Postpartum hemorrhage: Clinical Guidelines

List of Abbreviations

BP – blood pressure

aPTT – activated partial thromboplastin time

HES – hydroxyethyl starch

DIC – disseminated intravascular coagulation

IMV – invasive mechanical ventilation

IOR – intraoperative autologous red blood cell reinfusion

CS – cesarean section

ABR – acid-base balance

INR – international normalized ratio

CBC – complete blood count

BV – blood volume

FDP/F – fibrin/fibrinogen degradation products

PT – prothrombin time

PTI – prothrombin index

PPH – postpartum hemorrhage

ARDS – acute respiratory distress syndrome

ROTEM – rotational thromboelastometry

FFP – fresh frozen plasma

TEG – thromboelastogram

US – ultrasound

RR – respiratory rate

HR – heart rate

ECG – electrocardiography

SpO₂ – oxygen saturation of capillary hemoglobin

Terms and Definitions

Physiological blood loss – blood loss <10% of BV, or <0.5-0.7% of body weight, or <5 mL/kg (<500.0 mL).

Massive blood loss – acute loss of ≥1500 mL of blood (25-30% of BV) or ≥2500 mL of blood (50% of BV) within 3 hours.

Early (primary) postpartum hemorrhage – hemorrhage occurring within ≤ 24 hours after fetal delivery.

Late (secondary) postpartum hemorrhage – hemorrhage occurring >24 hours and ≤6 weeks (42 days) postpartum.

Shock index – HR / systolic blood pressure

Uterine hypotonia – a condition characterized by a sharp decrease in uterine tone and contractility with a preserved reflex response.

DIC syndrome (disseminated intravascular coagulation, consumption coagulopathy, thrombohemorrhagic syndrome) is a clinical-pathological syndrome complicating a number of diseases. It is characterized by systemic activation of coagulation-initiating and regulating pathways capable of triggering fibrin thrombus formation. This leads to organ dysfunction associated with the consumption of platelets and clotting factors, which in turn leads to bleeding [1].

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Postpartum hemorrhage – is blood loss resulting from vaginal delivery or operative delivery via Cesarean section, equal to or exceeding 500 mL in vaginal delivery and 1000 mL or more in operative delivery, or any clinically significant volume of blood loss (leading to hemodynamic instability) occurring within 42 days after fetal delivery.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The most common causes of postpartum hemorrhage are impaired uterine contractility (90%) and birth canal trauma (7%). In 3% of cases, postpartum hemorrhages are associated with retained placental tissue or hemostatic disorders [2]. Depending on the time of onset, early (primary) and late (secondary) postpartum hemorrhages are distinguished. Early or primary postpartum hemorrhage is defined as bleeding occurring within 24 hours after delivery; after this period (up to 42 days (6 weeks) after fetal delivery), it is classified as late or secondary [3–5].¹

Main etiological factors of postpartum hemorrhage depending on the time of onset:

1. Early postpartum hemorrhage:

   • T (tonus) impaired uterine contraction (atony) – multiple pregnancy, polyhydramnios, fetal weight of 4000.0 grams or more, prolonged tocolytic therapy, labor induction or augmentation with oxytocin, general anesthesia, chorioamnionitis, large uterine myoma, intensive cord traction, fundal placental attachment, uterine inversion;

   • T (tissue) tissue (placenta) – placenta previa, morbidly adherent or increta/percreta placenta, incomplete removal of placental parts during delivery, accessory placental lobe, history of uterine surgery;

   • T (trauma) trauma – operative vaginal delivery, rapid labor, episiotomy, tears of the cervix, vagina, perineum, uterine rupture;

   • T (thrombin) blood coagulation disorders – thrombocytopenia, disseminated intravascular coagulation (DIC), HELLP syndrome, amniotic fluid embolism, hemorrhages, petechial rash, fetal death, abruptio placentae, fever, sepsis, congenital hemostatic defects (hemophilia, von Willebrand factor deficiency, etc.), severe infection, excessive infusion of crystalloids and hydroxyethyl starch preparations (ATC: Solutions affecting the water-electrolyte balance), therapeutic administration of anticoagulants (ATC: Antithrombotic agents), hypothermia [6–8].^2,3

2. Late postpartum hemorrhage:

   • retained placental tissue;

   • uterine subinvolution;

   • postpartum infection;

   • hereditary hemostatic defects.

Risk stratification for postpartum hemorrhage:

Low risk – singleton pregnancy, fewer than 4 previous deliveries, no history of uterine surgery, no history of postpartum hemorrhage.

Moderate risk – multiple pregnancy, ≥4 previous deliveries, history of Cesarean section or other uterine surgery, large uterine myoma, chorioamnionitis, labor induction or augmentation with oxytocin**.

High risk – placenta previa, morbidly adherent or increta/percreta placenta, hematocrit <30, blood loss upon admission, diagnosed coagulation defect, history of postpartum hemorrhage.

¹ Clinical guidelines (treatment protocol) "Prevention, management algorithm, anesthesia and intensive care in postpartum hemorrhages" [Letter of the Russian Ministry of Health dated March 26, 2019, No. 15-4/i/2-2535]

² Clinical guidelines (treatment protocol) "Prevention, management algorithm, anesthesia and intensive care

in postpartum hemorrhages" [Letter of the Russian Ministry of Health dated March 26, 2019, No. 15-4/i/2-2535]

³ Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/063, March 2016). Geburtshilfe Frauenheilkd. 2018 Apr; 78(4):382-399

1.3 Epidemiology of the Disease or Condition

Postpartum hemorrhage is a leading cause of maternal morbidity and mortality worldwide, affecting up to 10% of all deliveries [3,9]. In Africa and Asia, it accounts for approximately 30% of maternal deaths [4]. In the USA, postpartum hemorrhages account for 4.6% of all maternal mortality cases [10]. The region and the method of blood loss measurement influence the estimated prevalence of postpartum hemorrhage [5]. With objective assessment, the prevalence of postpartum hemorrhage is approximately 10.6%, with subjective assessment methods up to 7.2%, and with undefined assessment up to 5.4% [3,11,12]. Crucially, visual estimation of blood loss during delivery can in some cases lead to an underestimation of the blood loss volume by 30-50% [13]. The majority of deaths resulting from postpartum hemorrhage occur within the first 24 hours after delivery, accounting for approximately 2-5% [5,14].^4,5

The main complications of massive blood loss are adult acute respiratory distress syndrome (ARDS), hypovolemic shock, disseminated intravascular coagulation (DIC), acute kidney injury, loss of fertility, and pituitary necrosis (Sheehan's syndrome).⁶

⁴ WHO handbook for guideline development. Geneva, World Health Organization, 2012.

⁵ WHO recommendations for the prevention and treatment of postpartum hemorrhage Switzerland, March 2012.

⁶ ACOG. Postpartum hemorrhage. Clinical guidance practice bulletin10. 2017

1.4 Features of Coding the Disease or Condition

Chapter XV: Pregnancy, childbirth and the puerperium; Block (O60-075) Complications of labor and delivery:

O72 Postpartum hemorrhage:

O72.0 Third-stage hemorrhage;

O72.1 Other immediate postpartum hemorrhage;

O72.2 Delayed or secondary postpartum hemorrhage;

O72.3 Postpartum coagulation defects (postpartum afibrinogenemia, postpartum fibrinolysis);

O67 Labor and delivery complicated by intrapartum hemorrhage, not elsewhere classified:

O67.0 Intrapartum hemorrhage with coagulation defect

O67.8 Other intrapartum hemorrhage

O67.9 Intrapartum hemorrhage, unspecified

1.5 Classification of the disease or condition

Classification of postpartum hemorrhage:

• primary (early) postpartum hemorrhage – hemorrhage occurring within 24 hours after delivery;

• secondary (late) postpartum hemorrhage – hemorrhage occurring after 24 hours post-delivery and up to 6 weeks of the puerperium⁷.

⁷ World Health Organization. WHO recommendations on prevention and treatment of postpartum haemorrhage and the WOMAN Trial December 19, 2019.

1.6 Clinical presentation of the disease or condition

The clinical signs of postpartum hemorrhage are [12,15–17]:

• vaginal bleeding or passage of blood clots;

• deterioration of general condition (weakness, dizziness, fainting sensation, drowsiness, nausea, palpitations, seeing "floaters" before the eyes, blurred vision, etc.);

• pallor of the skin and mucous membranes;

• pain in the uterine area, lower abdomen, adnexal projection, or diffuse abdominal pain, pain radiating to the rectum or subclavian region, and bursting pain in the vagina and perineum.

In addition, the main clinical manifestations of postpartum hemorrhage depending on the cause are [16,18]:

T (tonus) – on palpation, the uterine fundus is located above the umbilicus, the consistency of the uterus is soft, and it does not contract.

T (tissue) – examination of the delivered placenta reveals a breach of its integrity or missing parts; when the separation and expulsion of the placenta are impaired, signs of placental separation are absent.

T (trauma) – inspection of the birth canal reveals tears of the cervix, vagina, and perineum;

- for vaginal or perineal hematoma – pain or a feeling of pressure in the perineum, rectum, or buttocks. On examination – a painful mass in the perineal region;

- for uterine rupture – history may include uterine surgery, tenderness in the postpartum uterus, the uterus is dense with no retained placental tissue in the presence of postpartum hemorrhage;

- uterine inversion – a firm, bright red mass in the vagina or outside the vulvar cleft (with or without the placenta). The uterus is not palpable through the anterior abdominal wall. Pain shock disproportionate to the degree of blood loss, as well as bradycardia (vagus nerve stimulation due to traction on the ovaries and fallopian tubes).

