[Anesthesiologists at the initial stage of postpartum hemorrhage]

Adequate management of postpartum hemorrhage (PPH) requires, after early recognition, four components undertaken simultaneously: communication, resuscitation, monitoring, investigating the cause of bleeding, arresting the bleeding. Early recognition of PPH relies on either a perceived or a quantified blood loss of 500-1000 ml and over (using a collecting bag), or the presence of clinical signs of shock (hypotension, tachycardia, tachypnea, altered mental status). Precise timing of the diagnosis of PPH must be must annotated. Once the diagnosis is established, appropriate senior professionals, including the anesthesiologist at the early stage, must be called in. The cornerstones of initial resuscitation are restoration of blood volume and oxygen carrying capacity, achieved, with adequate intravenous access, initially with cristalloids, followed by colloids, associated with oxygen by face mask. Initial resuscitation is performed and its efficiency is assessed by continuous monitoring, hemoglobin bedside tests (Hemocue), full blood count and clotting screen. Oxytocine (Syntocinon) efficacy and side-effects are evaluated by anesthesiologists. Adequate anesthetic technique must be performed to permit to the obstetricians to perform a diagnostic procedure (manual removal of placenta, uterine revision), and to most frequently obtain arrest of bleeding. Hemodynamic stability is required for loco-regional anesthesia, while on the other hand, general anesthesia with crush induction and intubation will be performed. Anesthesiologists must anticipate in case of failure of initial measures, including in alerting the blood transfusion service and calling for additional help.