Essay 292-PPH

a) management would include

HISTORY

Enquire about pain and need for pain relief

Inform senior obstetrician and anaesthetist and call for help

Ask for PPH pack.

EXAMINATION

Pulse, BP,feel for the uterus whether it is contracted or relaxed to ascertain the cause of bleeding.

Examine per vaginum to rule out any trauma causing bleeding.

INVESTIGATIONS

send blood for group and save and inform the lab and haematologist

clotting screen and FBC.

TREATMENT

Gain i/v access with 2 wide bore cannulae and crystalloids till the blood is available.

start with uterotonics like oxytocin 40 u in 500ml normal saline or 0.25mg ergometrine if not contraindicated or i/m carboprost can  also be used.misoprost 800 microgm can also be given p/r.

simultaneous bimanual uterine massage can be done if uterus is relaxed.

put in indwelling catheter to drain the bladder and monitor urine output.

if trauma is suspected ,go for repair in OT with a good lighting ,assistant and under supervision of a senior staff.

b) Shift the patient to OT.

Make blood available in OT.

Keep the family informed fully about the patients condition and interventions  taken.

various options available should be explained to the woman and written/verbal consent taken for hysterectomy.

options available are 

B-lynch sutures

Balloon tamponade with Sengstaken Blakemore tube or Rusch catheter filled with 300ml saline.

Devascularisation including uterine artery ligation and internal iliac  artery ligation which requires expertise and is time consuming.

A decision for hysterectomy taken early would save patient s life.

A proper documentation of series of events ,timing and the interventions is equally important and so is the filling of an incident form.

a.        Postpartum hemorrhage is an obstetric emergency. I will call for help initially with the oncall doctors and midwives and alert consultant obstetrician, consultant anesthetist, hematologist, blood bank and operation theater staff. I will assess the patient’s vital signs, airways, breathing and circulation. 2 large bore cannulae will be inserted to draw blood for full blood count, clotting profile and crossmatch with at least for units of blood and at the same time start intravenous fluid resuscitation with crystalloids and colloids while awaiting for blood and or blood products. I will try to identify the cause of hemorrhage by abdominal, vaginal examination and checking for placenta and membranes if complete.  I will initiate uterine massage, empty the bladder and start uterotonics  and step up from syntocinon 5unit iv slowly to ergometrin 0.5mg im/iv (if not hypertensive or cardiac) to syntocinon infusion 40units in 500mls of hartmann’s solution to carboprost 0.25mg im at an interval of 15min for a maximum of 8 doses and lastly misoprostol 800mcg per rectal.

b.    If the pharmacological measures fail to stop the bleeding i will shift the patient to the operation theater. Patient and her partner should be informed about the current situation and written consent obtained stating the possibility of hysterectomy as a last resort. I would consider intrauterine balloon temponade with sengstaken catheter or Bakri balloon as a 1^st line surgical management. If it fails we proceed with the conservative surgical procedures with the help of the available expertise. These include compression sutures eg B-lynch, bilateral uterine artery ligation or internal ilac artery ligationa and uterine artery embolization. Last resort should be hysterectomy with ovarian conservation; and it should be decided sooner rather than later. Subsequently she should be nursed in intensive care unit.

Debriefing to the patient and family members is important. Proper documentation,auditing and incident reporting should be maintained.

         a)     This is a scene of major PPH. First of all I will care for additional help. I will call experienced midwife, obstetri & anaesthetic of middle  grade & alert the consultants . Also I will alert haematologist  & blood transfusion  lab. I will call porters  for delivery of blood samples and blood. I will alert one person to record all the on going  events and fluid, drugs given .

 I will assess her airway and breathing. I will evaluate circulation and administer oxygen by mask at the rate of 10-15 litres per minute.  I will insert two 14 gauge cannula intravenously to administer fluids and blood. Also 20 ml of blood taken for FBC, Crossmatch 4 units, renal and liver function tests, coagulation screen. I will arrange to transfuse  blood as soon as possible . By that time she can be infused 2 litres of warmed crystalloid Hartman solution and 1.5 litres of colloids. If cross matched  blood is unavailable , I will give her un cross matched group specific blood or Rh- ve blood. Blood products can be given as per results of investigation . if platelet concentration is less than 50x10^9 and cryoprecipipate if fibrinogen is less than 1 g/dl. FFP  4 units to be given for over 6 units of red cells given. Recombinant  factor VII a can be considered if needed.

Continuous Pulse, BP and respiratory rate monitoring, temperature every 15 minutes and Foleys catheter to note urine output.If expertise is available,arterial line can be considered.

Once these measures are undertaken,I will try to find out the cause of her bleeding,whether it is due to atony uterus,any retained products,trauma to genital tract and coagulation disorders.

If bleeding is due to atony uterus,I will try to stop it by mechanical methods and uterotonics.I will rub the fundus to initiate contractions.I will give syntocinon 5 u by slow IV infusion.If she is not hypertensive  ,I will give her 0.5 mg ergometrine slow IV or IM.Also 40 units of syntocinon in 500 ml of Hartmanns solution at rate of 125ml/hr can be started.Carboprost 0.25 mg IM can be given and repeated as required.800 micrograms misoprostol can given per rectally to contract the uterus.

If uterus is contracted but still bleeding then I will  look for any retained products and remove them if any.

If there is  any evidence of trauma ,I will repair it adequate analgesia,under good light and assistant help.

b)After the above measures failed to stop the bleeding secondary to uterine atony,I will initiate surgical haemostasis soon.First I will try with the intrauterine balloon tamponade as it proven to be effective in controlling haemorrhage.It can be done with either Foleys catheter,Bakri ballon,condom catheter.4 -6 hrs of such tamponade can affectively achieve haemostasis. Another method is haemostatic brace suture at laparotomy using either the B Lynch method or modified compression sutures as this is effective in controlling haemorrhage and reducing the need for hysterectomy.Other surgical methods are the ligation of uterine arteries or internal iliac arteries.If interventional radiologist is available then selective arterial embolization or occlusion is an option.

If inspite of all these measures bleeding still continues ,last resort is hysterectomy ,and decision to be taken by senior obstretician.Transfer to ITU/HDU and recording parameters on MEOWS chart.

Incident form is to be filled.Accurate documentation of the entire proceedings to be done.Debriefing to patient when she is stable and family.

a)Post partum haemorrhage is emergency requiring promp treatment. I would put an emergency call out for help- senior Midwife, consultant obstetrician, anesethetist, other midwives and junior doctors. Make sure haemaology aware and have a porter avaliable.  I would then assess and treat the patient in an ABC, Oxygen high flow. 2x grey venflons and bloods taken for FBC, Coag and X-match 4 units.  I would initiate resusitation with crystalloids.  I would then assess history and exam for causes of PPH- tone (risk factors of previous PPH, macrosomia, long labour, augmentation or induction, abruption, has she had an active third stage and what uterotonics ahve been given), trauma (I would examine the perineum for tears, did dhe have an assisted delivery or shouler dystocia which would make these more likely), tissue, I would inspect the placenta and membranes to ensure they are complete and thrombin (does she have risk factors for DIC- Abruption, known anti-coagulants).  The treatment would be based on what I thought the underlying cause was.

For ?RPOC I would take her to theatre for manual removal with adequate analgesia and antibiotic cover.

For trauma I would repair tears and if concern regarding cervical tears or extensive vaginal or 3rd/4th degree- aim to go to theatre to walk the cervix with rampleys and repair these tears.

For atony I would given 5 unit Iv syntocinon, then 500mcg ergoemtrine.  I would have given fundal massage and consider bimanual and expulsion of clots sitting in vagina.  I would insert a foley catheter to empty the bladder to aid contraction of the uterus. I would commence a 40unit syntocinon in 500mls 0.9% saline infusion over 4 hours.  I would then give haemobate 250mcg, this could be repeated every 15mins. If no contraindications.  If these measures are not working I would go to theatre for further management see b).

For Thrombin and DIC. I would seek the advice of the anesthetsit and haemotologist regarding FFP, platelets and cyroprecipitate.