T (thrombin) – coagulopathy – prolonged blood clotting time (modified Lee-White method >7 min). Blood flowing from the uterus does not clot, clots are soft and friable.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnosis of postpartum hemorrhage is established based on:

1. Complaints and medical history;

2. Physical examination;

3. Results of laboratory and instrumental tests;

2.1 Complaints and Anamnesis

• To assess risk factors for postpartum hemorrhage at the antenatal stage, it is recommended to take a detailed obstetric and gynecological history and inquire about complaints [19–23].

GCR ALeE 2Grade of Recommendation A (Level of Evidence - 2)

Comments: Information should be gathered throughout the entire pregnancy during every outpatient and inpatient examination. Risk stratification facilitates appropriate referral of patients to level II and III hospitals, preparation, and prevention of blood loss, which collectively reduce the risk of postpartum hemorrhage and associated complications.

• History of uterine surgery (cesarean section, myomectomy, reconstructive plastic surgery, etc.);

• Changes in the hemostatic system manifested by the character of menstruation, spontaneous hematoma formation, and increased tissue bleeding tendency. Use of anticoagulants,

• Pain in the uterus, lower abdomen, adnexal projection, or diffuse abdominal pain, radiation of pain to the rectum, subclavian region, bursting pain in the vagina and perineum;

• General weakness and dizziness, drowsiness, nausea, palpitations, flashing «floaters» before the eyes, blurred vision, and other signs of anemia;

2.2 Physical Examination

⁸

• In the early postpartum period, it is recommended to assess the condition of the puerpera, taking into account the following indicators: measuring heart rate, measuring blood pressure in peripheral arteries, measuring respiratory rate, level of consciousness, condition of the skin, diuresis, state of the uterus (height of the uterine fundus, tone, tenderness), presence and nature of vaginal discharge to decide on the need for additional preventive measures and early diagnosis of postpartum hemorrhage [17,24].⁹

• All puerperas with postpartum hemorrhage are recommended to have the localization of bleeding determined (from the uterus, cervix, vagina, perineum) through visual inspection of the external genitalia, inspection of the cervix using specula, and manual exploration of the postpartum uterus [25,26].^10,11

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

⁸ The recommendations apply to all puerperas, regardless of the method of delivery.

⁹ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

¹⁰ Surveillance report 2017 – Postnatal care up to 8 weeks after birth (2006) NICE guideline CG37

¹¹ NICE. Intrapartum Care: Care of Healthy Women and their Babies during Childbirth. NICE. Clinical Guideline 190. London; 2014.

2.3 Laboratory Diagnostics

¹²

• All puerperas diagnosed with postpartum hemorrhage, with ongoing bleeding, as well as on the 1st and 3rd days postpartum, are recommended a complete (clinical) blood count (assessment of total hemoglobin, red blood cells, platelets, and hematocrit) to estimate the volume of blood loss and monitor therapeutic measures [27–30].¹³

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: In massive hemorrhage, the frequency of laboratory tests is increased.

• In postpartum hemorrhage, for the diagnosis of coagulopathy, selection and monitoring of therapeutic measures, it is recommended to perform a coagulogram (exploratory hemostasis study) to determine the following blood clotting parameters: prothrombin (thromboplastin) time in blood or plasma (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), and blood fibrinogen level [31,32].^14,15

LoR CGoE 3Level of Recommendation C (Level of Evidence - 3)

Comments: Coagulopathy can develop rapidly; therefore, in cases of ongoing blood loss, repeat determinations of blood clotting parameters must be performed (at least once every 30 minutes and with any change in the clinical situation).¹⁶ The most sensitive parameter that negatively correlates with the volume of blood loss is the fibrinogen level. In coagulopathy, the fibrinogen level drops first, even if the levels of other procoagulant factors are within the normal range [31–33].

• For the early diagnosis of coagulopathy, it is recommended to perform a «bedside test» (modified Lee-White method — clotting time of non-stabilized blood or non-activated plasma recalcification) [34].¹⁷

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: The testing technique is simple, cost-effective, and allows for the suspicion of coagulopathy and, if necessary, the initiation of therapeutic measures.

Technique: Take a pre-warmed glass tube in your hand to ensure it reaches body temperature, then draw 1 ml of venous blood from an intact vein using a needle, preferably by free flow without using a tourniquet. Discard the first few drops of blood onto a wipe to avoid contamination with tissue factors. Then, gently tilt the tube every minute while holding it tightly to check if a clot has formed. Clot formation: the blood has clotted completely, and the tube can be turned upside down. Delayed clot formation (more than 7 minutes) or the formation of a soft, friable clot that breaks down easily provides grounds to suspect coagulopathy [34].

• In postpartum hemorrhage, when feasible, viscoelastic tests (thromboelastography (TEG) or rotational thromboelastometry (ROTEM)) are recommended for the early diagnosis of coagulopathies and the selection of transfusion therapy prior to receiving coagulogram results (evaluative hemostasis study) (INR, APTT, prothrombin time, fibrinogen level) [31,35–38]¹⁸ (see Appendix A3.3).

Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)

Comments: Coagulopathy and the need for transfusion therapy do not always develop in postpartum hemorrhages. Rapid assessment of the blood coagulation system using TEG and ROTEM allows for selecting the appropriate therapy tactics and justifying the administration of a specific blood component. Studies have shown that the use of TEG and ROTEM significantly reduced blood component transfusions and associated complications [31,35,36].

• In women with symptoms of late postpartum hemorrhage, microbiological (culture) examination of female genital discharge for aerobic and facultatively anaerobic microorganisms is recommended [39–41].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: If postpartum endometritis is detected, treatment should be carried out in accordance with the clinical guidelines "Postpartum Infectious Complications".

• During intensive care for massive blood loss and anesthetic management, the recommended procedures include assessment of acid-base balance and blood gases, blood ionized calcium levels, and a general therapeutic biochemical blood test (determination of total blood protein, glucose, urea, creatinine, total bilirubin, conjugated bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase, potassium, sodium, chlorides, C-reactive protein, and lactic acid in the blood) to assess the severity of hemorrhagic shock and correct water-electrolyte disorders [42,43].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

¹² Performed in all postpartum women with postpartum hemorrhage, unless otherwise specified

¹³ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

¹⁴ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

¹⁵ Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. 2016

¹⁶ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

¹⁷ Postpartum Hemorrhage (2018) [Letter of the Ministry of Health of the Russian Federation dated March 26, 2019, No. 15-4/i/2-2535].

¹⁸ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

2.4 Instrumental Diagnostics

• To determine the cause of bleeding, a comprehensive ultrasound examination of the pelvic organs (transvaginal and transabdominal) with an assessment of the uterine cavity state and the presence of free fluid in the abdominal cavity is recommended [44–50].

GCR ALeE 2Grade of Recommendation A (Level of Evidence - 2)

2.5 Other Procedures

2.5.1 Assessment of circulating blood volume deficit20:

• In postpartum hemorrhage, to assess circulating blood volume deficit, the gravimetric method is recommended by direct collection of blood into graduated containers (collection bags, kidney dishes, cylinders, or intraoperative blood salvage devices) combined with weighing blood-soaked wipes and surgical linen [36].

GRR BLEL 2Grade of Recommendation B (Level of Evidence 2)

Comments: The use of graduated containers (collection bags, kidney dishes, cylinders, or intraoperative salvage devices) is an objective tool for assessing blood loss volume with an accuracy of 90% [51–56]. The visual method for assessing blood loss volume is associated with a 30% underestimation. The error increases with a greater circulating blood volume deficit; therefore, clinical criteria for the severity of blood loss are important [51,57].

• When assessing circulating blood volume deficit in women with postpartum hemorrhage, it is recommended to evaluate clinical symptoms of hypovolemia [58,59]²¹.

LoR CGoE 3Level of Recommendation C (Level of Evidence - 3)

Comments: During physiological pregnancy, circulating blood volume in the 3rd trimester increases by 45% and ranges from 85 to 100 ml/kg. Therapeutic measures require a cumulative assessment of blood loss volume taking into account the patient's body weight at all stages of medical care. In obese pregnant women, the total blood volume by the end of the 3rd trimester practically does not exceed that in women with normal weight (8103 ± 2452 vs. 6944 ± 2830 ml, P = 0.1), but the blood volume per kilogram of body weight is significantly lower (73 ± 22 vs. 95 ± 30 ml/kg, P = 0.007) [227].

• To assess the degree of hemorrhagic shock in women with postpartum hemorrhage, it is recommended to determine the shock index (SI) [60–62].

GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)

Comments: The shock index (the ratio of heart rate to systolic blood pressure) is an early marker of hemodynamic disorders and outperforms other parameters in identifying women at risk for adverse outcomes. Normal postpartum shock index values are 0.7–0.9. In massive obstetric hemorrhage, a shock index >1.0 can be used to assess blood loss and predict the need for blood product transfusion [60–62].

¹⁹ Applicable to all postpartum women with postpartum hemorrhage, unless otherwise specified

²⁰ Applicable to all postpartum women with postpartum hemorrhage, unless otherwise specified

²¹ Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1. Conservative treatment22:

• From the first minutes of bleeding, the organization of medical care is recommended to be carried out according to the multidisciplinary team principle with clear distribution of duties and simultaneous notification, determination of the cause of bleeding, assessment of circulating blood volume deficit, and implementation of therapeutic measures in a deployed operating room [63–68]^23,24 (see Appendices B1, B2, B4, B5).

