Management of Anemia During Labor
For a pregnant woman with anemia presenting in labor, immediately assess hemoglobin levels and prepare for potential postpartum hemorrhage, as anemia increases transfusion risk and maternal morbidity—oral iron therapy is ineffective during active labor, so focus on supportive care, active management of third stage, and readiness for blood transfusion if needed. 1, 2
Immediate Assessment During Labor
Obtain or review recent hemoglobin/hematocrit levels to classify anemia severity: mild (Hb 10-10.9 g/dL), moderate (Hb 7-9.9 g/dL), or severe (Hb <7 g/dL). 3
Alert the blood bank and ensure type and screen is current for women with moderate to severe anemia (Hb <10 g/dL), as maternal anemia significantly increases the likelihood of requiring transfusion at delivery. 1, 2
Assess for signs of hemodynamic instability including tachycardia, hypotension, or poor perfusion, particularly in women with severe anemia (Hb <7 g/dL). 3
Intrapartum Management Priorities
Avoid interventions that increase blood loss risk including unnecessary episiotomies, instrumental deliveries when avoidable, and prolonged third stage of labor. 2
Implement active management of third stage of labor with prophylactic uterotonics (oxytocin) immediately after delivery to minimize postpartum hemorrhage risk, which is particularly dangerous in anemic women. 2
Maintain adequate intravenous access with at least one large-bore IV catheter in women with moderate to severe anemia to allow rapid fluid resuscitation or blood product administration if needed. 2
Blood Transfusion Thresholds
Consider transfusion for hemoglobin <7 g/dL even in asymptomatic women, as severe anemia poses significant maternal risk and is associated with poor pregnancy outcomes including maternal death. 3, 2
Transfuse at higher thresholds (Hb <8-9 g/dL) if the woman is symptomatic with tachycardia, dyspnea, chest pain, or if significant blood loss occurs during delivery. 2
Common Pitfalls to Avoid
Do not attempt oral iron supplementation during active labor—absorption is inadequate and gastrointestinal side effects may worsen patient discomfort; oral iron is only appropriate for postpartum management. 4, 5
Do not delay transfusion in severely anemic women (Hb <7 g/dL) awaiting "further workup"—the priority during labor is maternal stabilization and safe delivery, with diagnostic evaluation deferred to the postpartum period. 3, 2
Do not assume intravenous iron can be administered during labor—IV iron requires time for effect (days to weeks) and carries infusion reaction risks that are inappropriate to manage during active labor. 6, 1
Postpartum Planning
Initiate oral iron supplementation 60-120 mg elemental iron daily immediately postpartum for all women with documented anemia during pregnancy. 4, 5
Schedule hemoglobin reassessment at 4-6 weeks postpartum for women with anemia persisting through third trimester or excessive blood loss at delivery (>300 mL). 4
Consider intravenous iron therapy postpartum (ferric carboxymaltose preferred) for women with severe anemia (Hb <9 g/dL), oral iron intolerance, or need for rapid iron repletion. 4, 3
Refer to hematology if hemoglobin remains <9 g/dL postpartum or if anemia is unresponsive to iron therapy for further evaluation of alternative etiologies. 4