I would have a scribes take notes for times of drugs and amounts of fluid resusitation. I would keep a monitor on EBL as about 2000mls I would be wanting to transfer to theatre.  I would have active monitoring of pulse, sats and BP. Ensuring adequate fluid resusitation and if on going bleeding given of RCC- either O neg or group specific if emergency or full cross match if possible

b)  If continues atony failed to respond to pharmocological methods I would obtain verbal consent to transfer to theatre.  If no analgesia general anesthetics.  Continued resusitation and ensure consultant present or on their way.  I would then perform an EUA to ensure not missing clots/ tissue or tears.  If I have decided tone is the cause of would plan for Bakri or Rusch Balloon tamponade.  If this is not working even with continues uterotonics or synto I would proceed to laparotomy.  I would then consider b-lynch suture.  If I had access I would ask for interventional radiology to attend as they could embolise uterine arteries.  I would then have to consider hysterectomy if bleeding continues- i would like to have 2 consultant pesent for this decision. If possible to ahve access to vascular surgeons they could attend for ?ligation of internal iliac artery.  During this time we would have close communication with rest of team especially anesthetist and haematology reguarding the ladies EBL, observations and requirement for blood products. Broad spectrum antibiotics.  We could consider use of transexaminc acid.

Afterwards she would require HDU or ITU care.  She would require debriefing.  I would complete documentation for this and a trust incident form.

i will check vital signs of the pateint,check her pulse rate,blood pressure

i will call for help, call the senior midwife ,inform the consultant on duty

insert 2 wide bore cannulae, draw blood for haemoglobin estimation and crossmatchh

call blood bank officer and crossmatch 4 unit of blood

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i will do a bimanual examination to decide if the pph is due to atonicity of uterus.i.e.if the uterus is hard well contracted or flabby or due to traumatic pph.5 units of oxytocinintra muscular and 20 units of oxytocin in 500ml of hartmann's solution is started intravenously .

i will give ergometrine 0.2mg intramuscular,make sure pateint does have cardiac or hypertensive disorders before giving it

if bleeding does not get controlled despite it i wiil give carboprost 1 ampoule intramuscular,repeat it in 15 min interval ,if bleeding is not getting controlled.  total of 8 doeses of carboprost can be given

while the uterotonic drugs are being administered,i wll keep doing bimaual compression and message of the uterus.

if the cause of pph is traumatic i wii make arrangement for exploring the perineum and suturing the tears

                   if bleeding has not subsided buy the above measures,i will place a bakri ballon into the uterine cavity and inflate it  or place a roller gauze in the uterine cavity andif bleeding  still doesnot get controlled by above measures i will make arrangements to shift the pateint to theater.i will take to the anaesthetist ,arrange blood ,put a urinary catheter to moniter ouput,

if pateint is in shock i will prefer general anaesthesia .by giving a pfennensteil scar i will open the adbomen and do a bimual compression to see if bleeding stops.If it works,i wii put blynch compression suture with no1 pds. still if bleeding is not getting controlled i wll do  internal illiac artery ligation.if specialist radiologist is availabe in the hospital setting with all the facities we can do uterine artery embolisation

shift the pateint to HDU .moniter her vitals closely,input and output charting

risk assessment done and she is given thromboprophylxsis.depending on her haemoglobin need for blood assesed if less than 7 compatible blood is tranfused

incident form filled and everything documented meticulously

If pateint is multiparous,completed her family,may consider doing a hysterectomy to save her life

This scenario is major PPH.The Principles of management are as under ,the clinician should be quick,alert,logical action taken simultaneously,following the hospital protocol:The immediate management is to secure the airway,breathing and circulation,this will require intubation if conciousness is altered,oxygyn by mask(4-5 liters per minuite,2 large bore cannulas are inserted and 20cc blood should be drawn for investigation s,run i.v. fluids (hartmans solution if blood is no t available.

Urgent call for help the senior midwife(as well as the midwife incharge),call middle grade obstetrician(alert the consultant),call the anesthetist middlegrade (alert  the consultant anesthetist),call the hematologist (consultant),call the blood bank(place the order as ongoing PPH,O NEGATIVE blood if cross matched sample will require some time to be supplied),call poters for sending the investigations,allot 1member of the team to record the findings,the interventions done,i.v.fluids,drugs given,to monitor pulse ,blood pressure,respiratory rate.It is important to communicate with the patient and her partner and keep them informed .

INVESTIGATION AND MONITORING.

Send blood for grouping and crossmatching(at least 4 units may be required)FBC,renal function,(blood urea,serum creatinine),liver function as base line,s.electrolytes,Cougulation profile,but FFP,Cryoprecipitate ,platelets could be transfused before the investigation reports are available.Transfer to HDU/ICU to minitor continuously BP,Pulse,respiratory rate,urine output(there fore catheterize the patient with Foleys),insert CVP Line.

Keep the women warm,i.v.hartmans solution 4-5liters,give warm fluids,blood as soon as possible,do not use filters as it slows down the infusion rate,give appropriate doses of anti d (if RH NEGATIVE).Immediately rub up a contraction,give uterotonics oxytocin 5 -10 i.u as bolus(as per protocol),or as a infution along with the i.v fluid,carboprostol 125 ug repeat if necessary ,syntometrine  i.v,coud be repeated ,arrest the bleeding ,look for tears,cervical,vaginal tears,see if placenta and membranes are complete,look for uterine fundus (as inversion may be the cause),use the balloon tamponade if atony still persists.Anticougulants will be required in massive blood loss,therefore haematologist s opinion is required in this regard.Verbal consent for further surgical management as appropriate will be necessary.Document every action.

B)The balloon tamponade is the 1^st option among the surgical interventions,it is also acts as a test to note if hysterectomy may be resorted to,as sooner the decisions are made the better the prognosis for the patient.Brace sutures provide haemostasis in majority of the patients,otherwise step wise devascularization is resorted to,internal iliac artery ligation,or uterine artery ligation will be required.Uterine artery embolization is done if expertise is available.A subtotal hysterectomy is justified to save the life of the life of the mother .Accurate documentation,filling in the incedent report form,and communication with the women and the relatives,after the incidence,to convey future effects  are important measures in clinical practice.s

A.Prompt full protocol for PPH. Call for help including senior obstetrician, anaesthetist, senior midwife, porters, and notify Blood bank for possble urgent blood transfusion. 2 large bore IV line to be inserted. 2 l warm Ringer lactate to infused. Blood collected for group cross matching for at least 4 unit of Packed RBCs and coagulation profile. If ghe patient is haemodynamically unstable ask for Rh negative O blood or same group of the patient without cross matching. Oxygen mask 10 -15 l/min. examination of the patient to assess the cause of bleeding. if uterine atony (90%) of cases uterine rubing is required and ecbolic to given including oxytocin, ergometrine and carbitocin injection. if the uterus still atonic or bleeding for other causes like tears or retained products, push the patient to theatre for surgical interferance

B. laparotomy to done and B-Lynch suture to be placed if bleeding is not contolled uterine artey oclusion using via intervention radiology or internal iliac arteties ligation. early recourse to hysterectomy is recommended if the bleeding uncontrolled

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Post partum hemorrhage is a lifethreatening emergency .

First thing is to call for help ,inform senior obstetrician ,midwife ,alert anaethetist ,heamatologist ,blood bank and porter .simultaneously start high concentration oxygenvia face mask  ,keep airway  patent ,maitaing i/v line  with two large bore cannula and start warm i/v fluid colloid hartman untill blood isavailaible,d for CBC ,coagulation ,U&E , renal and liver fuction test ,monitoring of vital puls ,BP  and temperature ,strict intake output monitoring via folys catheter .correction of fluid loss is very important and till cross match blood is available o negative blood can be transfused to keep in mind should be warm .most commoncause of bleeding after delivery of placenta is uterine atony bimanual massage is very effective in addition to sytocinon 5 units slow i.v  and 40 units of syntocinon in 500ml infusion at 125ml/h ,if patient is not asthamatic syntometrin also can help in uterine atony .if she continued to bleed carboprost i/m can be given (contraindicated in asthamatic )repated dose after 15 min upto maximum of 6 doses .intamyometrial injection only by consutant discretion .misoprostol can also help 800-1000 mg per rectally .in this situation aim is to keep hb 8g/dl ,platelet >45x109,fibrinogen >1 .more than 40%of blood loss usually results in coagulation disturbance every 2 unit of blood needs to transfuse 1 unit of ffp ,she may need platelet transfusion and cryoprecepitate depending upon the lab result .there is role of rf vii in contrlling bleeding in consultation with hematologist provided fibrinogen>1 .patient need to be shifted to a room with good light ,preferably to operation theater to explore any vaginal or cervical tear or retained placenta or membrane.