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: From the moment bleeding occurs, continuous verbal communication with the patient is necessary, with clear information about what is happening. The following notification procedure must be observed: call a 2nd obstetrician-gynecologist and a 2nd midwife, call an anesthesiologist-resuscitator, an anesthetist nurse, a transfusiologist (if available) and a laboratory doctor (if available), and notify the obstetric distant consultation center. In case of massive hemorrhage, inform the duty administrator, call a physician skilled in vessel ligation and hysterectomy techniques, and prepare the operating room.²⁵

Comments: Ensure venous access by catheterizing 2 peripheral veins with venous catheters no larger than 16G (12G, 14G, 16G). A 14G venous catheter is used electively during labor or cesarean section. In case of hemorrhage, it is necessary to catheterize a second peripheral vein with a catheter of the same or larger diameter. The indication for placing a central venous catheter is the inability to catheterize 2 peripheral veins with large-diameter catheters. The right internal jugular vein is recommended as the access of choice. The patient should be placed in a horizontal position with the foot end of the operating table (bed) raised and kept warm.

• As first-line measures in postpartum hemorrhage, it is recommended to perform urinary bladder catheterization and external uterine massage [71].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• Aortic compression in postpartum hemorrhage is recommended as a temporary measure to stop bleeding before initiating specialized therapy [72].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• Uterotonic therapy for postpartum hemorrhage is recommended to start with an infusion of oxytocin** (see Appendix A3.1) [73].

Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)

• If uterotonic therapy with oxytocin** is ineffective, administration of #misoprostol** 800 mcg is recommended (see Appendix A3.1) [73].^26,27

Level of Evidence AGrade of Recommendation 1Level of Recommendation A (Level of Evidence — 1)

Comment: The indication for the treatment of postpartum hemorrhage is not approved for #misoprostol** in the Russian Federation; therefore, the use of #misoprostol** is possible only in life-threatening bleeding that could not be stopped with other drugs, provided there is approval by the medical commission of the medical organization. Studies have shown that regardless of the route of administration (vaginal, rectal, or sublingual), the uterotonic effect of #misoprostol** occurs in 1–2.5 hours [74]. The WHO (2012)²⁸, the International Federation of Gynecology and Obstetrics²⁹, and the Royal College of Obstetricians and Gynaecologists³⁰ recommend using #misoprostol** sublingually.

• If uterotonic therapy fails in postpartum hemorrhage, it is recommended to insert an intrauterine balloon (intrauterine hemostatic balloon catheter) – the 1st-line intervention for most women in whom uterine atony is the sole or primary cause of bleeding (Appendix B7) [75–80].

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2)

• To restore and maintain circulating blood volume (CBV) in postpartum hemorrhage, it is recommended to initiate infusion therapy immediately with balanced crystalloid solutions (ATC: Electrolytes) [81–86].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: When postpartum hemorrhage develops with hemodynamic instability, it is necessary to initiate infusion therapy with warm crystalloid solutions (ATC: Electrolytes); if arterial hypotension persists, it is necessary to continue infusion therapy with crystalloids (ATC: Electrolytes) or colloids (ATC: Blood substitutes and plasma protein fractions) up to 30 ml/kg [87]. Colloid drugs of choice are human albumin solution** (infusion solution 5% for maintaining colloid osmotic pressure, infusion solution 10% or 20% for the correction of hypoalbuminemia/hypoproteinemia) and synthetic (modified) gelatin** in a volume of no more than 1000 ml. The recommended ratio of infusion-transfusion therapy to blood loss volume is 1:1 [88]. Exceeding this ratio leads to dilutional coagulopathy and increased bleeding [89]. In massive hemorrhage, the calculation of the volume of infusion-transfusion therapy must take into account a fresh frozen plasma (FFP) volume of at least 15–20 ml/kg.³¹

• In postpartum hemorrhage, it is recommended to warm infusion solutions to 35–40°C to prevent hypothermia and associated hypocoagulation, which helps reduce the volume of blood loss [83,90–92].

GCR ALeE 2Grade of Recommendation A (Level of Evidence - 2)

• In a situation where the volume of blood loss after vaginal delivery reaches 1000 ml and bleeding continues, and/or there are clinical signs of shock, it is recommended to immediately initiate a rapid infusion of a crystalloid solution (ATC: Electrolytes) and transfer the patient to the operating room, with all subsequent therapeutic measures performed in the operating room (see Appendix B2, B5) [71].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• When diagnosing massive hemorrhage within the first 10 minutes, it is recommended that the anesthesiologist ensure venous access (catheterization of two peripheral veins with 14G–16G catheters); collection of laboratory samples (for complete blood count, coagulography [screening hemostasis test]), monitoring of vital signs (BP, HR, ECG, RR, SpO2, body temperature), and assessment of hourly diuresis [43,44,71,94].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• In severe hemorrhage, it is recommended to consider dynamic assessment of fluid responsiveness and non-invasive cardiac output monitoring using impedance cardiography or ultrasound methods for assessing volume status (echocardiography) to select the volume of infusion therapy and optimize preload [95].³²

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• Immediately upon admission to the operating room, regardless of SpO2 values, to maintain a stable oxygenation level, it is recommended to inhale humidified #oxygen via a face mask (reservoir mask) at a rate of 10–15 l/min regardless of SpO2 values [30,71,96].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)

Comments: A biological test is performed regardless of the volume and type of donation, with the exception of cryoprecipitate transfusion. During the transfusion of multiple units of donor blood components, the biological test is performed before the transfusion of each new unit of donor blood component. The biological test is also performed during emergency transfusions. For the biological test, donor blood and/or its components are transfused at a rate of 2 ml per minute for the first 15 minutes of the transfusion, while monitoring the recipient's condition.

• When prescribing blood transfusion, it is recommended to be guided by clinical and laboratory data. An absolute indication for starting a blood transfusion in ongoing postpartum hemorrhage is a hemoglobin level of less than 70 g/l, and when the hemoglobin level is above 70 g/l – the presence of signs of hemic hypoxia (tachycardia, confusion, headaches, dizziness, shortness of breath, blurred vision) [98]^34,35.

GRC BLeE 1Grade of Recommendation B (Level of Evidence – 1)

• In massive hemorrhage and the absence of laboratory data, it is recommended to initiate the implementation of the "massive transfusion protocol" as early as possible with a component ratio of donor red blood cells: FFP: platelet concentrate: cryoprecipitate – 1:1:1:1 [101–105].

GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)

Comments: The well-known 1:1, 6:4 ratio (donor red blood cells: FFP) is based on studies of traumatic hemorrhage [106–109]. There is no evidence that this ratio is also effective in the treatment of postpartum hemorrhage. If monitoring of hemostatic parameters is possible, a "controlled massive transfusion protocol" is performed with targeted administration of blood components depending on critical decreases in specific parameters [104,105,110,111] (see Appendix A3.3, B5).

In an urgent situation, for vital indications, it is possible to transfuse O(I) Rh-negative donor red blood cells, type IV FFP regardless of rhesus factor, and cryoprecipitate regardless of blood group and rhesus factor.³⁶ If apheresis-derived platelet concentrate is available, transfusion is possible regardless of blood group and rhesus factor.

• In the absence of platelet concentrate and cryoprecipitate, it is recommended to administer FFP and donor red blood cells in a 1:1 or 4:6 ratio [71,103,112–114].

GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)

• In coagulopathy and/or massive hemorrhage, it is recommended to perform FFP transfusion at a dose of 15–20 ml/kg [71,114].³⁷

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)

Comments: In the period prior to the start of plasma transfusion, it is permissible to administer coagulation factors II, VII, IX, and X in combination [Prothrombin complex]** (ATC: Blood coagulation factors) (Appendix A3.2), which includes factors II, VII, IX, and X, calculated according to the instructions: 1 IU of coagulation factor activity is equivalent to the amount in one ml of normal human plasma. If there is no effect within 20 minutes, repeat administration at the same dosage. Data on safety and efficacy in obstetrical practice are limited [115–117]. Also, if prothrombin complex concentrate products are administered, the calculated amount of required FFP must be reduced in accordance with the number of IU of the administered prothrombin complex concentrate. Transfusion of FFP carries a high risk of adverse complications – TACO and TRALI syndromes [121,122].

• When prothrombin time (PT)/aPTT values 1.5 times the upper limit of normal are detected against the background of ongoing bleeding, it is recommended to transfuse FFP [106,114,123].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: An FFP volume exceeding 15 ml/kg may be required [124].

• FFP transfusion is recommended to be started as early as possible in case of massive hemorrhage due to placental abruption or amniotic fluid embolism, as these situations are associated with early coagulopathy [125,126].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: Studies have shown that a fibrinogen level below 2 g/L is associated with an increased risk of bleeding progression and a subsequent need for blood transfusion [128]. FFP transfusion is of low efficacy, as it leads to only a slight increase in the level of fibrinogen, which plays a major role in clot formation [129]. It is known that 2 units of cryoprecipitate increase the fibrinogen level by approximately 1 g/L [127,130]. In the absence of TEG/ROTEM tests, it is recommended to calculate cryoprecipitate doses based on the circulating blood volume and body weight:

, where FGNdes is the desired fibrinogen concentration (g/L), FGNact is the actual fibrinogen concentration (g/L), BW is body weight (kg), 70 is the conversion factor of body weight to circulating blood volume, Hct is hematocrit, and 250 is the average amount of fibrinogen in mg in a single unit of cryoprecipitate.

The target fibrinogen level should be maintained at least 2 g/L, or with ROTEM FIBTEM A5 at least 12 mm [131], or with TEG angle α < 45^o [10].

