Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus.

OBJECTIVE: There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN: Systematic review and three-stage modified Delphi expert consensus. SETTING: International. POPULATION: Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES: Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS: Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION: These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.

Point-of-care assessment of combined umbilical arterial and venous lactate: A potential screening test for neonatal acidosis.

OBJECTIVE: To examine the relationship between point-of-care (POC) measurement of combined umbilical arterial and venous (CUAV) lactate and umbilical artery (UA) lactate to determine whether POC assessment of this sample could be an alternative screening modality for neonatal acidosis and aid prediction of neonatal morbidity. METHODS: In this cross-sectional pilot study, UA and CUAV cord blood samples were collected from live, singleton neonates delivered between June and August 2019, at a tertiary care center. UA samples were analyzed for pH and lactate using a blood gas analyzer. CUAV lactate was also assessed on a blood gas analyzer and at the POC. Linear regression was used to determine the correlation between these samples. RESULTS: A total of 152 neonates were included. There was a statistically significant correlation between CUAV lactate concentrations and UA lactate concentrations (R2  = 0.744). Additionally, CUAV lactate concentration measured at the POC was significantly correlated with that measured on a traditional blood gas analyzer (R2  = 0.928). CONCLUSION: POC testing of CUAV lactate is reliable and closely correlated with UA lactate concentrations, making POC testing of CUAV lactate a potential screening test for neonatal acidosis. More data are needed to establish standardization of this test relative to its predictive value in clinical neonatal outcomes.