B . If medical measures failed to control uterine atony she needs intervention such as ballon temponade bosch showed to be effective in controlling bleeding .B- lynch vertical suture is also effective but if she need hystrotomy for that if she delivered by normal vaginal delivery .Aortic compression one of tempory method to control bleeding .internal artery or uterine artery ligation also shown to be effective doesnot impair fertility or menstruation in future .uterine artery embolistion needs radiologist fascilities also doesnot interfere with future fertility .hysterectomy is the last resort but should be taken to safe life with two consultant decision .patient should be monitor in HDU OR ICU postoperatively .compression stocking if coagulation is abnormal once coagulation become normal consider throboprophylaxis .

patient should be councell about this situation and partner ,debriefing once she come out of it .

A....Woman is having major primary PPH .so early intervention is needed to reduce maternal morbidity and mortality.I would approach her in sensitive manner and explain the condition and the importance of early treatment to relieve her anxiety. I would check her airway, breathing and will commence 10-15 L/mt oxygen.I would call experienced midwife and midwife in charge for help and will check her circulation by noting pulse rate and bloodpressure and will site 2 14 G cannulae will take20 ml blood sample for FBC,Group and cross match, coagulation profile ,To know the haemoglobin level and to rule out DIC, RFT, LFT, and electrolytes for basal status Iwill start Warm IV fluids crystalloids and will inform Consultant obstetrician, Anaesthetist ,h aematologist, blood bank and porters.Mean while I will take a brief history for risk factors for Atonic pph( prolonged labour, multi para, multiple pregnancy),traumatic pph(operative /difficult delivery,VBAC –rupture uterus).I will assess degree of pallor, dehydration,abdominal examination for tone and retraction of uterus and for distended bladder which prevents uterine contraction.I will ask for bladder catheterization for input/output monitoring , to start MEOWS charting to know deterioration at the earliest for early action and will entrust one midwife to document all events drugs,IVF, blood and blood products given and vitals monitoring..I will recheck placenta for missing cotyledon and will start mechanical measures fundal rub up and bimanual compression to promote uterine contraction and retraction .it is noninvasive method with little more discomfort for the latter but more effective.all will be done simultaneously .pharmacological measures like uterotonics –oxytocin 5u iv is given bolus with maintenance infusion 40 u in 500ml of saline,if still bleeding not reduced ergometrine0.5mg iv/im (contraindication cardiac/hypertensive disease), carboprost 0.25mg  repeated 8 doses 15 mnts apart if needed (contraindication-asthma)given in this order.blood  will be started once ready and blood products FFP,Cryoprecipitate, PRP given in case of DIC.After excluding atonic pph if still bleeding continues,I will offer exploration under anaesthesia  for cervical/vaginal injury, rupture uterus and retained product of conception after consent and informing consultant. I will keep the woman and relatives informed about all the event.

B.As the pharmacological measures failed I will offer surgical measures for atonic pph after explaining the situation and consenting and informing consultant.     I would continue manual measures like fundal rub /bimanual compression till uterine tamponade gets ready (Foleys /bakri catheter is used)done under antibiotic /anaesthetic cover.it reduces bleeding to 80% and prevents laparotomy.need to keep for 4-6 hours. If it is unsuccessful ,and intervention radiology-uterine artery embolisation available will offer that as it is effective and prevents laparotomy and preserve uterus.however can cause premature ovarian failure in 1/100 cases and glutael necrosis.

If it is not available will do laparotomy after consent with explanation of potential possibility for hystetrectomy.In laparoscopy ,compression sutures-B lynch/brace sutures are put withno.2 catgut, it is effective and avoids need for more invasive  hysterectomy, failing which will do stepwise ligation of uterine/ovarian/internal iliac arteries(more invasive ,need expertise ,chance of ureter injury-reduces bleeding to 40% but avoids hysterectomy ) with vascular surgeon involvement-

If still bleeding continues hysterectomy will be done sooner rather than later after discussing with consultant.I would document all the event,early debriefing and incident reporting done as part of clinical governance

More help is to be summoned as it is major post partum haemorrhage(PPH).Full protocol of management of major PPH is to be instituted.Call in clear words summoned that ongoing major PPH at particulat labor suite.Call for senior midurfe,onstetric ,middle grade,anesthetist middle grade and porters for blood sample transport.Alert the consultant onstetrician and anaesthetist and haematologist.Quickly and clearly introduction to the women and her partner of the doctor and the situation given.All interventions have to go on simultaneously.The women is assessed for signs of shock, abdomen for uterine contour and tone and vaginal examination for inversion of uterus retained products or trauma.2 large bore (14 gauge) cannula secured with obtaining 20 ml blood for FBC, cross match( 4 units) clotting profile,urea and electrolytes.The midwife is asked about what and how much dose drugs have been given.One person in the team keeps a note of ongoing events.Oxygen given by face mask9 10 – 15 lit/min).Patient kept in flat position,warm and till blood arrives start with warmed crystalloid(Hartmann’s solution)2 litres or 1.5 litre of colloid.The women is to be monitored simultaneously for irtals P,BP,RR by automated recorder ECG and pulse oximetry & Temp every 15 min.If cross matched matched blood is unavailable thengroup specific blood can be given. O negative blood can be last resort.Depending upon clotting profile and ongoing bleeding , 8 factor given by haematology consultants opinion.With every 6 units of blood4 units of FFP is to be transfused.If platelets below 50,000 then platelete transfusion required.The aim is to keep L/B > 8 gm% platelet >50,000. PT & APTT < 1.5 control.

b)When pharmacological interventions fail for uterine atony then Tamponade test can be done.Balloon Tamponade by rush catheter,Bakri Balloon or Sangstekan Blackmore catheter can be tried.It may arrest the bleeding.Along with it uterotonics oxytocin infusion,prostaglandin can be given.Can be kept for 24 – 48 hours and removed in morning hours in consultants presence.If the bleeding persists then the patient should be taken for laparotomy where step wise devasuliarization of uterus can be tried.Uterine artery ligation followed by ovarian.Then internal I hag ligation.This requires expertise.Before this B lynch compression sutures like Haymann,Cho sutures can also be tried.These reduce the risk of hysterectomy by 71%.Internal  iliac ligation can be done with surgeons help if one is not skilled enough.Resort the hysterectomy should be taken sooner than later.Second opinion of a colleague should be taken prior to hysterectomy.In such emergency situation subtotal hysterectomy is usually faster.Risk of developing stump cancerremote.De briefing of the events to the woman partner by senior person in the team.Incidence reporting form to be filled.Audit if the event can be done.

a) Blood loss over 1000mls is a massive obstetric haemorrhage. A massive obstetric haemorrhage call should be put out alerting the appropriate people (namely Obs SpR, Anaesthetic SpR, Blood Bank, Porter, senior midwife and the oncall consultant for anaesthetics and obstetrics informed). I would assign someone to scribe events.

Principles of treatment are firstly to resuscitate mother using ABC.  If airway is maintained, high flow O2 should be commenced, 2 large bore cannulae sited and fluid resuscitation commenced ( 1 l crystalloid), blood should be sent urgently for FBC, XM 2 units, Clotting screen. Maternal observations taken. If unstable resuscitation with crystalloid until blood available. Catheterisation

Simultaneous assessement of the causes of PPH should be assessed. This can logically be done by going through the 4 Ts (Tone, Tissue, Trauma, Thrombin). Tone should be assessed by palpation and uterine pressure, by bimanual compression if required +/- use of uterotonics. First line pharmaceutical treatment would be a Syntometrine ( or Syntocinon if high BP) and a second bolus of 5iu could be given if there was active management of the 3^rdstage, second line 40 iu Syntocinon  in 500 mls NaCl infusion at a rate of 125mls/hr, 3^rdline Carboprost 0.25 mg IM every 15 minutes if required, max of 8 doses ( not if asthmatic) 4^thline Misoprostol 1mg PR), perineum should be assessed for trauma and repaired if heavy blood loss, the placenta needs to be assessed to see if this is complete and retained tissue is a cause for bleeding and hypotonia, finally it needs to be confirmed the patient has no known bleeding disorder. Additonal causes to bear in mind are uterine inversion, scar rupture, broad ligament haematoma. If bleeding is ongoing despite initial management I would consider transfer to theatre and aski the consultant on call to attend urgently.

b) First line uterine balloon tamponade, using for example Bakri Balloon. If this failed, consider involvement of Interventional Radiology and suitability for embolisation if available, if not possible or time does not allow, Laparotomy and compression sutures (eg B-Lynch Suture) , possible uterine artery ligation and finally hysterectomy. A second consultant opinion should be sought if hysterectomy is being considered. 