• Donor platelets are recommended to be transfused at a platelet count below 50*10⁹/L and at a platelet count below 80*10⁹/L in the setting of ongoing bleeding [106].³⁹

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• During the management of massive postpartum hemorrhage, it is recommended to maintain the following parameters: hemoglobin above 70 g/L, platelet count above 50*10^9/L, PT and APTT not exceeding the normal range by 1.5 times, and fibrinogen above 2 g/L [71,106,128,131,132].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• Correction of arterial hypotension and shock is recommended to begin with plasma substitute infusion. Restoration of BCC deficit and maintenance of adequate cardiac output are ensured primarily (starting solution) by crystalloids (ATC: Solutions affecting the water-electrolyte balance) (optimally polyelectrolyte and balanced), and in case of ineffectiveness, by synthetic (modified gelatin**) and/or natural (human albumin**) colloids (ATC: Blood substitutes and plasma protein fractions) [81–84,133].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: In massive blood loss and hemorrhagic shock, infusion therapy is recommended at a volume of 30–40 mL/kg at the maximum rate, and in decompensated shock, vasopressors (ATC: Adrenergic and dopaminergic agents) should be added.

In the absence of a hemodynamic stabilization effect (systolic BP above 90 mm Hg, mean BP above 65 mm Hg) from the administration of 30–40 mL/kg of plasma substitutes within 1 hour, initiate the administration of vasopressors (ATC: Adrenergic and dopaminergic agents) and inotropic drugs (ATC: Adrenergic and dopaminergic agents) in case of a low cardiac index [134].⁴⁰ Vasopressors (ATC: Adrenergic and dopaminergic agents) must be used immediately in decompensated hemorrhagic shock and the need for emergency surgery under general anesthesia and mechanical ventilation [43].

• Infusion therapy for the estimated circulating blood volume deficit is recommended to be performed when central hemodynamic parameters can be monitored, including echocardiography (determination of cardiac output, left ventricular preload parameters, assessment of myocardial contractility), inferior vena cava diameter and collapsibility index, and the passive leg raise test. In case of limited capabilities, central venous pressure monitoring should be used [30,71,86,137,138].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: A restrictive strategy for infusion therapy solutions (ATC: Solutions affecting the water-electrolyte balance) is recommended [89,102,139–142].

• The criteria for adequate infusion therapy are recommended to be considered an increase in BP and a decrease in heart rate by 10% or more, diuresis greater than 30 mL/hour, arterial blood lactate level less than 2 mmol/L, capillary refill time less than 3 seconds, and normalization of body temperature [112].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comment: For blood loss up to 1000 mL, 15 mg/kg (on average 1000 mg) of tranexamic acid** is administered intravenously over 10 minutes, with a possible dose increase of #tranexamic acid** up to 4000 mg in case of ongoing bleeding [146,147]. Re-administration is possible after 8 hours. A high dose of tranexamic acid** can reduce blood loss volume, hemoglobin drop, and the need for donor blood product transfusions. Currently, it has been shown that timely administration of tranexamic acid** in an adequate dose helps reduce mortality, hysterectomy rates, and morbidity in women with massive hemorrhage [143]. The efficacy of etamsylate** and calcium chloride** as hemostatic agents has not been proven.

• The use of #aprotinin** for hemostatic purposes is not recommended, since studies in cardiac surgery patients revealed a direct correlation with increased mortality [148,149].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comment: #Eptacog alfa (activated)** is administered only for uncontrolled bleeding at a dosage of at least 90 mcg/kg. If necessary, administration can be repeated after 3 hours. The efficacy of the drug is noticeably reduced in hypothermia (below 34 °C), acidosis (pH below 7.2), and low platelet (less than 50*10⁹/L) and fibrinogen (<0.5 g/L) levels, so normal homeostasis must be maintained. The use of #eptacog alfa (activated)** should not delay or be considered a substitute for surgical intervention [150,155–159].

• When using coagulation factors II, VII, IX, and X in combination [Prothrombin complex]**, #eptacog alfa (activated)**, and FFP, it is recommended to mandatory monitor coagulogram parameters (rough assessment of the hemostatic system) (investigation of blood fibrinogen level, APTT, INR, PT, FDP) after 6 hours, as well as prevention of venous thromboembolic complications by prescribing anticoagulants (ATC: (B01A) Antithrombotic agents) 12 hours after cessation of bleeding (end of surgery) [96,160–163].⁴³

LeveL of Recommendation BGrade of Evidence 3LeveL of Recommendation B (Grade of Evidence - 3)

Comments: The indication for the administration of Prothrombin complex** at a dose of 10–15 IU/kg according to rotational thromboelastometry is CT EXTEM > 80 s and A5 FIBTEM ≥ 12 mm. Prevention of venous thromboembolic complications should be carried out after each case of massive blood loss and blood component transfusion cases in the absence of contraindications. The drug of choice among anticoagulants is LMWH (ATC (B01AB) Heparin group) at a prophylactic dosage (see clinical guidelines "Venous complications during pregnancy and the postpartum period. Obstetric thromboembolism").

²² Applicable to all postpartum women with postpartum hemorrhage, unless otherwise specified

²³ Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol. 2017

²⁴ National and International Guidelines for Patient Blood Management in Obstetrics: A Qualitative Review.2017.

²⁵ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

²⁶ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. 2016

²⁷ WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012

²⁸ WHO recommendations for the prevention and treatment of postpartum haemorrhage. 2012

²⁹ International Federation of Gynecology and Obstetrics. Treatment of Post-Partum Haemorrhage with Misoprostol. FIGO Guideline Annotated Version. London: FIGO; 2012.

³⁰ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

³¹ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

³² Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology]. 2016.

³³ Order of the Ministry of Health of the Russian Federation dated October 28, 2020, No. 1170n "On approval of the rules for the provision of medical care to the population in the profile 'transfusiology'"

³⁴ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

³⁵ Management of coagulopathy associated with postpartum hemorrhage: guidance from the SSC of the ISTH. 2016;

³⁶ Decree of the Government of the Russian Federation dated June 22, 2019, "On approval of the rules for harvesting, storage, transportation, and clinical use of donor blood and its components and on invalidating certain acts of the Government of the Russian Federation"

³⁷ Decree of the Government of the Russian Federation dated June 22, 2019, "On approval of the rules for harvesting, storage, transportation, and

clinical use of donor blood and its components and on invalidating certain acts of the Government of the Russian Federation"

³⁸ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

³⁹ RCOG. Prevention and Management of Postpartum Haemorrhage. Green‐top Guideline No. 52. December 2016

⁴⁰ Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology]. 2016.

⁴¹ The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition// Crit Care 2019

⁴² The Association of Anaesthetists of Great Britain and Ireland. Blood Transfusion and the Anaesthetist: Intra-operative Cell Salvage. AAGBI Safety Guideline. London: AAGBI; 2009.

⁴³ RCOG. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top Guideline No. 37a. 2015.

⁴⁴ Intraoperative blood cell salvage in obstetrics. NICE interventional procedure guidance 144. Manchester: NICE; 2005.

⁴⁵ The Association of Anaesthetists of Great Britain and Ireland. Blood Transfusion and the Anaesthetist: Intra-operative Cell Salvage. AAGBI Safety Guideline. London: AAGBI; 2009.

3.2. Surgical treatment:

• If bleeding develops during cesarean section, it is recommended to place hemostatic compression sutures in a modification mastered by the physician [76,169–173].

GoR CLoE 3Grade of Recommendation C (Level of Evidence - 3)

Comment: In the absence of effect or impossibility of applying compression sutures (e.g., a negative "compression test") in a life-threatening situation to save the patient's life and while awaiting assistance, other alternative methods of stopping bleeding may be used: a temporary tourniquet on the uterine arteries, elastic bandaging of the uterus. Compression of the abdominal aorta before and during surgery is possible ⁴⁶ and the use of other methods [174–176].

• In refractory bleeding, uterine balloon tamponade (insertion of an intrauterine balloon) and the application of hemostatic compression sutures are recommended to be used in combination [177–179].

GCR CLEL 4Grade of Recommendation C (Level of Evidence - 4)

Comments: It is possible to use a dual-balloon catheter (with uterine and vaginal modules), which provides additional advantages in the form of compression of the lower uterine segment vessels. To reduce blood loss volume, uterine balloon tamponade insertion should be continued until hysterectomy (if required).⁴⁷

Comments: Perform a lower midline laparotomy in case of bleeding after vaginal delivery or relaparotomy in case of operative delivery via cesarean section. Perform uterine devascularization, which includes: ligation/temporary clipping of major uterine vessels and/or ligation of internal iliac arteries; or endovascular embolization of uterine arteries

(if available). Separate or combined bilateral ligation of the uterine artery and vein is possible. In case of continued bleeding and ineffectiveness of the first ligature, a second ligature may be placed lower down to ligate the branches of the uterine artery supplying the lower uterine segment and cervix. If ineffective, perform ligation of the utero-ovarian vessels [180]. Ligation of the internal iliac arteries is performed by an experienced certified specialist due to the high risk of injury to the ureter and veins. If bleeding cannot be stopped after ligation of the uterine vessels, endovascular methods of hemostasis may be used: endovascular embolization of the uterine arteries, as well as temporary balloon occlusion of the abdominal aorta (endovascular balloon vascular occlusion).

• In uncontrolled bleeding, when the measures of previous stages to stop uterine bleeding are ineffective, it is recommended to perform a total laparotomic hysterectomy [76].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

Comments: If it is impossible to ensure the principle of staged surgical hemostasis (in level 1 and 2 obstetric hospitals), a total laparotomic hysterectomy should be performed as quickly as possible as the most effective method of stopping bleeding.

