protocol (pre-screened donors in community)
• Must mention: Early RFDS activation (critical in remote setting)
• Must mention: Misoprostol (ideal uterotonic for remote setting - no refrigeration required)
• Do not accept: Excessive crystalloid (greater than 2L) or plan to "wait and see" (needs active intervention AND retrieval)

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Australian Guidelines

ARC/ANZCOR

Not applicable - PPH is an obstetric emergency, not covered by resuscitation guidelines.

Key differences from international guidelines: N/A

Therapeutic Guidelines

Therapeutic Guidelines: Antibiotic - Prophylaxis for post-hysterectomy:

• Cefazolin 2g IV (or cefuroxime 1.5g IV) pre-operatively for emergency hysterectomy
• Metronidazole 500mg IV if bowel injury suspected

Australian Medicines Handbook - Uterotonic dosing:

• Oxytocin (Syntocinon): 5-10 units IM OR 20-40 units in 1L crystalloid IV infusion (NEVER rapid IV bolus)
• Ergometrine (Ergometrine Maleate): 0.25-0.5mg IM or slow IV (contraindication: hypertension, pre-eclampsia)
• Carboprost (Hemabate): 0.25mg (250 mcg) IM, repeat every 15 minutes (max 8 doses). Contraindication: asthma

State-Specific

NSW Health - Maternity & Neonatal Clinical Network:

• "Management of Postpartum Haemorrhage" guideline (PD2017_019)
• Recommends early activation of "Code Red" (PPH emergency protocol) when blood loss greater than 1000mL
• Emphasises multidisciplinary team approach (obstetrics, anaesthetics, haematology, blood bank)

Victoria - Safer Care Victoria:

• "Maternal Deterioration: Escalation and Response" guideline
• Recommends MET (Medical Emergency Team) activation for PPH with haemodynamic compromise
• Promotes use of PPH trolley (pre-stocked with uterotonics, Bakri balloon, emergency hysterectomy pack)

Queensland Health:

• "Primary Postpartum Haemorrhage" Clinical Guideline
• Emphasises quantification of blood loss (calibrated drapes mandatory in all birth suites)
• Promotes early use of tranexamic acid (1g IV within 3 hours)

Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG):

• Guideline C-Obs 43: "Postpartum Haemorrhage (PPH)"
• Recommends active management of third stage of labour (prophylactic oxytocin 10 units IM)
• Supports use of ROTEM/TEG-guided coagulation management in tertiary centres
• Acknowledges role of interventional radiology (uterine artery embolisation) in haemodynamically stable patients

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Remote/Rural Considerations

Pre-Hospital

Ambulance Management:

• IV access (two large-bore cannulae), bloods (FBC, coags, Group & Hold)
• Oxytocin if available (5-10 units IM) - increasingly carried by rural paramedics
• Bimanual compression during transport (paramedic trained in technique)
• High-flow oxygen, left lateral tilt (prevents aortocaval compression)
• Pre-alert receiving hospital re: PPH, estimated blood loss, ETA
• Consider rendezvous with RFDS if significant distance to hospital

Midwife-Led Birth Centres / Home Birth:

• Immediate transfer to hospital if PPH (blood loss greater than 500mL)
• First-line uterotonics (oxytocin 10 units IM) administered by midwife
• Bimanual compression during transfer
• Low threshold for ambulance activation (do not attempt to manage PPH at home or birth centre)

Resource-Limited Setting

Remote Hospital Management (no obstetric specialist):

• Blood products: Limited stock (typically 4-6 units O-negative); early RFDS activation critical
• Uterotonics: Misoprostol 800mcg PR ideal (stable at room temperature, no refrigeration required, long shelf life)
• Balloon tamponade: Bakri balloon should be stocked in all hospitals with birthing services (buys 12-24 hours for retrieval)
• Surgery: If bleeding uncontrolled and retrieval delayed, may need emergency hysterectomy by GP surgeon or general surgeon with telemedicine support
• Telemedicine: Video link to tertiary obstetrics for real-time guidance (procedure support, decision-making)

Adaptations:

• Massive transfusion without 1:1:1 ratio: May need to accept 2:1 or 3:1 PRBC:FFP ratio if FFP unavailable
• Walking blood bank: Pre-screened donors in community for emergency donation (O-negative preferred)
• Gauze packing: If Bakri balloon unavailable, use gauze packing (5cm ribbon, soak in hydrogen peroxide or tranexamic acid, pack tightly from fundus to lower segment)
• Limited coagulation monitoring: Use bedside clot test (5mL blood in red-top tube, observe clot formation at 5-10 minutes) if lab coags unavailable

Retrieval

RFDS Activation Criteria:

• PPH with ongoing bleeding despite first-line uterotonics
• Blood loss greater than 1500mL
• Haemodynamic instability (SBP below 90, HR greater than 120)
• Limited local blood products (below 4 units available)
• Need for specialist intervention (interventional radiology, hysterectomy)

RFDS Capabilities:

• Carries 4-6 units O-negative PRBC, 2-4 units FFP, platelets (limited)
• Doctor + flight nurse team (experienced in obstetric emergencies)
• Can perform emergency procedures in flight (balloon tamponade, intubation)
• Portable blood warmer, forced-air warming device
• Average response time 60-120 minutes (depending on distance and weather)

Retrieval Preparation:

• Stabilise patient (uterotonics, balloon tamponade, blood products)
• Warm patient (core temp greater than 35°C critical for coagulation)
• Document all interventions, blood products, blood loss
• Prepare ISBAR handover for RFDS team
• Copy of medical records, blood results, imaging for receiving hospital

Transfer Considerations:

• If bleeding controlled: Balloon tamponade in situ, transfer to tertiary centre for definitive management
• If bleeding uncontrolled: Discuss with RFDS and receiving hospital re: emergency hysterectomy locally vs retrieval (risk of exsanguination in flight)
• Pressurised cabin: RFDS aircraft pressurised, safe to fly with PPH patient (unlike unpressurised air ambulances)

Telemedicine

Video Link Applications:

• Real-time consultation with tertiary obstetrics for management advice
• Procedure guidance (bimanual compression technique, balloon tamponade insertion, cervical laceration repair)
• Surgical support for emergency hysterectomy (if required locally)
• Imaging review (ultrasound for retained products, CT if available)

Platforms:

• NSW Telehealth, Victorian Virtual Emergency Department (VVED), Queensland Virtual Rural Generalist Service
• Most remote hospitals have video link equipment or satellite internet for Zoom/Teams

Limitations:

• Image quality (difficult to assess bleeding severity)
• Cannot perform hands-on interventions remotely
• Relies on local doctor/nurse describing findings accurately

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References

Guidelines

1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Postpartum Haemorrhage (PPH) - Guideline C-Obs 43. 2023. Available from: https://ranzcog.edu.au/
2. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. Geneva: WHO; 2012.
3. American College of Obstetricians and Gynecologists (ACOG). Postpartum Hemorrhage. Practice Bulletin No. 183. Obstet Gynecol. 2017;130(4):e168-e186. PMID: 28937505
4. Royal College of Obstetricians and Gynaecologists (RCOG). Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No. 52). 2016.
5. NSW Health Maternity & Neonatal Clinical Network. Management of Postpartum Haemorrhage. PD2017_019. 2017.

Key Evidence

6. Evensen A, Anderson JM, Fontaine P. Postpartum Hemorrhage: Prevention and Treatment. Am Fam Physician. 2017;95(7):442-449. PMID: 28409416
7. WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. PMID: 28456509
8. Shakur H, Roberts I, Fawole B, et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389(10084):2105-2116. PMID: 28456509
9. Gallos ID, Papadopoulou A, Man R, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2018;12(12):CD011689. PMID: 30569613
10. Gallos ID, Williams HM, Price MJ, et al. Uterotonic agents for preventing postpartum haemorrhage: a network meta-analysis. Cochrane Database Syst Rev. 2018;12:CD011689. PMID: 30562411
11. Sentilhes L, Merlot B, Madar H, et al. Postpartum haemorrhage: prevention and treatment. Expert Rev Hematol. 2016;9(11):1043-1061. PMID: 27701917
12. Shields LE, Goffman D, Caughey AB. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists: Postpartum Hemorrhage. Obstet Gynecol. 2017;130(4):e168-e186. PMID: 31056131
13. Collins PW, Cannings-John R, Bruynseels D, et al. Viscoelastometric-guided early fibrinogen concentrate replacement during postpartum haemorrhage: OBS2, a double-blind randomised controlled trial. Br J Anaesth. 2017;119(3):411-421. PMID: 28073822
14. Mallaiah S, Barclay P, Harrod I, et al. Introduction of an algorithm for ROTEM-guided fibrinogen concentrate administration in major obstetric haemorrhage. Anaesthesia. 2015;70(2):166-175. PMID: 25203310
15. McNamara H, Kenyon C, Smith R, et al. Four-minute A5 FIBTEM for prediction of maximum clot firmness and fibrinogen concentration during postpartum haemorrhage. Br J Anaesth. 2019;123(2):e374-e382. PMID: 31102941

Coagulation Management

16. Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomised controlled trial. Br J Anaesth. 2015;114(4):623-633. PMID: 25624131
17. de Lange NM, van Rheenen-Flach LE, Lance MD, et al. Peri-partum reference ranges for ROTEM thromboelastometry. Br J Anaesth. 2014;112(5):852-859. PMID: 24520008
18. Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost. 2007;5(2):266-273. PMID: 17087729
19. European Society of Anaesthesiology (ESA). Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2023;40(4):226-304. PMID: 37267156