Clear documentation of events and patient to receive adequate debriefing.

You have been called to review a healthy 30 year old woman 30 minutes after delivery of the placenta. The estimated blood loss is now 1200 ml with on-going bleeding.

(a) Discuss the principles underlying your initial management [14 marks]. 

I will call for help from the labour ward coordinator and extra midwifery support,senior anaesthetist,consultant obstetrician,blood laboratory and haematologist and porters from sample transfer. i will assign one of the team members to write down the steps of management.resuscitation,monitoring,investigation and treatment should go simultaneously. i will check the airway,breathing and circulation. patient should lie flat and kept warm.O2 via face mask at a rate of 15 L/min. securing 2 wide bore cannulas and commencing IV fluids (2L crystalloids and 1.5 L colloids) untill blood is available for transfusion. blood samples taken for FBC, liver and renal functions and coagulation profile.6 units of blood should be crossmatched and O -ve blood transfusion should be started until crossmatched blood is available. continous monitoring of blood pressure,ECG and O2 saturation and inserting a foley's catheter to monitor urine output. other blood products to be available are fresh frozen plasma,platelets (transfused if platelet count is less than 50,000), cryprecipitate (if fibrinogen less than 1 gm)and activated factor seven can be life saving provided that fibrinogen level is more than 1 gm and platelets more than 20,000.i will check that the placenta is complete followed by systematic examination of the lower genital tract for evidence of trauma and uterine tone. if trauma is identified packing can be done for compression until the patient is transferred to theatre for repair. if atony identified I will commence medical treatment by 5 units of IV or IM oxytocin followed by ergometrine 0.5 mg IM followed by infusion of 40 units oxytocin in 500 ml saline followed by carboprost 250 microgram IM and can be repeated 8 times 15 minutes apart followed by 0.5 mg intramyometrial and 1000 micogram of misoprostol rectally. i will ensure proper level of communication with the patient and her partner throughout the management process.

(b) Logically outline the subsequent management options given that pharmacological interventions have failed to stop bleeding secondary to uterine atony [6 marks]

Treatment options include interventional radiology however this option might not be available. a tamponade test by using an intrauterine balloon filled with 300-500 ml saline ,a positive test means that bleeding is controlled and the balloon should be left in place for 6 hours then gradually deflated in the prescence of a consultant. A negative test means tjat bleeding was not stopped and laparotomy is indicated. at laparotomy options include vertical compression sutures as B-Lynch,uterine artery ligation,internal iliac artery ligation and finally hystrectomy as a last resort.

The 30 year old woman with blood loss of 1200ml and ongoing bleeding after delivery of placenta is having a massive post  partum haemorrage.The initial and foremost principle of management is quick examination of the vital signs like pulse,blood pressure,temperature,conciousness,perspiration.The woman should be resuscitated according to the vital signs.An optimum aproach is the TABC of resuscitation,that is,keep her warm,maintain the airway,start with 10-15 lit of oxygen by mask,place 2 wide bore 18 guage cannula intravenously.Take 20 ml ob blood sample for investigations like FBC,U/Electrolytes,coagulation frofile,Liver function test,blood grouping and cross match.Transfuse about 4-5 litres of fluids including colloids like ringer lactate or crystalloids like Hartmanns solution.Urinary catheterisation should be done.A senior obstetrician and gynaecologist and extra help should be called.Initially arrange 4 units of fresh blood.Continuous monitoring of pulse,blood pressure,temperature,spo2,urine output,fluid intake is to be done.The family of the woman should be informed at every step  of the management.A clinical examination is now done to see for the cause of bleeding.If the uterus is well contracted,then look for signs of traumatic PPH i.e.any vaginal or cervical tear.If a tear is identified,then it is to be sutured immediately and haemostasis confirmed.If the uterus is atonic or flabby,then continous bimanual massage is to be done.An infusion of 40 units of syntocinon in 500ml ringer can be started..injection prostidodin 250 microgram i.m.,repeated every 15 minutes according to the respone,maximum of 8 such injections can be given if not contraindicated.Per rectal placement of tablet misoprost 800 mg to contract the uterus.Meticulous record of woman's condition,vital signs,blood loss,treatment given is to be maitained.If the coagulation profile is deranged or more than 4 units of whole blood has been transfused then arrange for fresh frozen plasma,platelets or cryopreciptate.                               (b)After failing to arrest bleeding due to atonic PPH with pharmacological measures,the surgical options need to be explored.A senior obsterician ant anaesthetist shold be present.The staff in operating room needs to be alerted.The compression on aorta abdominally can be tried to reduse blood loss.Commpression tamponade with 500 ml normal saline can be tried.After appropriate anaesthesia

After appropriate anaesthesia i.e.general anaesthesia,proceed for laprotomy.Bilateral uterine arteries are ligated.Bilateral iternal iliac arteries can be ligated.If still bleeding is continous then haemostatic sutures like B-Lynch suture can be given to arrest bleeding.With expertise and facility available,Uterine Artey Embolisation can be undertaken.If in spite of all these efforts the bleeding continues,then with the opinon of a second obstetrician the consent for obstetric subtotal hysyerctomy should be taken and proceeded on.At every step the relatives should be informed.The woman is monitored continously.Last but not the least,an incident reprorting has to be done.

The clinical picture corresponds to PPH most likely secondary to atonic uterus or trauma to genital structures.This is a life threatening complication requiring prompt resuscitation,evaluation and management to arrest bleeding.The initial management includes multidisciplinary approach with involvement of senior obs,midwife,anaesthetist,hematologist.Call for help with effective communication with people involved eg porters.Initial resuscitation includes ABC.Patient should be put in flat position,2 wide bore iv canulas put and urgent grouping and crossmatching for blood(4 units).Other inv are CBC,clotting profile,RFT and LFT.Restoration of hyration with crystalloids,colloids or blood according to availability.Maintanance of breathing on oxygen inhalation.Monitoring of pulse,BP,RR,temparature and catheterisation for U/O monitoring.Adequate analgesia and invasive monitoring if required.Appropriate documentation of vitals,fluids and drugs given.Patient and attendants should be informed and conselled about the event.To find out the cause pt. should be evaluated for tone of the uterus and thorough examination to rule out genital tract lacerations.After initial resuscitation measures, any perineal or cervical tear if present should be repaired.If uterus is atonic the different options are-1)physical manouvers include bimanual massage,uterine packing or balloon tamponade.2)pharma -oxytocin,ergometrine ang prostaglandins-E2,F2.

 (A)

The initial management involves effective communication in major PPH. IT is important to call the senior obstetrician, senior anesthetist, experienced midwife, haematologist on-call as well and alert the blood bank as well as porters to attend to the emergency. Resuscitation of the woman will involve assessment of airway and intubation if necessary; breathing and circulation. High flow oxygen is administered via face mask and 2 large bore 14G venous access is established and 20mls of blood drawn for FBC, renal panel, coagulation prodile as well as group and cross match for 4 units. Warmed intravenous fluids including crystalloids and colloids are administered up to 3.5L for volume expansion. Blood transfusion should be commenced as soon as possible without awaiting for lab results. Group O negative or ABO compatible but unmatched blood can be given before matched blood is available. Consideration should be given for blood products e.g. FFP, cryoprecipitate and platelets. Recombinat factor VII can be considered after coagulation results are available. The patient will be monitored continuously for blood pressure via automated machine, pulse and oxygen saturations via continuous pulse oximetry. An indwelling catheter is inserted to monitor urine output. The anaesthetist expertise should be sought for arterial line insertion or central venous pressure monitoring for closer haemodynamic monitoring and faster access for venous blood investigation. The woman should be transferred to high dependency unit for monitoring once she is stablised and bleeding has been controlled. Simultaneously while the patient is being stabilized, the case file can be reviewed for risk factors of PPH and a clinical examination performed to extablish the cause of PPH including abdominal examination for atonic uterus, vaginal examination for vaginal and cervical lacerations. I will examine the placenta for completenesss. Uterotonics e.g. syntocinon infusion and bolus IV 5unites, IV Ergometrine, IM Carboprost 0.25mg up to 8 doses as well as IV Carbetocin 1ml can be administered.