• If placental tissue remnants are detected in the late postpartum period (more than 24 hours after delivery), it is recommended to perform hysteroscopy and surgical removal (diagnostic fractional curettage of the uterine cavity, hysteroresectoscopy) [71,186].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

⁴⁶ WHO guidelines for the management of postpartum haemorrhage and retained placenta. 2011;

⁴⁷ RCOG. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52. December 2016

⁴⁸ RCOG. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52. December 2016

3.3. Anesthesia

• For puerperas with massive and/or ongoing postpartum hemorrhage, it is recommended to conduct intensive therapy for postpartum hemorrhage and anesthetic management, which should aim to prevent the development of: hemorrhagic shock, respiratory failure (ARDS), renal failure, liver failure, and coagulopathy [187]^49,50.

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

• In massive blood loss and hemorrhagic shock, if necessary, it is recommended to use general anesthesia with mechanical ventilation [43,188–190].⁵¹

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)

Comments: In hemorrhagic shock, the drug of choice for anesthesia induction is ketamine**. The use of other anesthetics (inhalation anesthetics, propofol**, benzodiazepines (ATX: Benzodiazepine derivatives)) is not recommended due to their negative impact on hemodynamics [43,188,189].

• Maintenance of general anesthesia in patients without signs of hypovolemic shock is recommended using any available inhalation agents or via intravenous administration of anesthetics [188,189,191–193].

GCR CLEL 5Grade of Recommendation C (Level of Evidence - 5)

Comment: Drugs for general anesthesia via intravenous administration include ketamine** (1-1.5 mg/kg), propofol** (at a dose not exceeding 2.5 mg/kg), sodium thiopental** (4-5 mg/kg), opioid drugs (ATX: Opioids). Drugs of these groups are contraindicated during breastfeeding; however, due to hemorrhage, breastfeeding is started later when these drugs are no longer detected in breast milk.

• Regional anesthesia is recommended when blood loss does not exceed 15% of the circulating blood volume deficit (no more than 1000 ml), with stable hemodynamics, hemostasis, ASA physical status II–III, and no other contraindications [86].

GCR CLOE 5Grade of Recommendation C (Level of Evidence 5)

Comments: When performing any type of regional anesthesia, it is necessary to have the capability for a rapid switch to general anesthesia [188,191,194].

• In the perioperative period during mechanical ventilation, it is recommended to monitor core vital parameters to the following extent: blood pressure, heart rate, SpO2, capnometry, thermometry, and diuresis [71,112].

LoR CGoE 5Level of Recommendation C (Grade of Evidence - 5)

⁴⁹ RCOG. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52. December 2016

⁵⁰ Committee, Queensland Clinical Guidelines Steering. Primary postpartum haemorrhage. 2018.

⁵¹ RCOG. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52. December 2016

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Prevention of venous thromboembolism in the postpartum period is carried out in accordance with the clinical guidelines "Venous complications during pregnancy and the postpartum period. Obstetric embolism".⁵²

In massive blood loss and blood transfusion, it is necessary to inform the woman about potential adverse outcomes (Sheehan's syndrome) and recommend follow-up with relevant specialists.

⁵² Russian Society of Obstetricians and Gynecologists. Clinical guidelines "Venous complications during pregnancy and the postpartum period. Obstetric embolism". 2021.

5. Prevention and Dispensary Observation

• To reduce blood loss, it is recommended to use uterotonic therapy after delivery of the fetus during cesarean section [199].^54,55

GCR ALOE 1Grade of Recommendation A (Level of Evidence - 1)

Comment: Uterotonic therapy can be performed with the following drugs: oxytocin** 1 ml (5 IU) intravenously slowly (over 1–2 min) after the birth of the fetus, or intravenously via an infusion pump at a rate of 16.2 ml/h (27 mIU/min) after the birth of the fetus, or via an IV drip at a rate of 40 drops/min (5 IU in 500 ml of sodium chloride** solution); carbetocin** 1 ml (100 mcg) intravenously immediately after the birth of the fetus slowly over 1 minute (only in the presence of risk factors for intra- and postoperative bleeding).

Comment: Oxytocin** is administered intramuscularly into the lateral thigh in a dose of 2 ml (10 IU) or intravenously in a dose of 5 IU in 500 ml of sodium chloride** solution or dextrose. Oxytocin** may be administered intravenously in a dose of 5 IU in 50 ml of sodium chloride** solution at a rate of 16.2 ml/h using a syringe pump. The oxytocin agonist carbetocin** is administered intramuscularly or intravenously slowly immediately after the birth of the baby in a dose of 100 mcg/ml [203].

Comments: Active management of the third stage of labor implies the use of uterotonics, delayed cord clamping between 1 and 3 minutes after the birth of the fetus, spontaneous delivery of the placenta, or its delivery via external maneuvers within 30 minutes. The placenta may be delivered by controlled cord traction, which should be performed exclusively by trained medical personnel attending the birth. If the medical staff lacks these skills, one must wait for signs of placental separation and deliver the placenta using external methods. Performing controlled cord traction reduces the risk of retained placenta and manual removal of the placenta [206–208].⁵⁹

• In patients who have received medical prevention of postpartum hemorrhage, routine external uterine massage is not recommended for the prevention of postpartum hemorrhage [211].^61,62

LeveL of Recommendation BGrade of Evidence 2LeveL of Recommendation B (Grade of Evidence - 2)

• Following vaginal delivery, women at high risk for hemorrhage are recommended intravenous administration of #tranexamic acid** 1.0 g (see Appendix B3) [143,212].

GCR ALEL 1Grade of Recommendation A (Level of Evidence 1)

• During cesarean section, after cord clamping, it is recommended to deliver the placenta via controlled cord traction [213–215].⁶³.

GCR ALeE 2Grade of Recommendation A (Level of Evidence - 2)

Comment: This method of placental delivery is associated with lower blood loss, a smaller postpartum drop in hematocrit, and a reduced rate of endometritis and hospital stay compared to manual placental removal and delivery.

⁵³ Applies to all postpartum women unless otherwise specified

⁵⁴ WHO recommendations: uterotonics for the prevention of postpartum haemorrhage.World Heal Organ. 2018; 53p.

⁵⁵ RAGA. Clinical guidelines "Singleton childbirth, delivery via cesarean section." 2021.

⁵⁶ RAGA. Clinical guidelines "Singleton childbirth, spontaneous delivery in occipital presentation (normal labor)." 2021.

⁵⁷ Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG An Int J Obstet Gynaecol. 2017;

⁵⁸ RAGA. Clinical guidelines "Singleton childbirth, spontaneous delivery in occipital presentation (normal labor)." 2021.

⁵⁹ RAGA. Clinical guidelines "Singleton childbirth, spontaneous delivery in occipital presentation (normal labor)." 2021.

⁶⁰ RAGA. Clinical guidelines "Singleton childbirth, spontaneous delivery in occipital presentation (normal labor)." 2021.

⁶¹ RAGA. Clinical guidelines "Singleton childbirth, spontaneous delivery in occipital presentation (normal labor)." 2021.

⁶² RAGA. Clinical guidelines "Singleton childbirth, delivery via cesarean section." 2021.

6. Organization of Medical Care

Medical care for patients with postpartum hemorrhage is provided as specialized, including high-tech, and emergency, including specialized emergency, medical care in medical organizations licensed to carry out medical activities, including works (services) in "obstetrics and gynecology (excluding the use of assisted reproductive technologies and artificial termination of pregnancy)."

Medical care for pregnant women is provided based on routing sheets that determine the category of the obstetric hospital where delivery is performed, depending on the risk degree of potential maternal and fetal complications. Indications for choosing the category of the obstetric hospital are determined based on the requirements of Order No. 1130n of the Russian Ministry of Health dated October 20, 2020, "On Approval of the Procedure for Providing Medical Care in the Profile 'Obstetrics and Gynecology'."⁶⁴ Timely antenatal identification of risk factors for postpartum hemorrhage facilitates proper patient routing to level II and III hospitals, preparation, and prevention of blood loss, which collectively reduces the risk of postpartum hemorrhage and associated complications.

⁶³ RAGA. Clinical guidelines "Singleton childbirth, delivery via cesarean section." 2021

⁶⁴ Order of the Russian Ministry of Health No. 1130n dated October 20, 2020, "On Approval of the Procedure for Providing Medical Care in the Profile 'Obstetrics and Gynecology'"

7. Additional Information

None.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Shmakov Roman Georgievich – Doctor of Medical Sciences, Professor, Professor of the RAS, Director of the Moscow Regional Research Institute of Obstetrics and Gynecology (MONIIAG). There is no conflict of interest.

2. Pyregov Aleksey Viktorovich – Doctor of Medical Sciences, Professor, Deputy Chief Physician for Anesthesiology and Intensive Care at the Moscow Regional Perinatal Center, Chief freelance specialist in obstetric anesthesiology and intensive care of the Ministry of Health of Moscow Region. There is no conflict of interest.

3. Shifman Efim Munevich – Doctor of Medical Sciences, Professor, President of the Association of Obstetric Anesthesiologists-Resuscitators (AAR), Professor of the Department of Anesthesiology and Intensive Care at the Faculty of Advanced Medical Training of the Moscow Regional Research Clinical Institute named after M.F. Vladimirsky, Honored Physician of the Republic of Karelia, expert in anesthesiology and intensive care of the Federal Service for Surveillance in Healthcare, member of the Presidium of the FAR, board member of the World Society of Intravenous Anesthesia (SIVA), (Moscow). There is no conflict of interest.

4. Baev Oleg Radomirovich – Doctor of Medical Sciences, Professor, Honored Physician of the Russian Federation, Head of the 1st Maternity Department, Head of the Department of Obstetrics and Gynecology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). There is no conflict of interest.

5. Artymuk Natalia Vladimirovna – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology named after Prof. G.A. Ushakova at Kemerovo State Medical University of the Ministry of Health of the Russian Federation, President of the Kemerovo Regional Public Organization "Association of Obstetrician-Gynecologists", Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of the Russian Federation in the Siberian Federal District, member of the Presidium of the Association of Obstetric Anesthesiologists-Resuscitators (Kemerovo). There is no conflict of interest.

