Objectives To describe transfusion management during post‐partum haemorrhage (PPH) and the usefulness of standard or point‐of‐care (POC) laboratory tests for guiding haemostatic management. Background PPH is the leading cause of maternal mortality and severe maternal morbidity worldwide. Despite the efforts made in recent years, PPH is often burdened by preventable death. Recent data from the active Italian Obstetric Surveillance System (ItOSS) highlighted the following main critical issues: inadequate communication between healthcare professionals, inability to correctly and promptly assess the severity of haemorrhage, delays in diagnosis and treatment, failure to request blood promptly and inappropriate monitoring post‐partum. Materials and Methods Data in the literature have been compared with the rotational thromboelastometry (ROTEM)‐ and the thromboelastography (TEG)‐guided algorithms applied in the authors' departments. Results PPH transfusion therapy may have an empirical approach based on the standard use of blood products or a targeted approach based on coagulation monitoring by laboratory or POC tests. Here, the authors describe how they manage PPH in their departments, according to the Italian guidelines, along with the addition of a ROTEM‐ and a TEG‐guided algorithms developed by themselves. Conclusion Although the proposed algorithms have not been validated by trials or observational studies conducted in our departments, we believe that these indications could be useful for supporting clinical practice. Furthermore, we deem it appropriate to emphasise the importance of a multidisciplinary approach and the need for standardised and shared protocols to support the decisions of healthcare professionals.

Pre-eclampsia (PE) is a clinical pregnancy-related condition, characterised by an elevated blood pressure and proteinuria. The author treated selected cases of PE with long-term epidural analgesia (LTEA), that reduced labour pain and operated directly on the PE aetiopathogenesis, not on the symptoms. A total of 15 women with PE were hospitalised at 35-37 weeks of pregnancy, checked for blood pressure, liver and renal function, platelet count and had an epidural catheter inserted for a continuous administration of an analgesic mixture of Naropin, Sufentanil and Clonidine. The average weeks at delivery were 37 weeks and 1 day; 10 women had a spontaneous delivery and five a caesarean section: the mean birth weight was 2,906 g and the Apgar scores at 1 min and 5 min exceeded 7 in all cases. All the parameters improved after hospital admission and at discharge. All the patients were discharged in good condition and no patients needed supplementary antihypertensive treatment. The LTEA utilisation for 1 week is well tolerated and improves uteroplacental perfusion, but further studies and a larger number of patients are required to evaluate this pharmacological procedure and determine its place in the management of PE.

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Purpose:  An association between epidural analgesia and dystocia in the second stage of labor remains controversial. To compare severe labor pain and dystocia at the time of epidural placement for predicting cesarean section (c.s.) risk. We hypothesized, the dystocia causes severe labor pain, such that more epidural medication is required to maintain comfort. Methods:  We examined the relationship between labor outcome and severe labor pain defined by the number of supplemental anesthetic boluses, by cervical dilatation, clinical evaluation of pelvic dimension, sonographic fetal weight and ultrasonographic examination of fetal axis in cephalic presenting deliveries. This prospective study included 375 women in labor with have singleton fetuses at term in vertex presentations. We excluded women with pre‐eclampsia, placenta previa, repeat c.s. Results:  Seventy‐nine of the 375 patients receiving early epidural analgesia were delivered by c.s. (68 due to dystocia, 11 due to fetal distress). A multiple logistic regression model evaluated demographic and labor‐related variables associations with cesarean risk. By using multivariate analysis, the odds ratio of c.s. among patients who required at least three boluses was 2.4 compared with those who required two boluses or less (P < 0.001). Variables that proved to be statistically significant in increasing the likelihood of c.s. were station at time epidural placement (P < 0.01) and severe labor pain associated with dystocia (P < 0.01). The relationship between severe labor pain‐dystocia and labor arrest (persistent occipito‐posterior or occipito‐transverse position in labor progress) we confirmed with sonography examination during the first and second stage of labor (82% of cases) (P < 0.01). Conclusions:  This is a prospective study demonstrating an association between severe labor pain and c.s. The abnormality of fetal axis exists and it can affect the progress of epidural analgesia labors. The sonographic examination in labor reducing the time of labor failure, the possibility of fetal and maternal complications. Furthermore it reduces forensis implications because of the possibility to give evidence of the intrapartum head fetal axis.

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