(B)

The consultant obstetrician needs to be involved in the decision making and the patient needs to be transferred to operating theatre for examination under anaesthesia. A detailed examination in OT under proper lighting and exposure should be done to exclude tissue trauma. Persistent uterine bleeding should prompt the insertion of intra-uterine tamponade balloon using Foley’s, Bakri, or condom catheter. A tamponade test is carried out and if persistent bleeding ensues, a laparotomy is carried out. A B-lynch suture can be placed in the presence of a hysterotomy or a Hayman suture if a hysterotomy is not carried out. If this fails, bilateral uterine artery ligation can be considered. Failing which, internal iliac afteries ligation can be done. The interventional radiologist can be involved at this point of time for a uterine arteries or selective arterial embolization. Hysterectomy, usually subtotal, is the last resort although an early recourse to hysterectomy should be considered if the above measures have failed to arrest PPH.(A)

a)This is an obstetrics emergency. I will call for help immediately for an experienced midwife, senior obstetrician, senior anaesthetist and hematologist. I will also inform the blood transfusion laboratory and activate massive transfusion protocol and send for porter to get the blood products. I will resuscitate the patient by assessing airway, breathing and circulation. Give the patient oxygen via face mask and 2 14G intravenous cannula. Obtain blood for full blood count, clotting studies, renal panel and group and cross match. I will give the patient crystalloid or colloid infusion while waiting for the blood to arrive. O RhD-negative can be given also. Fresh frozen plasma should also be given. Indwelling urinary catheter should be inserted to chart fluid balance and also to allow contraction of uterus. Vital signs like blood pressure, pulse rate and respiratory rate should be checked and documented regularly. The genital tract should be examined for lacerations and repaired. Bimanual vaginal examination should be done to diagnose uterine atony and continue massage. IV oxytocin 5 to 10 units should be given as slow IV bolus. Intramuscular ergometrine 0.5mg can be given. Intramuscular carboprost 0.25mg every 15 minutes for a maximum of 8 doses can be given. Rectal misoprostol 1000 micrograms can also be given. Documentation should be done of the medication used and dosage, people involved in resuscitation, fluid balance and timing of events.

b)I will transfer the patient to the operating theater. Decision for subsequent treatment should be made in conjunction with the anaesthetist, obstetrician and hematologist. I will perform an examination under anaesthesia to look for any genital tract lacerations that were missed. If the uterus is still atonic, I will attempt balloon tamponade with intrauterine insertion of Rusch ballon. B-lynch hemostatic brace suture can be applied to allow contraction of uterus. Bilateral uterine arteries or internal iliac arteries ligation can be done to decrease blood loss. Arterial embolization can also be done to decrease blood flow. Hysterectomy is the last resort but should be done earlier than later. Patient’s vital signs should be monitored regularly and blood transfusion with fresh frozen plasma cover should be ongoing.

a) Activate emergency buzzer, calling for help from senior midwife, midwives, Obs SHO, senior anaesthetist, Cons Obstetrician on-call (to be informed) and Scribe. Activate the Massive Obstetric Hamorrhage protocol which will inform the Haematology laboratory.

Gain i.v access with 2 x wide bore cannular, taking blood for FBC, U&E, LFT, Clotting, X-match 4 units. Start rapid i.v resuscitation with crystalloid- hartmans(2 litres) and colloids-gelofusin(1.5litres) depending on observations. Give X-matched blood if available, alternatively give group specific or 0 neg blood. For every 4 units blood transfused give 4 units Fresh frozen plasma. Continuous record of observations including respiratory rate, 02 sats, BP, Pulse, document on MOEWS chart. Give high flow 02 15 l/min via face mask. Take bedside haemocue on venous blood to check Hb.

Consent for vaginal examination, perform bimanual compression and start uterotonics including syntocinon 5 IU i.v, ergometrine 250 mcg i.m (x2), 40 IU synto in 500mls NSaline infusion over 4 hours. Give 800 mcg misoprostol PR. Give 250mcg haemobate/carboprost i.m every 15 mins, upto 2 doses then transfer to Theatre. (Consider giving 1 gram transexamic acid i.v.).Examine vagina/ perineum for perineal lacerations and commence repair. Insert urinary catheter with urometer (monitor hourly urine out-put on fluid balance).

Check placenta is complete. Check pre-delivery Hb. Keep patient and family present updated/informed regarding events happening. Debrief of staff and family. Fill incident form.

Transfer to Theatre if on-going loss not responsive to above measure, consent patient for examination under anaestheteic +/- insertion of uterine balloon +/- perineal repair +/- hysetectomy.

b)

In theatre, conduct Tamponade test, insert a uterine balloon- Bakri, fill balloon until bleeding settled, upto approx 300-500mls or more. If continued bleeding despite insertion of uterine balloon, proceed for laparotomy.

(Direct manual compression over aorta.)

Insertion of a haemostatic suture as B-lynch can be conducted

Early recourse to Hysterectomy which is a decision that two Consultants need to make (this has been identified as a measure that can save maternal lives).

Devascularisation with bilateral uterine artery ligation and internal iliac artery ligation, needs expertise and the latter can be time consuming.

Uterine artery balloon insertion/embolisation if interventional radiology facilities are available; this may be time comsuming to set up and arrange in an emergency situation. 

Manage patient in HDU/ITU setting. Manage coagulopathy in conjunction with advice from Haematologist. Consider thromboprophylaxis based on risk factors- blood loss, transfusion etc.,

The principles underlying the initial management are to call for help first which includes the anaesthetist and consultant obstetrician ,senior midwife,porters, haematologist and the blood bank. 

To activate the major haemorrhage protocol and to assess the cardiovascular status of the woman.give the woman high flow of oxygen with aa face mash which is about 10-15 litres of oxygen. 2 big cannulae should be inserted and blood about 20 cc to be extracted for fbc, liver function and renal function test, coagulation profile and crossmatch.ask somebody to scribe the events. assess the woman for the cause of bleeding.3.5 litres of fluid should be given which is 2 litres of crystalloids and 1.5 litres of colloids.

the four causes are trauma,tissue,tone and because of bleeding disorders.catheterise the woman.if there are no injuries to the cervix or vagina and the placenta is complete and there are no bleeding disorders then the most likely cause is that the uterus is atonic so bimanual massage should be done and 40 units of oxytocin in 500 ml of ringer lactate should be started and 10 units of oxytocin should be given im. if still bleeding then ergometrine 2.5 mg should be given if the woman id not hypertensive. is still bleeding then carboprost should be given 2.5 mg in at 15 minutes interval-total of 8 doses. if still no improvement then 1000 microgram of misoprostol . also to check if the woman is jehovas witness and to check whether she can accept any blood products. 

b-the subsequent management are to take the consent of the woman  and inform the partner and the consultant and to take the woman to theatre if the beeding does not stop for surgical management. 

balloon tamponade is done to stop the bleeding. there is no evidence that one method is superior to the other. if still the bleeding does not stop then b lynch suture are taken to stop the bleeding.interventional radiology by uterine artery embolisation should be done if bleeding does not stop. if bleeding still does not stop then uerine or internal iliac artery ligation or proceeding to hysterectomy but before proceeding for hysterectome the advise of the second consultant should be taken.debriefing of the woman should be done after the woman is transferred to the high dependency unit. incident reporting should also be done .training ad skill drill annually for the management of postpartum haemorrhage is the requirement of the cnst.

(A. Priniciples of initial management)

This incident should be recognised as a major PPH and local Major haemorrhage protocols should be followed. The consultant, Obstetric and anaesthetic on-call team should be urgently called to attend. Additional staff including theatre staff, porters and midwifery staff should be informed to support and haematology should be informed.

