Diagnostics and bleeding localization

Estimate of blood loss:
• Less severe: 500 - 1000 ml 
• Severe: more than 1000 ml
• Peripartum hemorrhage: rapidly increasing blood loss, clinically estimated to be above 1500 ml or as any blood loss associated with the development of    clinical and/or laboratory signs of shock/tissue hypoperfusion 

Organization of care according to estimated blood loss:
• Less severe blood loss=An obstetrician is always called 
• Severe blood loss=An anesthesiologist is always called in 
• Peripartum hemorrhage=A multidisciplinary crisis team is always activated 

Identification of the source of bleeding:
1. Palpation / bimanual examination 
2. Examination in mirrors 
3. Ultrasound examination 

Other procedures:
1. Assessment and stabilization of basic vital signs 
2. Start monitoring of basic vital signs 
3. Initiation of oxygen therapy 
4. Securing/controlling vascular access 
5. Initiation of fluid replacement/fluid resuscitation
6. Catheterization of the bladder 
7. Consider the following procedures: 
        - Uterine massage 
        - Bimanual compression of the uterus 
        - External aortic compression 

Recommended initial laboratory tests:
1. Blood count
2. Coagulation tests (aPTT, PT, antithrombin III)
3. Fibrinogen level
4. Pre-transfusion testing (blood group, screening for irregular erythrocyte antibodies, compatibility test)
5. Consider viscoelastic examination

Initial requirements for transfusion products:
1. Plasma (in the initial phase ensure availability of at least 4 T.U) 
2. Erythrocytes (in the initial phase ensure the availability of at least 4 T.U) 

Ensuring the stability of the indoor environment:
1. Acid-base balance
2. Temperature
3. Level of ionized calcium (Ca2++)

Tromboelastometry provides rapid information on acute hemostatic status, allows differentiation of the causes of bleeding and deployment of targeted treatment.