6. Barinov Sergey Vladimirovich – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology No. 2 at Omsk State Medical University of the Ministry of Health of the Russian Federation, freelance expert of the territorial department of Roszdravnadzor in Omsk Region (Omsk). There is no conflict of interest.

7. Bashmakova Nadezhda Vasilievna – MD, PhD, Professor, Chief Researcher, Ural Research Institute of Maternal and Infant Care of the Russian Ministry of Health, Chief Freelance Specialist of the Russian Ministry of Health in Obstetrics and Gynecology in the Ural Federal District (Yekaterinburg). No conflict of interest.

8. Bezhenar Vitaly Fedorovich – MD, PhD, Professor, Head of the Clinic of Obstetrics and Gynecology, Head of the Department of Obstetrics, Gynecology and Neonatology, Head of the Department of Obstetrics, Gynecology and Reproductology at the Academician I.P. Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Northwestern Federal District (Saint Petersburg). There is no conflict of interest.

9. Bezrukikh Vadim Andreevich – Hematologist, Junior Researcher at the Perinatal Center of the V.A. Almazov National Medical Research Centre. There is no conflict of interest.

10. Belokrinitskaya Tatyana Evgenyevna – MD, PhD, Professor, Honored Doctor of the Russian Federation, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining at the Chita State Medical Academy of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Far Eastern Federal District, Board Member of the Russian Society of Obstetricians and Gynecologists, Presidium Member of the Association of Obstetric Anesthesiologists-Resuscitators, Deputy of the Legislative Assembly of Zabaykalsky Krai, President of the Zabaykalsky Society of Obstetricians and Gynecologists (Chita). There is no conflict of interest.

11. Vartanov Vladimir Yakovlevich – MD, PhD, Head of the Department of Resuscitation, Anesthesiology and Intensive Care at the Maternity Hospital of the Togliatti City Clinical Hospital No. 5 (Togliatti). There is no conflict of interest.

12. Volkov Alexander Borisovich – Head of the Department of Anesthesiology and Intensive Care No. 1, Irkutsk City Perinatal Center (Irkutsk). There is no conflict of interest.

13. Gorokhovsky Vadim Semenovich – Candidate of Medical Sciences, Associate Professor, Head of the Department of Anesthesiology, Resuscitation, Transfusiology and Emergency Medical Care at the Far Eastern State Medical University of the Russian Ministry of Health, Chief freelance anesthesiologist-resuscitator of the Far Eastern Federal District, Presidium Member of the Association of Obstetric Anesthesiologists-Resuscitators, Chairman of the Public Organization of Anesthesiologists-Resuscitators of Khabarovsk Krai (Khabarovsk). There is no conflict of interest.

14. Dolgushina Nataliya Vitalyevna – MD, PhD, Professor, Deputy Director - Head of the Department of Scientific Activity Organization at the V.I. Kulakovo National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, Chief freelance specialist in reproduction of the Russian Ministry of Health (Moscow). There is no conflict of interest

15. Drobinskaya Alla Nikolaevna – Candidate of Medical Sciences, Associate Professor of the V.L. Zelman Mirror Department of Anesthesiology and Intensive Care at the Institute of Medicine and Psychology of the Novosibirsk National Research State University of the Russian Ministry of Health, Chief freelance obstetric anesthesiologist-resuscitator of the Ministry of Health of the Novosibirsk Region, Honored Doctor of the Russian Federation, Presidium Member of the Association of Obstetric Anesthesiologists-Resuscitators (Novosibirsk). There is no conflict of interest.

16. Zabolotskikh Igor Borisovich – MD, PhD, Professor, Head of the Department of Anesthesiology, Resuscitation and Transfusiology of the Faculty of Advanced Training and Professional Retraining at the Kuban State Medical University of the Russian Ministry of Health, Head of the Anesthesiology and Resuscitation Service of the Regional Clinical Hospital No. 2 of the Ministry of Health of Krasnodar Krai (Krasnodar). There is no conflict of interest.

17. Kan Natalya Enkynovna – Professor, MD, PhD, Deputy Director for Research, V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation. There is no conflict of interest.

18. Klimov Vladimir Anatolyevich – Candidate of Medical Sciences, Chief freelance specialist in obstetrics of the Russian Ministry of Health, Head of the Medical Care Organization Service at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation. There is no conflict of interest.

19. Ketskalo Mikhail Valeryevich – Candidate of Medical Sciences, Deputy Director – Director of the National Medical Research Center for Anesthesiology and Resuscitation (for pregnant women), Deputy Director of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation, Presidium Member of the Association of Anesthesiologists-Resuscitators of Russia, President of ROSECMO LLC. There is no conflict of interest.

20. Kinzhalova Svetlana Vladimirovna – MD, PhD, Head of the Intensive Care and Resuscitation Department at the Ural Research Institute of Maternal and Infant Care of the Russian Ministry of Health, Member of the Association of Anesthesiologists-Resuscitators (Yekaterinburg). There is no conflict of interest.

21. Kogan Igor Yuryevich – MD, PhD, Professor, Corresponding Member of the RAS, Acting Director of the D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology (Saint Petersburg). There is no conflict of interest.

22. Krasnopolsky Vladislav Ivanovich – MD, PhD, Professor, Academician of the RAS, President of the Moscow Regional Research Institute of Obstetrics and Gynecology (Moscow). There is no conflict of interest.

23. Kukarskaya Irina Ivanovna – MD, PhD, Professor, Chief Physician of the Perinatal Center, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training at the Tyumen State Medical University of the Russian Ministry of Health, Chief freelance obstetrician-gynecologist of the Department of Health of the Tyumen Region, Presidium Member of the Association of Obstetric Anesthesiologists-Resuscitators (Tyumen). There is no conflict of interest.

24. Kulikov Alexander Veniaminovich – MD, PhD, Professor, Professor of the Department of Obstetrics, Gynecology and Transfusiology at the Ural State Medical University of the Russian Ministry of Health, Vice-President of the Association of Obstetric Anesthesiologists-Resuscitators, Board Member of the Federation of Anesthesiologists and Resuscitators (FAR), Chairman of the FAR Committee on Anesthesia and Intensive Care in Obstetrics and Gynecology (Yekaterinburg). There is no conflict of interest.

25. Kurtser Mark Arkadyevich – MD, PhD, Professor, Academician of the RAS, General Director, Board Member of Mother and Child Group of Companies, Head of the Department of Obstetrics and Gynecology of the Pediatric Faculty at the N.I. Pirogov Russian National Research Medical University of the Russian Ministry of Health (Moscow). There is no conflict of interest.

26. Malyshkina Anna Ivanovna – MD, PhD, Professor, Director of the V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Central Federal District (Ivanovo). There is no conflict of interest.

27. Marshalov Dmitry Vasilyevich – MD, PhD, Associate Professor, Leading Researcher at the National Medical Research Center for Anesthesiology and Resuscitation (for pregnant women) of the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of the Russian Federation; Associate Professor of the Department of Emergency Anesthesiology, Resuscitation and Simulation Technologies in Medicine at the V.I. Razumovsky Saratov State Medical University of the Russian Ministry of Health; Member of the FAR Committee on Anesthesiology and Intensive Care in Obstetrics, Member of the FAR Committee on Clinical Transfusiology and Hemostasiology (Moscow). There is no conflict of interest.

28. Matkovsky Andrey Anatolyevich – Candidate of Medical Sciences, Assistant Professor at the Department of Anesthesiology, Resuscitation and Transfusiology of the Faculty of Advanced Training and Professional Retraining at the Ural State Medical University of the Ministry of Health of the Russian Federation, Head of the Department of Anesthesiology, Resuscitation and Intensive Care at the Regional Children's Clinical Hospital, Regional Perinatal Center (Yekaterinburg). There is no conflict of interest.

29. Mikhailov Anton Valeryevich – MD, PhD, Professor, Chief Physician of Maternity Hospital No. 17, Professor of the Department of Obstetrics, Gynecology and Reproductology at the Academician I.P. Pavlov First Saint Petersburg State Medical University of the Russian Ministry of Health, Honored Doctor of the Russian Federation. There is no conflict of interest.

30. Alexey M. Ovezov – D.Sc. in Medicine, Associate Professor, Physician of the Highest Qualification Category, Chief freelance specialist in anesthesiology and reanimatology of the Ministry of Health of Moscow Region; Chief Researcher and Head of the Department of Anesthesiology; Head (Professor) of the Department of Anesthesiology and Reanimatology at the Faculty of Advanced Medical Training of the Moscow Regional Research Clinical Institute (MONIKI) named after M.F. Vladimirsky; Member of the Profile Commission on Anesthesiology and Reanimatology of the Ministry of Health of the Russian Federation; Member of the Board of the Federation of Anesthesiologists and Reanimatologists (FAR), Member of the FAR Committees on Education, Guidelines, and Clinical Research; Head of the CME expert group; Member of the Presidium of the Association of Obstetric Anesthesiologists-Reanimatologists, Full Member of the European Society of Anaesthesiology (ESA) and the International Anesthesia Research Society (IARS); Honorary Member of the Association of Obstetric Anesthesiologists-Reanimatologists and the Association of Anesthesiologists-Reanimatologists of the North-West (Moscow). No conflict of interest.

31. Grigory A. Penzhoyan – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics, Gynecology, and Perinatology at the Faculty of Advanced Training and Professional Retraining of Kuban State Medical University of the Russian Ministry of Health (Krasnodar). No conflict of interest.