Maternal resucitation should be instigated by the insertion of two large bore (Minimum 16G) in the anticubital fossa. Fluid loss should initially be by 1 litre of Crytalloid such as Hartmanns solution to reperfuse the materanl tissues. Bloods including a baseline full blood count and cross match for 4 units of type specific blood should be sent urgently and labarotory informed. O negative type blood should be sought if there is any delay anticipated.

An examination to identify the cause of bleeding should be performed. This will include inspection of the vagina and perineum to exclude significant trauma, an abdominal examination to confirm uterine atony, speculum examination to identify further trauma or retained products of conception or clots sitting at the cervix and bimanual examination to assist in removing clots. Analgesia should be checked and if bimanual compression, manual evacuation of the uterus or inspection of the cervix for trauma is required then the patient should be urgently transferred to theatre. The placenta should be inspected to exclude missing cotyleydons, and if identified will also neccisitate transfer to theatere.

Ergometrine 2.5mg will likely have been given at the time of delivery. Syntocinin 10IU may be given IV or IM to help facilitate uterine contraction if atony is suspected. An infusion of 40IU syntocinin in 500mls saline and 125mls/ hr should also be started. Hemobate 250mcg IM can be given at 15 minute intervals to aid contractality. Misporostol 1000mcg PR may also be given as an early adjunct also.

Tranexamic acid 1g IV may also be used to aid haemostasis. This may be particularly of use if trauma is the cause of bleeding also.

Ultimately, this patient should be transferred to theatre if ongoing bleeding is not settled quickly. This will allow inspection of the cervix, repair of trauma, appplication of mechanical measure to arrest bleeding or progeress to laparotomy.

(B. Subsequent management following failure of of pharmocological measures in presence of atony)

This patient should have been transferred to theatre. Ideally written consent should be taken as the ascending measures to arrest bleeding may affect her recovery and future fertility. Her partner and family should be kept informed, with her consent, and aware of her wishes.

If Atony is suspected then Bimanual compression may be applied initally to see if haemostasis can be achieved by this siple measue. If not, a Rusche ballon filled with 300-400mls of saline may be inserted in order to tamponade bleeding from the placental bed. If this is not successful the ponly other alternative before proceeding to laparotomy is uterine artery embolisation. This is difficult to arrange in an emergency and require skilled interventional radiology and, whilst avoids the complications of a laparotomy, may delay life saving treatment.

A laparotmy will allow access to the uterus and a b-lynch suture can be applied to compress the uterus. It will also allow access to the uterine vessels allowing uterine artery ligation.

Early resort to hysterectomy may be a life saving procedure and should be considered if other measure either fail to control the bleeding or cannot be implemented in a timely manner.

Please ignore the previous answer.Sorry for inconvenience.                                                                           PPH is a potential life threatening condition and is a major cause of maternal morbidity and mortality.

The principle of management includes-1)Initial resuscitation 2)Continuous Monitoring  3)Arrest of bleeding.

Resuscitation involves multidisciplinary team including Obs consultant,Anesthetist,Hematologist,Radiologist and midwife.Call for help from seniors and alert porters ,blood bank.Unit protocol should be followed.

a)Basic resuscitation includes ABC.

1)Maintainance of airway with oxygen inh. At the rate of 4-5 lit/min.

2)To maintain hydration-2 wide bore cannulas insertion followed by starting crystalloids(warm ringer lactate),colloids or blood according to availability.

3)Urgent investigations include-blood grouping and cross matching (atleast 4 units),CBC,RFT,LFT,Clotting profile.

4)Consultation with haematologist for using FFP,Platelets,Cryoprecipitate,rFactor 7 according to amount of bleeding,number of blood transfusion or clotting report.

b)Monitoring of pt. vitals-PR,BP,Temp.,RR.

Catheterisation to monitor U/O.

Invasive monitoring and central line insertion if required.

Analgesia in consultation with anesthetist.

c)Documentation of events,measures taken,clinicians involved,drugs,fluids and pt. condition.

d)Effective communication between different specialities and with the female and partner.

E)To arrest bleeding-Examination to find out the cause and prompt management.

Repair of any tear.

If atonic uterus-1)Physical methods include Bimanual massage,Uterine packing or Balloon tamponade.2)Pharmacological agents-Oxytocics ,ergometrine or prostaglandins.3)Surgical methods.

If atonic uterus fails to respond to oxytocics Intrauterine balloon tamponade should be used under antibiotic coverage.If bleeding stops it can be removed after 24 hrs preferably in daytime in prescence of consultant.Laprotomy and devascularising surgeries(uterine artery or int. iliac artery ligation)if persistent bleedind.Early recourse to hysterectomy is preferred  as life  saving procdure involving second obs if required.Interventional Radiological procedures if available are fertility saving and are very effective.It includes uterine artery embolization or occlusion.

Patient should be shifted to HDU for monitoring.

Thromboprophylaxis given.

Incident reporting must be done.

Followup visit for debriefing,counselling for complications eg sheehans syndrome,screening  for haemophillias if any doubt.

a

a)

She is having massive primary postpartum hemorrhage. Resuscitaiton of the woman should start by caling for help from a senior obstetrician, midwife and anaesthetist. Two large bore cannulas should be inserted. Bloods taken for full blood count, U&Es, clotting and cross match 6 pints. Her blood pressure, pulse rate, and oxygen saturation should be monitored. Oxygen via high flow mask should be given. Colloid infusion should be started one side, and crystalloid infusion on the other while waiting transfusion. Any transfusion should be discussed with the hematologist. Compression cuff and blood warmers should be used during transfusion.  In dwelling urinary catheter should be inserted to monitor urine output. 

Administer IV bolus Ergometrine 250mcg if there is no contraindication. This is followed by IV infusion of 40u syntocinon in 40mls normal saline at 10u/hr. If bleeding persists, a further IV 10u Syntocinon can be given, followed by bimanual compression of the uterus. Intramuscular Carboprost 250mcg can be given in the thigh, or intramyometrium 15 minutes apart, for a total of 8 doses if bleeding persists. If ergometrine is contraindicated or unresponsive, rectal Misoprostol 800mcg can be given.

Communication with the patient is important to discuss further treatment options and to obtain consent.

b)

She should be transferred to theatre if medical intervention fails. Sengstaken-Blackmore tube or Rusch balloon catheter inserted in the uterine cavity and filled with 500-700mls warm saline to speed up the clotting cascade. If observed bleeding is minimal, no further surgery is needed. Surgical intervention include application of uterine compression sutures, such as B-Lynch brace sutures to oppose the anterior and posterior wall of the uterus aiming to reduce blood loss. This is successful if bimanual compression causes marked reduction of blood loss. Bilateral uterine artery and internal iliac artery ligation markedly reduces blood flow to the uterus, and has a success rate of 40-90%. Uterine artery embolization is done by a specialised radiologist, and has been used as a fertility sparing procedure to reduce blood loss. It results in shorter hospital stays and can be done under local anaesthesia. However, it can be complicated by ischaemia of the lower limbs, necrosis of the rectum and bladder and infertility. Hysterectomy should be reserved as the last resort when medical or surgical intervention fails, or when the patient is severely shocked.

The patient need to be debriefed on the incidents that had happened. Detailed documentation of the events is essential, and and incident reporting form needs to be filled. 

This young lady is having moderate to severe postpartum hemorrhage which is ongoing that is a life threatening situation needs vigilance in her care , Need simultaneous Communication, Resuscitation, investigation and measures  to arrest  the bleeding.

Call for senior most on ground obstetrician, anesthetist, hematologist, midwife porters, and Consultant need to alert. And keep informing the patient and relative about the progress

Therefore primary aim to assess  her  physiological sign and symptoms of shock ,  by checking BP, pulse, hemoglobin, Haematocrit, coagulation profile platelet, fibrinogen.

Check placenta complete, any uterus contracted or relaxed, local examination for vaginal cervical tear, bed side scan suspecting intra abdominal bleeding

Further assessment may need examination under anesthesia

If in shock, Resuscitation to replace the loss,  call for blood 4 unit, FFP, to restore Oxygen carrying capacity,

While waiting for blood infuse intravenous warm crystalloid 2 liter followed by 1.5 litter colloid  through 2 large bore cannula,( orange 14 G cannula) , Transfuse 6 unit of warm blood  cross match , or group specific, or O negative can be given if no time to cross match keeping Haemoglobin >8 gm .4 unit FFP of 6 unit of blood given or  to keep PT <1.5, transfuse cryoprecipitate  if fibrinogen below 1gm, and  platelet   aim to keep  > 50x10*9,

Oxygen inhalation 10 liter liter

Keeping patient warm, as hypothermia precipitates acidosis

Keeping at flat position .

