The Role of the Anesthesiologist in Management of Obstetric Hemorrhage George Gallos, MD, Imre Redai, MD, FRCA, and Richard M. Smiley, MD, PhD Hemorrhage after childbirth, whether the delivery is vaginal or operative, is a clinical situation where knowledge, communication, and the availability and utilization of resources all play prominent roles. In this article we describe the thought processes and decisions that should occur, and the actions that should be taken by the anesthesiologist in the face of suspected, expected, or unexpected hemorrhage in the labor and delivery suite. Semin Perinatol 33:116-123 © 2009 Elsevier Inc. All rights reserved. KEYWORDS hemorrhage, accreta, percreta, anesthesiologist, obstetric, transfusion “When determining a course of action, it often helps to know what you’re up against.” Henry Kissinger I n a major hospital in the largest city in the Western world, a woman is dying of postpartum hemorrhage. Her obste- trician summons expert help, who establishes venous access, obtains blood, and directs transfusion therapy while the ob- stetrician continues his effort to stop the bleeding. In many ways, it appears we are observing a modern day obstetric anesthesiologist in action. However, anesthesia is yet to be discovered. The year is 1825. The helper is James Blundell, an obstetrician and physiologist at Guy’s Hospital in London, who, next to James Young Simpson perhaps, should be re- garded as the other forefather of obstetric anesthesia. 1 Although times have undoubtedly changed, and much for the better in the area of obstetric hemorrhage, the principles remain the same. Hemorrhage is a life-threatening emer- gency. Teamwork is essential, multiple tasks need to be ac- complished quickly and with expertise, and the role of the obstetric anesthesiologist is to maintain vital functions, re- place lost blood, and provide the conditions under which hemorrhage can be controlled. In this article, we will discuss the role of the anesthesiologist in managing obstetric hemor- rhage, both anticipated and unexpected. Unexpected Obstetric Hemorrhage The clinical scenario we are discussing in this section is when the anesthesiologist is called to see and assume care for a patient with an unexpectedly high blood loss after a vaginal delivery. The approach and issues are similar when the bleed- ing occurs during an expected routine cesarean delivery, but during a cesarean delivery, the anesthesiologist is already present, usually more prepared and certainly more familiar with the patient. It is our experience that more confusion, misinterpretation, and miscommunication occurs in the case of unexpected postpartum hemorrhage outside of the oper- ating room. Arrival and Initial Assessment Upon arrival, the anesthesiologist should expeditiously re- view the medical, obstetric, and anesthetic history and exam- ine the patient with a focus on blood pressure, oxygen satu- ration and heart rate, capillary refill, and the temperature of the extremities (Table 1). Assessing core temperature at this time is useful as hypothermia may compromise coagulation status, although usually not until the temperature is 34°C or lower. Most importantly, at first contact, hemodynamic sta- tus should be correlated to estimated blood loss, and discrep- ancies should be communicated to the obstetrician. A brief examination of the airway is mandatory; the airway in the obstetric patient may change during labor, and anticipated airway problems should be communicated to the obstetrician without delay, because the need for general anesthesia for hemorrhage is unpredictable but omnipresent. Adequacy of analgesia should also be addressed. Obstetric efforts to con- trol the hemorrhage are often painful, and adequate pain Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY. Address reprint requests to Richard M. Smiley, MD, PhD, Columbia Univer- sity College of Physicians and Surgeons, Department of Anesthesiology, 630 West 168th Street PH-5, New York, NY. E-mail: rms7@columbia. edu 116 0146-0005/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.semperi.2008.12.005