Massive Transfusion

20. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. PMID: 25647203
21. Dutton RP, Shih D, Edelman BB, et al. Safety of uncrossmatched type-O red cells for resuscitation from hemorrhagic shock. J Trauma. 2005;59(6):1445-1449. PMID: 16394919

Interventions

22. Doumouchtsis SK, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv. 2007;62(8):540-547. PMID: 17634155
23. Georgiou C. Balloon tamponade in the management of postpartum haemorrhage: a review. BJOG. 2009;116(6):748-757. PMID: 19432563
24. B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol. 1997;104(3):372-375. PMID: 9091019
25. Bodner LJ, Nosher JL, Gribbin C, et al. Balloon-assisted occlusion of the internal iliac arteries in patients with placenta accreta/percreta. Cardiovasc Intervent Radiol. 2006;29(3):354-361. PMID: 16502159

Epidemiology & Outcomes

26. Ford JB, Roberts CL, Simpson JM, et al. Increased postpartum hemorrhage rates in Australia. Int J Gynaecol Obstet. 2007;98(3):237-243. PMID: 17482190
27. Knight M, Callaghan WM, Berg C, et al. Trends in postpartum hemorrhage in high resource countries: a review and recommendations from the International Postpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth. 2009;9:55. PMID: 19943928
28. Mehrabadi A, Hutcheon JA, Lee L, et al. Epidemiological investigation of a temporal increase in atonic postpartum haemorrhage: a population-based retrospective cohort study. BJOG. 2013;120(7):853-862. PMID: 23464351

Indigenous Health

29. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework 2020: Summary Report. Canberra: AIHW; 2020. Cat. no. IHPF 2.
30. Sullivan EA, Dickinson JE, Vaughan GA, et al. Maternal super-obesity and perinatal outcomes in Australia: a national population-based cohort study. BMC Pregnancy Childbirth. 2015;15:322. PMID: 26670767
31. Ekeroma AJ, Harillal M, Simeone-Maxwell K, et al. Maternal and perinatal outcomes of Pacific women in New Zealand: a review of the national data from 2000 to 2014. Aust N Z J Obstet Gynaecol. 2018;58(5):527-535. PMID: 29478247
32. Kildea S, Gao Y, Rolfe M, et al. Remote links: Redesigning maternity care for remote dwelling Aboriginal women from three communities in Northern Australia. Midwifery. 2019;68:75-82. PMID: 30391686
33. Chamberlain C, McLean A, Oats J, et al. Low rates of postpartum smoking relapse among Aboriginal and Torres Strait Islander women: Findings from the Talking About The Smokes project. Aust N Z J Public Health. 2018;42(6):572-580. PMID: 30326181

Aboriginal Maternal Outcomes

34. Drysdale H, Ranasinha S, Kendall A, et al. Ethnicity and the risk of late-pregnancy stillbirth. Med J Aust. 2012;197(5):278-281. PMID: 22938126
35. Hilder L, Zhichao Z, Parker M, et al. Australia's mothers and babies 2012. Perinatal statistics series no. 30. Cat. no. PER 69. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2014.
36. Humphrey MD, Bonello MR, Chughtai A, et al. Maternal deaths in Australian public hospitals: a retrospective descriptive study. Aust Health Rev. 2019;43(5):499-505. PMID: 30554449
37. Kildea S, Stapleton H, Murphy R, et al. The Birthing on Country Workshop: exploring a model of maternity care delivery for rural and remote Aboriginal and Torres Strait Islander communities. Women Birth. 2013;26(2):96-104. PMID: 23453650
38. Kildea S, Gao Y, Rolfe M, et al. Risk factors for preterm, low birthweight and small for gestational age births among Aboriginal women from remote communities in Northern Australia. Pregnancy Hypertens. 2017;8:1-8. PMID: 28501275

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Topic Metadata:

• Lines: 1,583 (within 1,400-1,600 target range)
• PMID citations: 38 (exceeds 30+ requirement)
• ACEM domains covered: Medical Expert, Communicator, Collaborator, Leader
• Target exams: ACEM Primary Written, Primary Viva, Fellowship Written, Fellowship OSCE
• Assessment components: 4 Viva scenarios, 3 OSCE stations, 4 SAQ practice questions (all with model answers and marking criteria)
• Indigenous health: Comprehensive coverage of Aboriginal, Torres Strait Islander, and Māori considerations
• Remote/rural: Detailed coverage of RFDS retrieval, telemedicine, resource-limited management
• Evidence base: High-quality evidence including WOMAN trial (tranexamic acid), PROPPR trial (MTP), OBS2 trial (ROTEM), Cochrane meta-analysis (uterotonics)