Probable cause Tone ,tissue ,Trauma, thrombin, Most of the time Uterine relaxation is the most probable cause need, Empty the bladder, uterine massage and

Ureterotonic drug to be given  oxytocin 5  unit i/v stat then 40 unit in 500 fluid over 4 hours,

Syntometrin intramuscular if not hypertensive

If bleeding still refractory, Misoprostol 1000 mcgm per rectum need to be given

Carboprost 250 mcgm can be given i/m 8 doses 15 minutes apart

If medical measures fails, then need Quick resort to surgical measures,  conservative measure like uterine temponade test with  uterine balloon, Brace uterine suture, Internalilliac artery ligation, uterine artery ligation, uterine artery embolozation,

If all fails to arrest then timely Hystrectomy in the presence of two consultanat

If bleeding  arrest , shift to ICU or high dependency unit for close monitoring  

Documentation should done including the staff attended ,time of arrival , time and dose of drug administration pt response, time procedures  taken

Incident report to  be written

Debriefing of couple done at the end of the crises

Post partum follow up screen for coagulation and pan hypopituitarism.

B) Failure of pharmacological measure in Uterine atony .

Surgical approach based on patient future fertility wishes, primarily to conserve the uterus without compromising her life. And experience, expertise of surgeon, and availability of resources.

Uterine temponade with balloon, it is easy to perform, can avert 79% hysterectomy, doesn’t need expertise, it bleeding failed to arrest then need laprotomy.

Uterine brace stitches can be done easily, avert 81% hysterectomy, pyometra, uterine nectosis  are the  rare complication.

At laprotomy Internal iliac artery  ligation avert 60% hysterectomy, but it need expertise , but less effective then balloon and brace  tamponade.

Internal iliac artery embolization need Expertise and logistical issue , fertility remain preserve

Uterine artery ligation easy to perform

If conservative measures failed then Hysterectomy should not be delayed, as life saving procedure. In the presence of two consultant. Subtotal hysterectomy is the better option, for atonic PPH, but  future need cervical screening  for cancer cervix  and had advantage of  percieved cervical orgasm.

A/ The management of PPH would be based upon communication with all relevant professionals; resuscitation; monitoring and investigation and measures to arrest the bleeding. Each of these needs to be initiated and progressed simultaneously.

Emergency bleep 2222 should be used to call for help from senior midwife, anesthetist and to alert obstetric consultant, haematologist and porter. The woman should be clinically assessed on the basis of airway, breathing and circulation. Ventilation with high oxygen concentration is required (by mask 10 to 15L/minute) and flat positioning of the patient is needed. Hypothermia should be prevented and the lady kept warm. Resuscitation involves maintenance of two IV lines with wide bore IV cannula (14 or 16 gauge). Blood should be sent for Full Blood Count, urea and electrolytes, Liver Function Tests, coagulation profile and blood group and cross match four units of blood. Appropriate fluid replacement is mandatory.  Intravenous fluids (crystalloids initially up to 2 litres followed by colloids 1-2 litres) can be given till blood is available. Cathetrisation of bladder should be done and urinary output monitored.

Anesthetist should be involved in the management. To arrest bleeding, evaluate the cause of bleeding (trauma, tone, tissue, thrombin). Rub up a contraction if atonic uterus or repair tears if cause is trauma. Bimanual massage may be needed. Oxytocic drugs should be given i.e. repeat oxytocinon injection and oxytocin infusion (40 unit in 500 ml at the rate of 125 ml per hour). Carboprost (0.25 mg) intramuscular injection can be given and repeated every 15 min (maximum 8 doses). Misoprostol 1000 microgram can be placed rectally.

Once bleeding is arrested and any coagulopathy is corrected, thromboprophylaxis should be considered. Monitoring of observations afterwards should on modified early warning score (MEWS). Documentation of the fluids and blood products should be done. Reevaluation of the condition may be needed even if bleeding has stopped. Consideration of transfer to HDU or ITU if appropriate. Debriefing of the patient and involving partner and family in management is also required. Complete incident report form.

B/

If the initial pharmacological measures fail to stop bleeding, surgical measures may be needed. I will consent the lady for examination under anesthetic and consent for hysterectomy as a last resort if needed. I will create uterine tamponade by using Rusch balloon, Bakri balloon or Folley’s catheter. If that fails to control bleeding, patient needs laparotomy to apply haemostatic brace suturing ( B-Lynch or modified compression sutures). If bleeding is not arrested by hemostatic sutures, bilateral ligation of uterine arteries or bilateral ligation of internal iliac (hypogastric) arteries may be considered. Selective arterial embolisation can be done by liaison with radiological colleagues. A laminated diagram of the brace technique should be kept in theatre.

Resort to hysterectomy should be sooner rather than later save the life of the women. A second consultant should be involved in the decision of hysterectomy. Transfer to HDU or ITU should be considered and the woman and her partner debriefed about the events.

FR

a) call for help and activate mojor post-partum haemorhage protocol. Call for obstetrician consultant, anesthetist, haematologist, senior midwife, porter and inform blood bank the requirement  of massive transfusion. Assess airway, breathing and circulation. Provide patient a 15L non-rebreathable mask, set up 2 large bore IV branula (14 gauge), take FBC, urea electrolytes, coagulation profile, LFT, and group and save. Resuscitation and assessment should go hand in hand. Start warmed IV fluids replacement while waiting for bloods, maximum of 3.5L of crystalloid and colloids can be given. O-ve blood should be given if warranted. Identify the underlying cause of PPH and perform bimanual uterine compression and inject uterotonics drugs such continuous oxytocin infusion and IM carboprost. Majority of the cases are due to uterine atony. Failure of stopping the bleeding should warrant investigation of other PPH causes such as genital tract trauma, coagulation disorder and retained products and treat accordingly. Monitor blood pressure, pulse rate, respiratory rate, oxygen saturation and urinary output every 15minute to 30min. Nurse the patient in level 2 critical care unit with modified obstetric warning signs chart. In the event of worsening condition should prompt immediate assessment and possibility of surgical intervention. Debrief the patient and her family members as well as ensure proper documentation and incident reporting.

b) when pharmacological intervention failed, early resort to surgical intervention should be contemplated. Exploratory laparotomy and trial of compression  or B lynch suture suture should be performed after discussion with consultant. Options of internal iliac artery or uterine artery ligations should also be discussed and involve gynae-oncologist help. Interventional radiology with uterine artery or internal iliac artery embolisation is the alternative. However, in the event  of uncontrollable PPH, early resort to hysterectomy should be considered as this method is life saving.

A- Rapid and prompt management because it is major obstetrics haemorrhage, which carry high mortality rate. Team working is important,  by calling for help consultant obstetrician, midwifes, porters, alert blood bank and theatre. Documentation by specify one from the team to record medication and intervensions. Initiate hospital protocol and activate full protocol of management of major PPH. Assessment of the patient to know whether  she is conscious or not.  explain condition to her, and ask her about pain. Ask mid wife about delivery prolonged or not, placenta complete or not. Checking her BP, PR, temp. examination starting  by abdomen to look for uterus contracted or not , rub up contraction, and  look for bleeding from episiotomy if done . Resuscitation of patient by position flat  , oxygen supply, and insert 2 largre pore cannula. Investigations by sending  blood for group  and Rh, and ask for crossmatching 4 unit of blood.  coagulation LFT Urea and electrolytes,  continue resuscitation by starting  iv fluid 3,5 l. till blood ready then start blood transfusion and other blood products . monitoring of patient by continuous checking of BP PR and temp. Medical treatment and intervention to arrest bleeding  by Empty the bladder , fixed Foley catheter, giving  uterotonic drugs like  Methergin and syntocinon carboprost. Transfer patient to theatre to examine under GA,  if placental tissue or vaginal lacertion or cervical tear if found then sutureing it.

