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Essay 300 - PPH

Essay 300 - PPH Posted by PAUL A.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].
Posted by Johnson  O.
Post partum haemorrhage is an emergency situation. I would call for help, senior obstetrician, anaesthetist, junior doctors, more midwives. Haematologist and blood bank would alerted.
I would assess for resuscitation, airway, oxygen by face mask. Blood pressure and pulse would be measured. IV access with two wide bore cannular, blood would be taken for full blood count, coagulation profile, Group and crossmatch 4 to 6units of blood urgently. I
IV fluids would be given normal saline to run fast. Rub-up contraction of the uterus per abdomen, because uterine atony is the commonest cause of Post partum haemorrhage. Oxytocin 5units would be given IV/IM. With normal blood pressure ergometrin would be given in addition. I would ask if placenta was inspected and complete. Prostaglandin F2[Carboprost] 250mcg Im or intramural. It can be repeated every 15minutes with maximum of 8doses
Examination of the vulva for any perineal tear, vagina or cervical tear that may be causing bleeding. This would be sutured with absorbable stitches. Foley\'s catheter would inserted. In presence of persistent bleeding Oxytocin infusion to flow at 10units per hour. Blood transfusion according to local protocol. If the crossmatched blood is not immediately available, O rhesus negative would be transfused pending the availability of crossmatched blood.
Patient and her family would be kept informed of the situation and the intervention. Where bleeding persist, she would be transfered to theatre for examination under anaesthesia and proceed to laparatomy if required.
In theatre, uterine artery embolisation if facilities and expertise available. If not, laparatomy would be performed. B-lynch sutured can be effective in uterine atony. Ligation of Iliac artery would be performed. If bleeding is still persist, the last option is subtotal hysterectomy with conservation of the ovaries.
Initial post operative care would be in Intensive care or high dependence unit. Clear documentation of events with time and date and all staffs present.
She and her family would be debriefed about what happened and the reason for the procedure or intervention. Thromboprophylaxis according to local protocol. Anti-D would be given if required. Breastfeeding would be encouraged.
Arrangement for counselling, with provision of support with this traumatised events. Discharge letter would be written to community midwife and GP. Follow up would be arranged to discuss further about the events and she would able to ask questions. Appropriate contraception if required.
Posted by Akanksha G.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].
the woman has major primary postpartum hemorrhage (PPH). my 4 main aims of treating this women would be communication with relevant staff, resuscitation, monitoring and investigations, arresting ongoing bleeding all of which would be simultaneously carried out. i would call for help and involve most experienced midwife on call, senior obstetrician and alert the consultant, senior anesthetist and alert the consultant ansthetist, involve the consultant hematologist, alert the lab and blood bank(for atleast 4 units of red cells) summon the portors. one member of the team to record the events, watch the vitals pulse blood pressure, fluid input, output, drugs administered.
assess the airway and breathing. administer 10-15l/min of oxygen by face mask, if airway not patent due to reduced consciousness involve the anesthetist, 2 large bore (14 gauge) cannulas to be inserted, about 20ml of blood drawn for investigations (FBC, coagulation screen, RFT LFT) indwelling urinary catheter (would not only help in monitoring the output but also aid in uterine contraction). rush in about 3.5 L of fluids till blood arrives, about 2 L of warmed colloid and 1.5L of warmedcrystalloid should be rushed through the IV. if blood does not arrive by this time trasfuse O Negative blood or alternatively ABO and D antigen specific blood, till cross matched blood arrives. deciding on the trasfusion of blood products should done inconsulatation with the hematologist. for every 6 units of red cells transfused or if prothrombin time / activated partial thromboplastin time >1.5 time control 4 units of fresh frozen plasma should be transfused. platelet concentrate and cryoprecipitate would be transfused if platelet<50,000/ml or ,fibrinogen <1g/ml respectively. constant assessment of the degree of shock and coagulation screening would guide furthur management. the aim would be to maintain HB >8g/dl, platelets >75000/ml, fibrinogen >1g/L, prothrombin time and activated prothrombin times <1.5times the control. adequate measures to keep the mother warm are essential (like wraping the mother, using warmed fluids for transfusion).constant breifing the birthing partner of the women will help prevent panic.
