Transfusion protocols, algorithms and processes:

• Given that no specific transfusion criterion or protocol has been proven to be more effective than another, each hospital will need to address its specific resources and make modifications specific to its unique setting. While acknowledging the lack of firm criteria for initiating transfusion, the GDG emphasizes the importance of judicious use of blood products and suggests that health facilities should favour policies that promote their equitable use.
• Local management algorithms taking a multidisciplinary approach should be established and made available to health workers.
• A massive transfusion protocol should be available in health facilities with adequate blood banking capabilities. Massive transfusion has been variously defined but generally includes transfusion of four units of packed red blood cells (RBCs) within 1 hour when ongoing need for more blood is anticipated, transfusion of 10 or more units of packed RBCs within 24 hours, replacement of more than 50% of the total blood volume of the woman by blood products within 3 hours, or replacement of a total blood volume. Protocols should be established in agreement with local haematology departments.
• All transfusions should be done according to the clinical picture, particularly if vital signs are unstable and blood loss is significant (≥1000 mL) and ongoing. It is important to note that blood loss can be underestimated or concealed.
• The transfusion of individual blood components is preferred to whole blood alone. In settings where only whole blood is available, it should be considered, provided blood is crossmatched or low-titre type O blood is available.
• Health workers should be familiar with the procurement processes, logistic channels and potential limitations of blood product availability within their health service or network of care.
• It is essential to develop strategies and protocols to manage situations where women decline blood products because of religious beliefs, such as those of Jehovah’s Witnesses, or other personal reasons. Screening and testing:
• To ensure rapid intervention should transfusion of blood products be indicated, blood groups, phenotypes and irregular antibody screening results must be verified on admission of a woman to the labour ward. Monitoring of haematological response:
• In women with acute haemorrhage, haemoglobin levels may remain normal, making clinical evaluation crucial for timely decision-making. Point-of-care haemoglobin measurements in such cases could be falsely reassuring; therefore, they should be interpreted cautiously. Single haemoglobin or haematocrit measurements can be misleading and may delay the initiation of red cell transfusion; however, serial measurements are valuable for monitoring ongoing treatment.
• The decision to transfuse should not be based on haemoglobin levels alone, but also on the woman’s clinical needs. The following factors must be considered: morbid status, obstetric history, stage of pregnancy, evidence of organ hypoperfusion or failure, and presence of infection (e.g. pneumonia, malaria). Transfusion of blood products Red blood cells:
• If available, transfusion of red blood cells (RBCs) should be considered. Fully crossmatched RBCs should be used preferentially. When the ABO and rhesus group is known but crossmatching is not possible, ABO and rhesus-compatible uncrossmatched blood should be used. In an emergency scenario when crossmatching is not possible, O-negative RhD-negative blood should be used. The therapeutic goal is often set as haemoglobin >70 g/L.
• Type-specific or type O RhD-negative blood should be readily available and accessible in health facilities providing childbirth services. Transfusion protocols are recommended to enable the timely release of emergency blood products Fibrinogen:
• If available, transfusion of fibrinogen can be considered. The therapeutic goal is ≥2 g/L. If fibrinogen is <2 g/L, administer cryoprecipitate to achieve a target fibrinogen level of ≥2 g/L. This typically requires 3–4 g of fibrinogen, corresponding to approximately 8–10 units of cryoprecipitate, depending on the fibrinogen content per unit. If available, pathogen-reduced cryoprecipitate should be chosen.
• The effectiveness of recombinant factor VIIa and prothrombin complex concentrate remain uncertain. Fresh frozen plasma:
• If available, transfusion of fresh frozen plasma (FFP) should be considered. Transfusion of FFP should not be done for acute haemorrhage before haemostatic results are known and four units of RBCs have been transfused. AB plasma should be used if the ABO type is not known. If lab results are delayed, FFP can be administered at a ratio of 1 unit of FFP to 2 units of RBCs. The therapeutic goal is prothrombin time/ activated partial thromboplastin time <1.5 and international normalized ratio ≤1.5. Platelets:
• If available, transfusion of platelets should be considered when the patient shows clinical signs of microvascular bleeding and if concentrations fall below 50 × 109/L. The standard dose is 5–10 mL/kg. Massive PPH: In the management of massive PPH, haemostatic therapy should follow a stepwise approach:

• 1.Early TXA administration (1 g intravenously over 10 minutes).
• 2.If available, prioritization of fibrinogen replacement (fibrinogen concentrate or cryoprecipitate) over FFP when a coagulopathy is detected or highly suspected (e.g. amniotic fluid embolism, clinical symptoms).
• 3.FFP should be considered in cases of documented coagulation factor deficiency, guided by laboratory testing instead of empirical method ratios. For massive blood loss (needing to transfuse four units of RBCs) empirical ratios, for example, 1 unit of FFP to 2 units of RBCs could be used to lessen the development of dilutional coagulopathy.
• 4.If available, transfusion of platelets could be considered when the woman shows clinical signs of microvascular bleeding and if concentrations fall below 50 × 109 platelets/L. The standard dose is 5–10 mL/kg.