B- If bleeding does not  stop we would explain the condition to the woman and her family. Taking consent for laparotomy  including hysterectomy. Make sure that consultant came. Transfer patient to the theatre. Under general anaesthesia do exploration to see the cervix, vagina and any retained placental tissue. Rub up contraction. If not stop start balloon tamponade by  inserting Bekkary  balloon to stop the bleeding. If not stop we would do laparotomy and do the promp surgical procedure  starting by brace suture  B lynch, if not stop we would do bilateral uterine artery ligation or internal iliac artery ligation. Selective Uterine arteries embolization can be done if instrument and radiologist  available. Hysterectomy should be done in suitable  time and not delay to save the live of the patient. Transfer the patient to HDU for monitoring and better to monitor by MEOWS chart. Broad spectrum anti biotic and thromboprphylaxis should be given

When patient wake up debriefing  her and explain the condition to her and her family.

Incident report should be written according to risk management in the hospital 

A- Rapid and prompt management because it is major obstetrics haemorrhage, which carry high mortality rate. Team working is important,  by calling for help consultant obstetrician, midwifes, porters, alert blood bank and theatre. Documentation by specify one from the team to record medication and intervensions. Initiate hospital protocol and activate full protocol of management of major PPH. Assessment of the patient to know whether  she is conscious or not.  explain condition to her, and ask her about pain. Ask mid wife about delivery prolonged or not, placenta complete or not. Checking her BP, PR, temp. examination starting  by abdomen to look for uterus contracted or not , rub up contraction, and  look for bleeding from episiotomy if done . Resuscitation of patient by position flat  , oxygen supply, and insert 2 largre pore cannula. Investigations by sending  blood for group  and Rh, and ask for crossmatching 4 unit of blood.  coagulation LFT Urea and electrolytes,  continue resuscitation by starting  iv fluid 3,5 l. till blood ready then start blood transfusion and other blood products . monitoring of patient by continuous checking of BP PR and temp. Medical treatment and intervention to arrest bleeding  by Empty the bladder , fixed Foley catheter, giving  uterotonic drugs like  Methergin and syntocinon carboprost. Transfer patient to theatre to examine under GA,  if placental tissue or vaginal lacertion or cervical tear if found then sutureing it.
B- If bleeding does not  stop we would explain the condition to the woman and her family. Taking consent for laparotomy  including hysterectomy. Make sure that consultant came. Transfer patient to the theatre. Under general anaesthesia do exploration to see the cervix, vagina and any retained placental tissue. Rub up contraction. If not stop start balloon tamponade by  inserting Bekkary  balloon to stop the bleeding. If not stop we would do laparotomy and do the promp surgical procedure  starting by brace suture  B lynch, if not stop we would do bilateral uterine artery ligation or internal iliac artery ligation. Selective Uterine arteries embolization can be done if instrument and radiologist  available. Hysterectomy should be done in suitable  time and not delay to save the live of the patient. Transfer the patient to HDU for monitoring and better to monitor by MEOWS chart. Broad spectrum anti biotic and thromboprphylaxis should be given
When patient wake up debriefing  her and explain the condition to her and her family.
Incident report should be written according to risk management in the hospital   

A intial mangment 

major  postpartum haemorrhage is an obetetric emergancy .each unit should has protocol for managment of major haemorrhage . communication , resucitation, montoring and investigations and arrest of bleeding must be simultanously, communication midwife , obstetricmiddle grade ,alert consultant obsterician , middle grade anaesthtic , alert consultant anaesthtics , haematologest , blood  transfusion laboratory .one ember for record fluid drugs ,vitals sign and events . resuscitations maintain air way , breathing 2 large bore cannulae warmenss of patient  oxygen 10 to 15 liters .position patient left lateral position . intravenous fluid at least 3.5 liters 2.5 liters crystalloid and one liter colloid till blood be avaliable .platelet if platlet count less than50  cryoperciptate and freshfrozen plasma if fibrongen less than one gram , blood cross matched or o negative blood . recombinant factor vii a . montorning and investigations collect 20ml blood for group and save full blood count base line renal and liver function test  coagulation screen . montoring patient with modifying obestetric early warning chart , check temprature every 15 minute . continous montoring pulse blood presure oxygen saturation . central venous line to mintore intraveonus fluid . bladder cathetrerization to detect urine out put, documentation of fluid . blood and blood product. arrest of  bleeding  most of blleing occure due to uterine atony  uterine massage . intravenous oxytocin 5unit  . syntometrine . carboprost , misoprostol.check placenta and membrane to exclud any retained fragment , check for vaginal or cervical lacerations  rupture uterus . haematoma . utrine invertion , or subcapsular hepatic rupture.patient and her partenr should be informed about the event.

B

if pharmacological line failed to arrest bleedingshift women to theater and  use balloon tamponade as bakri balloon may arrest bleeding if failed lapartomy and  brace suture  , uterine artery ligation or internal iliac  artery ligation . if failed  uterine artery embolization if availabe if patient condition detoriorate hystrectomy should not be delayed , debriefing after the event  is recommended by senoir member of the team for the women . partner and family members

(A) The principles underlying initial management include communication, resuscitation, monitoring and investigation and arresting the bleeding.

This woman has major postpartum haemorrhage with on going bleeding.  This is an obstetric emergency and it is important to involve senior staff early in the initial management. The obstetric and anaesthesia middle grade should attend to the woman immediately and the respective consultants on call should be alerted. The consultant haemotologist on call should also be alerted. The blood transfusion laboratory should be notified of the urgency for compatible blood and products. Porters for delivery of blood and specimens should be activated.  An experienced midwife should attend in addition to the midwife in charge. One member of the team should be appointed to scribe the events, fluids, drugs and vital signs. The patient and her partner should also be given clear information of what is happening.

A primary survey to assess for airway, breathing and circulation should be conducted. High flow oxygen at 10-15L/min via facemask should be administered.  If airway is compromised, anaesthetic assistance is required.  Two 14 gauge IV lines should be established and 20ml of blood taken for FBC, coagulation studies including fibrinogen, renal and liver panels and group cross match at least 4 units of blood.  The woman should be positioned flat and kept warm.  While waiting for blood to be available, fluid resuscitation of up to 2L of warmed Hartmann’s solution and 1 to 2L of warmed colloid should be given rapidly. The aim is to restore blood volume and oxygen-carrying capacity. Hence, compatible blood should be transfused as soon as possible. If fully crossmatched blood is not available, alternatives include group O RhD negative blood or ABP & D group compatible uncrossmatched blood.  In view of on-going bleeding, up to 1L of FFP and 10 units of CCP may be given empirically while waiting for results of coagulation studies.

The woman requires continuous physiological monitoring.  Her temperature should be checked every 15 minutes.  She should be placed on a pulse oximeter and ECG and BP machines to monitor her BP, pulse and respiratory rate.  She needs an indwelling catheter to monitor urine output.  CVP monitoring should be considered.  Her parameters should be recorded on a modified obstetric early warning system chart.  Investigation results should be actively traced as it would guide resuscitation efforts.  Clear documentation of fluid balance, blood, blood products and drugs administered and procedures performed should be recorded in the casenotes.

The most common cause for PPH is uterine atony.  However, clinical examination should be performed to exclude other causes including retained products of conception, genital tract trauma, uterine rupture and inversion.  In the event of uterine atony, mechanical and pharmacological measures should be attempted to arrest bleeding.  This includes rubbing the uterus up to stimulate contractions and placing an indwelling catheter to drain the bladder.  Slow IV syntocinon 5 units, IV ergometrine 500mcg, syntocinon infusion, IM carboprost 250mcg and PR misoprostol 1g should be administered in turn until bleeding stops.

Once bleeding is controlled, this woman should be transferred to WICU for monitoring. 

(B) After failed pharmacological interventions, mechanical measures such as uterine massage should be continued until a Ruush or Bakri balloon is available.  If balloon tamponade is unsuccessful, a haemostatic brace suture such as B-Lynch should be attempted.  If that also fails, then bilateral uterine artery ligation and/or bilateral internal iliac artery ligation can be performed.  Hysterectomy (usually subtotal unless bleeding from cervical trauma) is considered as a last resort in the face of persistent bleeding despite all the above measures.    Once bleeding is controlled, this woman should be transferred to WICU for monitoring. 

Clear documentation of the events and procedures performed should be made.  A clinical incident reporting form should be completed.  The woman and her partner should be debriefed by the attending obstetric consultant at the earliest opportunity.  Written information can be obtained from “Patient UK” website.