• Rare but potentially fatal neonatal event
• Can occur in the following situations:
  • damage to cord before clamping
  • massive placental abruption
  • massive acute feto-maternal haemorrhage
  • subgaleal haemorrhage
  • unintended scalpel injury during caesarean section

• Actual/suspected blood loss with haemodynamic instability or 
• Blood loss 2–3 mL/kg/hr

Hypovolaemia

• High/increasing heart rate (>160 bpm)
• Low/falling Hb or haematocrit
• Poor peripheral perfusion with slow central capillary refill (>3 sec)
• Low or falling blood pressure [mean blood pressure (MBP) <40 mmHg in a term baby]
• Presence of, or worsening, metabolic acidosis 
• Echocardiography (if available) to assess volume status
  • small systemic veins and low ventricular filling volumes can indicate hypovolaemia

• Crossmatch
• FBC
• PT 
• APTT 
• Fibrinogen 
• U&E 
• Ionised calcium
• Blood gases
• If feto-maternal haemorrhage suspected, request maternal Kleihauer test 

Major haemorrhage pathway (MHP)

Table 1: Products

Table 2: Paediatric major haemorrhage pack contents

• Note: Pack contents –these are not packs that actually exist, but provide a way of thinking through what should be needed in suitable ratios. Many centres will need to design and implement a local protocol between haematology and neonatal teams to plan for this eventuality, based on this structure and flowchart

• The following may be necessary, discuss with neonatologist:
  • elective intubation and ventilation (following resuscitative blood and blood product replacement)
  • inotropic support

• Neurodevelopment follow-up for long-term neurological outcome