This chapter describes the types, key implications and management strategies of massive obstetric haemorrhage. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality. Visible blood loss greater than 2 litres, ongoing bleeding are some key pointers of massive obstetric haemorrhage. Immediate management involves active resuscitation to ensure a patient airway, breathing and maintaining circulation with intravenous fluids, blood and blood products as well as correction of coagulopathy. In women who are not acutely compromised or bleeding severely, interventional radiology can be considered. If the bleeding is predominantly from the lower segment, a total abdominal hysterectomy is warranted. Women with massive obstetric haemorrhage often need multi-organ support. Hence, transfer to an intensive care unit or high dependency unit should be considered for monitoring. Thromboprophylaxis should be considered once the coagulation parameters return to normal.

Obstetric haemorrhage results in massive blood loss endangering the life of the mother, and the infant in the case of antepartum haemorrhage (APH). This chapter discusses placenta praevia, vasa praevia, postpartum haemorrhage (PPH), uterine atony, genital tract trauma, clotting disorders, and uterine inversion. The Confidential Enquiry into Maternal and Child Health (CEMACH) recommends that all obstetric units have a protocol for the management of obstetric haemorrhage; all individuals working in delivery units should be familiar with local guidelines. APH is a major cause of perinatal morbidity and mortality, including an increased risk of premature delivery. Placental abruption may be partial or complete separation and can occur at any stage of pregnancy. The intervention following placental abruption is dependent upon the severity of the abruption and the presence of fetal compromise. General anaesthesia with relaxation by volatile agents is the most proven anaesthetic technique to correct the inversion.

Massive obstetric haemorrhage is usually due to placenta praevia, premature placental separation or postpartum causes and is often associated with coagulopathy. Most maternal deaths associated with ectopic pregnancy, which is the most common cause of death in early pregnancy, are due to haemorrhage. Many women who have died from ectopic pregnancy presented with symptoms of urinary or gastrointestinal conditions. The main causes of antepartum haemorrhage are placenta praevia and placental abruption. A high incidence of false positive diagnosis of placenta praevia is associated with second-trimester transabdominal ultrasound scans. The most common cause of primary postpartum haemorrhage is uterine atony. The signs and symptoms of secondary postpartum haemorrhage include a rising pulse rate, falling blood pressure, pallor, sweating, restlessness and oliguria. Haemorrhage can occur suddenly and unexpectedly in any woman. However, some women are at increased risk of bleeding.