32. Tatyana Yu. Pestrikova – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology at the Far Eastern State Medical University of the Russian Ministry of Health, Chief freelance specialist in obstetrics and gynecology of the Russian Ministry of Health in the Far Eastern Federal District (Khabarovsk). No conflict of interest.

33. Vasily A. Petrukhin – D.Sc. in Medicine, Professor, Professor at the Department of Obstetrics and Gynecology of the Faculty of Advanced Medical Training, MONIKI; Honored Doctor of the Russian Federation (Moscow). No conflict of interest.

34. Evgenia S. Polushkina – Ph.D. in Medicine, Senior Researcher at the Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

35. Andrey M. Prikhodko – D.Sc. in Medicine, Deputy Director for Scientific Work of the Institute of Obstetrics, Head of the Department of Innovative Development, Associate Professor at the Department of Obstetrics and Gynecology, Associate Professor of the Russian Academy of Sciences, obstetrician-gynecologist at the 1st Maternity Ward, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health. No conflict of interest.

36. Natalya V. Protopopova – D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology at the Irkutsk State Medical Academy of Postgraduate Education – branch of the Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Deputy Chief Physician for Obstetric Care at the Irkutsk Regional Clinical Hospital (Irkutsk). No conflict of interest.

37. Denis N. Protsenko – D.Sc. in Medicine, Chief freelance specialist in anesthesiology and reanimatology, Director of the Moscow Multidisciplinary Clinical Center "Kommunarka" of the Moscow Healthcare Department, Head of the Department of Anesthesiology and Reanimatology at the Pirogov Russian National Research Medical University of the Russian Ministry of Health, Member of the Presidium of the Association of Obstetric Anesthesiologists-Reanimatologists (Moscow). No conflict of interest.

38. Natalya Yu. Pylaeva – Ph.D. in Medicine, Associate Professor at the Department of General Surgery, Anesthesiology-Reanimatology, and Emergency Medical Care, V.I. Vernadsky Crimean Federal University, S.I. Georgievsky Medical Academy (structural unit), Simferopol. No conflict of interest.

39. Viktor E. Radzinsky – Corresponding Member of the Russian Academy of Sciences, D.Sc. in Medicine, Professor, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology at the Peoples' Friendship University of Russia (Moscow). No conflict of interest.

40. Yury S. Raspopin – Head of the Department of Anesthesiology and Reanimatology, Krasnoyarsk Regional Clinical Center for Maternal and Child Health; Assistant Professor at the Department of Anesthesiology and Reanimatology of the Institute of Postgraduate Education, Professor V.F. Voйно-Yasenetsky Krasnoyarsk State Medical University of the Russian Ministry of Health (Krasnoyarsk). No conflict of interest.

41. Oleg V. Rogachevsky – D.Sc. in Medicine, Head of the Department of Extracorporeal Treatment Methods and Detoxification, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

42. Alexander M. Ronenson – Ph.D. in Medicine, Head of the Department of Anesthesiology and Reanimatology, E.M. Bakunina Tver Regional Clinical Perinatal Center; Scientific Secretary of the Association of Obstetric Anesthesiologists-Reanimatologists; Assistant Professor at the Department of Anesthesiology, Reanimatology and Intensive Care, Tver State Medical University of the Russian Ministry of Health (Tver). No conflict of interest.

43. Oksana V. Ryazanova – Ph.D. in Medicine, Senior Researcher at the Department of Obstetrics and Perinatology, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology (Saint Petersburg). No conflict of interest.

44. Galina M. Savelieva – Academician of the Russian Academy of Sciences, D.Sc. in Medicine, Professor, Honored Scientist of the Russian Federation, Professor at the Department of Obstetrics and Gynecology, Pediatric Faculty, Pirogov Russian National Research Medical University (Moscow). No conflict of interest.

45. Yury A. Semenov – D.Sc. in Medicine, Head of the Ural Research Institute for Maternal and Infant Welfare of the Russian Ministry of Health. No conflict of interest.

46. Borislav V. Silaev – D.Sc. in Medicine, Director of the Institute of Anesthesiology-Reanimatology and Transfusiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation. No conflict of interest.

47. Viktor L. Tyutyunnik – Professor, D.Sc. in Medicine, Leading Researcher at the Center for Scientific and Clinical Research, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation. No conflict of interest.

48. Oleg V. Tysyachny – Ph.D. in Medicine, Researcher at the Center for Scientific and Clinical Research, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation

49. Ildar F. Fatkullin – D.Sc. in Medicine, Professor, Head of the Prof. V.S. Gruzdev Department of Obstetrics and Gynecology, Kazan State Medical University of the Russian Ministry of Health; Honored Scientist of the Republic of Tatarstan, Honored Physician of the Republic of Tatarstan; Chief freelance specialist of the Russian Ministry of Health in obstetrics and gynecology in the Volga Federal District; Chairman of the Public Organization of Obstetricians and Gynecologists of the Republic of Tatarstan; Member of the Board of the Russian Public Organization of Obstetricians and Gynecologists and the Russian Association of Perinatal Medicine Specialists; Member of the Presidium of the Association of Obstetric Anesthesiologists-Reanimatologists. No conflict of interest.

50. Tatyana A. Fedorova – D.Sc. in Medicine, Head of the Department of Transfusiology and Hemocorrection, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.

51. Oleg S. Filippov – D.Sc. in Medicine, Professor, Honored Doctor of the Russian Federation, Professor at the Department of Obstetrics and Gynecology of the Faculty of Advanced Training for Physicians, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Russian Ministry of Health (Moscow). No conflict of interest.

52. Marina V. Shvechkova – Head of the Anesthesiology and Intensive Care Service, Perinatal Center (Tyumen). No conflict of interest.

53. Alexey V. Shchegolev – D.Sc. in Medicine, Associate Professor, Honored Doctor of the Russian Federation, Head of the Department of Anesthesiology and Reanimatology, S.M. Kirov Military Medical Academy of the Ministry of Defense of the Russian Federation; Chief Anesthesiologist-Reanimatologist of the Ministry of Defense of the Russian Federation; Chief freelance specialist in anesthesiology and reanimatology of the Health Committee of the Government of Saint Petersburg; Member of the Presidium of the Association of Obstetric Anesthesiologists-Reanimatologists (Saint Petersburg). No conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience for these clinical guidelines:

1. obstetrician-gynecologists

2. obstetrician-gynecologist residents

Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Related documents:

• Order of the Ministry of Health of the Russian Federation No. 1130n dated October 20, 2020, "On Approval of the Rules for the Provision of Medical Care in the Field of Obstetrics and Gynecology". Federal Law No. 61-FZ dated April 12, 2010 (as amended on December 26, 2024) "On Medicinal Products Circulation".

• RUOG. Clinical Guidelines "Venous Complications During Pregnancy and the Postpartum Period. Obstetric Embolism". 2021.

• RUOG. Clinical Guidelines "Singleton Deliveries, Spontaneous Delivery in Occipital Presentation (Normal Labour)". 2021.

• Decree of the Government of the Russian Federation No. 797 dated June 22, 2019, "On Approval of the Rules for Procurement, Storage, Transportation, and Clinical Use of Donor Blood and Its Components and on Invalidation of Certain Acts of the Government of the Russian Federation"

• Order of the Ministry of Health of the Russian Federation No. 919n dated November 15, 2012 (as amended on September 14, 2018) "On Approval of the Procedure for the Provision of Medical Care to the Adult Population in the Field of Anesthesiology and Intensive Care"

• Order of the Ministry of Health of the Russian Federation No. 1170n dated October 28, 2020, "On Approval of the Procedure for the Provision of Medical Care to the Population in the Field of Transfusiology"

• National Institute for Health and Care Excellence. Antenatal Care. NICE clinical guideline 62. Manchester: NICE; 2008.

• British Committee for Standards in Haematology. UK guidelines on the management of iron deficiency in pregnancy. Br J Haematol. 2012.

• RCOG. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No. 52. December 2016

• Committee, Queensland Clinical Guidelines Steering. Primary postpartum haemorrhage. 2018.

• RCOG. Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium. Green-top Guideline No. 37a. 2015.

• Intraoperative blood cell salvage in obstetrics. NICE interventional procedure guidance 144. Manchester: NICE; 2005.

• The Association of Anaesthetists of Great Britain and Ireland. Blood Transfusion and the Anaesthetist: Intra-operative Cell Salvage. AAGBI Safety Guideline. London: AAGBI; 2009.

• Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology]. 2016.

• WHO recommendations: uterotonics for the prevention of postpartum haemorrhage.World Heal Organ. 2018;53p.

• Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52. BJOG An Int J Obstet Gynaecol. 2017;

• Blood Transfusion in Obstetrics Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 47 May 2015;

• American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology. 2015;

• Transfusion.Blood transfusion NICE guideline NG24 November 2015.

Appendix A3.1 Uterotonic drugs (ATC: Oxytocin and its analogues, ATC: Uterotonic drugs) for the treatment of postpartum hemorrhage

Appendix A3.2 Agents for prevention and management of coagulation disorders in bleeding

Appendix A3.3 Diagnosis and correction of coagulopathy during pathological and massive obstetric hemorrhage using ROTEM/TEG

Comments: FIBTEM A5/MCF values correlate with Clauss fibrinogen levels during postpartum hemorrhage and can therefore be used to identify patients with hypofibrinogenemia [217]. Fibrinogen deficiency may increase EXTEM CT; therefore, a decrease in coagulation factor levels should be verified and corrected provided that FIBTEM A5 ≥12 mm [224]. It has been proven that at FIBTEM A5 ≥12 mm, correction of fibrinogen levels is not required [218]. An EXTEM CT value of 70 sec represents the upper limit of the reference range, values above which indicate a deficiency of coagulation cascade factors [131]. A critical EXTEM CT value of 80 sec was calculated using ROC analysis [224] and confirmed in an international multicenter cohort study [226]. An observational study showed that in massive blood loss with EXTEM CT >100 sec, FFP administration reduced the use of blood products, fluid overload, and ICU stay compared to empirical red blood cell transfusion therapy (FFP:platelets in a 4:4:1 ratio) [219]. The use of tranexamic acid** in patients with abnormal and massive blood loss is essential [143]. ROTEM and TEG analyses will additionally help detect severe hyperfibrinolysis [220–223].

