Initial lab studies should be ordered and repeated as needed and at least every 4 hours, to include type & cross for six units of packed red blood cells (PRBCs), chemistry panel, complete blood count (CBC), coagulation panel, and fibrinogen. Unique to the postpartum

patient, D-Dimer studies may be sent; however interpretation must take into account that pregnancy itself results in elevated values, therefore limiting its utility [10]. At a minimum two large bore IVs (14 gauge) should be in place and if necessary, central intravenous access and Navitoclax supplier arterial lines should be inserted for central venous pressure monitoring, additional fluid infusion, continuous blood pressure monitoring and ease of subsequent lab draws. Appropriate personnel in the blood bank should be notified early and a

massive blood transfusion protocol initiated preemptively if blood transfusions are anticipated. Fluids should be replaced with the goal of matching all previous losses within the first hour. The rate is then titrated to provide maintenance fluids and make up for continued losses so appropriate vital signs can be maintained. It is prudent to limit fluids to no more than 2 L of crystalloids, 1.5 L of colloid or 2 units of type O-negative blood prior to providing cross-matched blood to the patient [11]. A more accurate assessment of volume loss can be assessed BMN673 by calculating the patient’s blood volume is (8.5-9% of a pregnant woman’s body weight) and comparing it to estimated blood loss (determined by changes in pulse, systolic blood pressure and mean arterial pressure) [12]. If bleeding persists with blood loss greater than 40% of estimated patient blood volume, packed red blood cells should be transfused [13]. Early consideration of PRBC transfusion in these patients is warranted due to their baseline moderate

hemodilution. Examination and Initial Interventions Establishing a cause of hemorrhage is the first step towards correcting the problem. The most common causes include, in decreasing incidence: uterine atony, retained products of conception, placental abnormalities, find more uterine inversion, uterine rupture, genital tract trauma and coagulopathies [14]. An initial physical exam is needed to identify atony and to repair lower genital tract trauma, as well as to identify and remove any retained placental tissue. Uterine atony refers to a floppy, flaccid uterus, one in which the myometrium is unable to contract effectively after the expulsion of the placenta leading to hemorrhage. Bimanual uterine massage should be performed, with one hand in the vagina, and the other hand placed on the abdomen at the level of the uterine fundus to stimulate uterine contraction. Retained uterine products are the most common cause of delayed (occurring more than 24 hours after birth) post partum hemorrhage [12]. In normal circumstances, uterine contractions expel the placenta within a few minutes of childbirth.