assessment of the cause of bleeding and measures to arrest the bleeding would go hand in hand with the above measures. A brief review of the case notes and the drugs administered so far should noted examination of the uterus to feel for contraction .
a through local examination and cervical exploration of cervix if genital tract trauma is suspected and repair of cervical/ vaginal lacerations would arrest the bleeding.
if uterine atony is identified ( examine the expelled placenta for retained bits, if yes explore the uterine cavity and do manual removel, if uterine inversion manual replacement )
pharmacological treatment with 5 U of oxytocin slow IV, methergin IM (contraindicated in preeclamsia and hypertension), carboprost 500mcg IM (contraindicated in asthma) every 15 mins not more than 8 doses, would be given till uterus is well contracted and bleeding stops, simultaneously 40 U of oxytocin in 500ml of saline by infusion at 125ml/hr would help maintain the contraction, measures like bimanual compression would aid and facilitate uterine contraction. if the above measures fail, procedures like uterine ballon(rusch baloon) tamponade should be attempted. if bleeding is controlled this should be left insitu for 4-6 hrs. failure of tamponade would be followed`by surgical measures likeBlynch suture, uterine artery ligation, internal iliac artery ligation. recourse to hysterectomy (
take second opinion from experienced staff) would be
early than later especially if rupture uterus is suspected. thromboprophylaxis would be considered
unless contraindicated as with altered coagulation profile.
adequate antibiotic cover with ampicillin and metronidazole would be given.patient would be transferred to ITU or HDU for minitoring and debreifing at the earlieat opportunity will help prevent or reduce psychological and medicolegal problems. information about support groups would be provided.
Posted by Bee N.
Post partum heamorrage is a leading course of maternal mortality.The patient should be accessed for airway, breathing and circulation. Oxygen should be commenced and intravenous access established. Patient should be managed in a multidisciplunary setting and help summoned including the obstetrician, hematologist, aneasthetist, interventional radiologist and midwives. Blood should be obtained for full blood count, coaggulation screening and 8 units of blood crossmatched. intravenous fluid administration with colloids or crystalloids should be commenced and this replaced by compatible blood once available. Blood pressure, pulse and oxygen saturation should be continuously monitored. Atony of the uterus constitutes over 70 % of the causes of post partum haemorrage and the uterus should be rubbed up for contraction if atonic. Placenta and membranes should be checked to ensure complete complete delivery. If uterus remains atonic despite rubbing up, oxytocics such as sytocinon, ergometrine and prostaglandins should be commenced based on unit protocol. The vagina and cervix can be examined if appropriate anagesia is in place.
Futher bleeding will necessitate transfer to the theatre after explaining to patients and relatives of the necessity and possibilty of laparotomy and hysterectomy.
In theatre, the patient under general anaesthesia should be further examined for vaginal of cervical tears. A central line will beneficial to monitor fluid input. An indwelling urinary catheter to monitor urine output. Procedures that would be considered in theatre would include uterine artery embolisation, laparotomy, B-Lynch sutures, uterine artery or internal iliac artery ligation. Hysterectomy will be a last resort. Transfusion of fresh frozen plasma or cryoprecipitate if disseminated intravascular coagulation is suspected. Patient should be closed up with staples and drain left intraperitoneally to monitor further bleeding.
Patient should be monitored post op in HDU with continuous pulse, blood preesure monitor at least for the first few hours. Blood investigations including full, blood count and coagulatio screen would be repeated as is necessary. Low molecular weight heparin for thromboprophylaxis should be considered once bleeding settles otherwise thromboembolic deterrent stockings would help. Early mobilisation should be encouraged with adequate hydration. Breast feeding should be encouraged and Anti-D given as required.
Patient should be discharged postnatally with advice about contraception and post natal clinic appointment to review events that have occured. Ugo
Posted by robina K.
