[Guidelines for management of critical bleeding in obstetrics]

Hemorrhage is the leading cause of maternal death. Pregnant woman can tolerate a larger amount of blood loss than non-pregnant woman, but obstetric hemorrhage is characterized by a high incidence of coagulopathy. The Japanese Society of Anesthesiologists and four related academic societies published "Guidelines for management of critical bleeding in obstetrics" in April 2010. The following points are emphasized in these guidelines. Firstly, the trend of the shock index (heart rate/systolic blood pressure) is useful to evaluate the necessity for blood transfusion. Secondly, coagulopathy should be evaluated in a timely manner and treated promptly, when blood loss including amniotic fluid exceeds 2,000 ml. Thirdly, an urgency code for hemorrhage should be introduced to facilitate communication among the related personnel with communication between the delivery/operating room and blood transfusion service. According to a triage tag in disaster medicine, code I or code red is an extreme emergency: overt hemorrhagic shock or evident massive hemorrhage. If code I is declared by the designated commander, transfusion of uncross-matched ABO-identical as well as ABO-compatible, non-identical red blood cells should be considered, if time is short or ABO-identical red blood cells are unavailable. The commander is selected from senior physicians of the anesthesiology or the obstetric department, and is responsible for crisis management. The major problems in crisis management are hesitation to declare an emergency and failure of communication. Declaration of an emergency is also essential for calling supportive medical personnel. To deal rapidly with critical bleeding, hospital actions to be taken should be prepared, and simulation exercise should be performed to correct inappropriate actions prior to an actual crisis. A systematic, not individual, approach is required to save the life of a bleeding pregnant woman.