Appendix B. Physician Action Algorithms

Appendix B1. Obstetric and anesthetic management depending on the volume of blood loss

Appendix B2. Management algorithm for postpartum hemorrhage

Transition phase – if bleeding persists

Surgical stage against the background of continued infusion therapy and uterotonics

Appendix B3. Care algorithm for blood loss not exceeding 500 ml during vaginal delivery and 1000 ml during cesarean section

Appendix B4. Algorithm for managing postpartum hemorrhage

Appendix B5. Algorithm for managing ongoing hemorrhage exceeding 1000 mL

Appendix B6. Uterine inversion reduction procedures

Appendix B7. Intrauterine balloon catheter insertion algorithm

Main indications for uterine balloon tamponade in postpartum hemorrhage:

Ø hypotonic hemorrhage after delivery or during cesarean section;

Ø vaginal tamponade for vaginal laceration or hematoma (temporary measure).

For prophylactic purposes, uterine balloon tamponade may be used in:

Ø delivery by cesarean section;

Ø placenta previa;

Ø placenta accreta;

Ø uterine overdistention due to multiple pregnancy, polyhydramnios, macrosomia; history of hypotonic hemorrhage.

Management of postpartum hypotonic hemorrhage. Uterine balloon catheter – 10 steps.

1. Place the reservoir on a pole at a height of 45-50 cm above the level of the uterus;

2. Fill the reservoir with warm sterile 0.9% sodium chloride solution**;

3. Close the clamp on the tubing;

4. Exposing the cervix with specula, grasp it with ring forceps, and under visual control using aseptic technique, insert the uterine balloon catheter into the uterine cavity up to the fundus;

5. Maintaining contact between the distal end of the catheter and the uterine fundus, connect its open end to the reservoir tubing;

6. Open the clamp;

7. Refill the reservoir, maintaining the fluid level at approximately half of its capacity;

8. Add solution until the level in the reservoir stabilizes while holding the catheter against the uterine fundus by hand. In most cases, 350-400 ml of solution is sufficient. Ultrasound is recommended to confirm proper expansion of the uterine balloon catheter within the uterine cavity;

9. In case of an insufficient hemostatic effect, raise the reservoir by another 10-15 cm to increase the pressure of the balloon wall on the placental site;

10. The uterine balloon catheter promotes the restoration of uterine tone and contractility. Therefore, (usually within 15-60 minutes) the solution begins to empty from the catheter into the reservoir: this can be observed by the rising fluid level in the reservoir.

Uterine balloon tamponade can be considered complete when, with the hemorrhage stopped, the balloon is spontaneously expelled, shifts into the vagina or superior to the intrauterine portion of the catheter, after which the latter can be removed from the uterine cavity. The efficacy of uterine balloon tamponade in the treatment of PPH with a closed cervix exceeds 95%.

Management of postpartum hypotonic hemorrhage. Double-balloon module.

1. Insertion of the uterine catheter;

2. Insertion of the vaginal catheter up to the vaginal fornix (guided by the uterine balloon catheter);

3. Filling the vaginal catheter (150-180 ml) using a syringe;

4. Filling the uterine catheter according to the method described above;

5. Monitoring the amount of genital tract discharge and the fluid level in the reservoir;

6. After 4-6 hours, draining the fluid from the vaginal catheter cuff;

7. Lowering the reservoir level, emptying and removing the uterine catheter.

Two-balloon technique for controlled tamponade during cesarean section

1. Place the reservoir on a stand 50 cm above the level of the uterus, close the clamp, and fill with sterile warm normal saline;

2. The operating surgeon inserts the uterine catheter retrogradely through the hysterotomy incision using a guide plug. Advance the balloon catheter cranially until it contacts the uterine fundus;

3. Suture the uterine incision without stitching through the balloon;

4. Holding the balloon, the assistant removes the guide, connects the balloon to the reservoir tubing, opens the clamp, and fills the balloon (300–400 ml);

5. Upon completion of the surgery, transfer the patient to the ICU with the clamp closed;

6. Open the clamp, monitor the fluid level in the balloon; if the level increases by 2 graduations, lower the reservoir by a corresponding height, repeating this action until the height reaches 10–15 cm;

7. Remove the balloon after 2–3 hours or once a height of 10–15 cm above the uterine level is reached.

Stage I (preoperative):

1. Insertion of the vaginal catheter;

2. Positioning relative to the anatomical axis and vaginal fornix (minus 1 cm);

3. Connecting the prepared syringe without inflating the cuff.

Stage II (during cesarean section, immediately after delivery of the placenta):

1. Inflating the vaginal module cuff with warm normal saline (150–180 ml).

Stage III (during cesarean section):

1. Placement of the uterine catheter according to the method described above.

Stage IV (post-cesarean section):

1. Monitoring the amount of genital tract discharge and the fluid level in the reservoir;

2. After 4–24 hours (depending on the severity of the situation and certainty of hemostasis), drain the fluid from the vaginal module cuff, lower the reservoir level, empty and remove both the uterine and vaginal catheters.

Postpartum vaginal lacerations and hematomas

The vaginal catheter is used when complete cessation of bleeding is not achievable, as a temporary or supplementary measure following surgical interventions (wound closure, suturing of the hematoma bed). Depending on the severity of the postpartum vaginal injury, vaginal packing is maintained for up to 24–36 hours. While the filled balloon is in the vagina, monitoring of genital tract discharge volume and continuous bladder catheterization are required.

Appendix B8. Intraoperative autologous red blood cell reinfusion technology

For intraoperative autologous red blood cell reinfusion (IAR), Cell Saver or Cats autotransfusion devices and disposable administration sets are used.

Contraindications to intraoperative autologous red blood cell reinfusion in obstetrics.

Absolute contraindications:

- presence of purulent contents in the abdominal cavity;

- presence of intestinal contents in the abdominal cavity;

- presence in the shed blood of substances contraindicated for intravascular administration (hydrogen peroxide, distilled water, collagen-based hemostatic agents, etc.).

Methodology: The principle of the procedure involves aspirating shed blood from the surgical wound, processing it in the device, and subsequently reinfusing the resulting autologous red blood cell suspension (Hct 60%) back into the patient's vascular bed.

Priming of the disposable sets is performed in the operating room prior to surgery.

The sterile suction tubing is handed to the surgical nurse.

Collection of blood shed into the wound is performed by the second assistant. The negative pressure generated by the vacuum aspirator must not exceed 100 mmHg.

Blood aspirated from the wound is mixed with an anticoagulant solution (ATC: antithrombotic agents), passes through a filter that retains tissue particles and blood clots, and collects in the reservoir. Once the volume of collected blood reaches the reservoir capacity, the first phase of device operation begins – filling the wash bowl (bowl).

This phase consists of several steps:

1. Acceleration of the centrifuge to 5600 rpm;

2. Transfer of blood from the reservoir to the wash bowl using a peristaltic pump, initiating the centrifugation process;

3. Filling of the wash bowl continues until red blood cells fill the entire bowl volume (bowl volume may be 125 ml, 175 ml, or 225 ml). Plasma separated during centrifugation is removed along with the anticoagulant (ATC: antithrombotic agents) into a designated container. Thereafter, the second phase begins automatically or manually – washing the red blood cells with sterile normal saline (sodium chloride solution).

Washing continues until the specified volume of washing solution (1000–1500 ml in obstetrics) has completely passed through the red blood cells. Centrifugation is maintained throughout this process.

The final phase of device operation – emptying the bowl:

1. The centrifuge stops, and the peristaltic pump begins rotating in reverse;

2. Washed autologous red blood cells are pumped from the wash bowl into the reinfusion bag;

The process is then repeated until all blood aspirated from the wound has been processed. The duration of the first described cycle is 3–5 minutes.

During operation, the device display clearly shows all required parameters: centrifuge speed, pump speed, and volume of processed solution. After each operating cycle, the volume of collected and washed red blood cells is displayed.

Autologous red blood cell reinfusion must be performed using a leukocyte filter within a maximum of 6 hours after obtaining the autologous red blood cells.

Autologous red blood cell reinfusion is an effective method for restoring globular volume in hemorrhages occurring during cesarean section. IAR is recommended for women with an anticipated intraoperative blood loss exceeding 20% of total blood volume (TBV).

IAR must be performed exclusively by qualified personnel who regularly carry out the procedure and possess the necessary knowledge and experience. Patient consent for IAR must be obtained. The use of IAR in obstetric hospitals should be subject to audit and monitoring. Limitations of the method are primarily related to the availability of appropriate personnel and equipment.

The use of IAR minimizes the use of donor blood components in hemorrhages of any volume and avoids massive blood transfusion syndrome, while significantly improving the postoperative course and shortening hospital stay.

Appendix C. Patient Information

During pregnancy, the patient must be informed about potential complications, primarily the possibility of bleeding during pregnancy, labor, and the postpartum period.

Any signs of genital tract bleeding or fetal status changes require immediate consultation with an obstetriciangynecologist.

The patient must be informed that the development of massive hemorrhage may necessitate surgical treatment, blood component transfusion, central venous catheterization, and the administration of coagulation factors.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

No.