1500 ml blood loss is a massive haemorrhage, there is also a possibility of under estimation.There is increased risk of maternal morbidity and mortality. Prompt resucitation ,rapid restoration of blood loss, identification of cause and immediate management is mandatory to save womans life . I will call for help of Anesthetist, SHO, Midwife ,Consultant, interventional radiologist if facility is available to manage the patient in a multi disciplinary team. I will follow the unit protocol for the management of massive hemorrhage . I will check her pulse and B.P , if she is in shock cardiopulmonary resuscitation is started with the help of CPR team . Two wide bore cannulae are passed , blood withdrawn for FBC, group and crossmatch, clotting profile, blood gases, U&E and LFTs. I.V fluids commenced ,Ringers lactate solution ,saline drip or colloid. O negative blood is started unless group specific blood is available . Pulse oximetry is started .
I willl examine the abdomen for uterine atony and massage is started if it is atonic . Bladder is catherised . I will examine placenta for any missing cotyledon . I will inquire about administration of uterotonics and if not given already oxytocin 10 units I.V is given slowly , or ergometrine 0.5 units given slow I.V. Another option is syntometrine a combination of syntocinon and ergometrine i.v. An infusion of syntocinon started , 40 i.u in 400ml of normal saline. If still bleeding prostaglandins are adminstered. PGF2 ( carboplast or hemabate ) alpha 250 ugm i.m . PGE 1 analogue (dinoprostone ) orally or rectally.
If still there is bleeding , other causes of hemorrhage like cervical, vaginal trauma, retained cotyleydon or coagulopathy should be ruled out . I will explain to the women about the urgent need of examination in theatre and possibility of hysterectomy ., verbal consent is obtained and will confirm any resenment for blood and blood products .I will also ensure that the relatives are kept informed . I will inform the theatre staff and blood bank for urgent blood and blood products . Meanwhile I will apply bimanual compression by placing left hand on the abdomen and right hand in the posterior fornix pressing uterine arteries .
In operation theatre I will re-examine the women after anesthetising ,if uterus has contracted I will put her in lithotomy position ,examine any vaginal or cervical lacerations and will suture it . If the cause of PPH is atony and she is hemodynamically stable uterine packing is done with sterile gauze piece or uterine baloon tamponade using blackmore catheter ,Rusch urological baloon or Bakri baloon is used . Uterine tamponade is simple and effective and may avoid hysterectomy in 80-90 % of cases .
If these measure fails I will perform Laparotomy ,to save the uterus provided women is hemodynamicaly stable ,I will apply compression sutures like B lynch .Devascularisation like uterine , ovarian or internal iliac ligation or embolisation of vessels by interventional radiology if expertise are available . In a hemodynamically unstable women I will not perform these time consuming procedures and will perform subtotal hysterectomy .Blood loss should be replaced with group specific blood ideally cotomegalovirus and kell negative . If the women did not consent for blood transfusion cell salvage therapy should be considered and help of hematologist and those expert in cell salvage therapy should be called.
Post operatively antibiotics and thrombo prophylaxis given . women is shifted to ITU or high dependency unit . Debriefing about all the events after recovery . incident report form is filled .FBC ,HB and clotting repeated .
Posted by H H.
This a case of primary post partum hemorrhage, which has a high risk of maternal mortality and morbidity if not managed properly.There should be local guidelines and protocols in each medical facility for management, these should be regularly rehearsed and audited for best care of patients.I would follow these protocols.If patient shocked,would call for help(midwives,anaesthetist,porters, consultant and alert the operating theatre) ,put patient flat ,head down, see to her airway,see if breathing and give oxygen, site 2 large bore IV lines and run iv fluids, send blood to lab and call hematologist for urgency of cross matching 4 units of blood (other blood tests done FBC, clotting screen ,urea and electrolytes) ,if urgently needed would give RH-ve group o blood. Would feel the abdomen for a lax uterus and would massage it if lax and give ecbolics with doses according to unit protocols .
While resuscitating I would assess the situation for possible cause of her bleeding , the commonest is an atonic uterus but may be due to trauma to genital tract, placental remnants , coagulation problem (coagulopathy,bleeding tendency, delivery while still on anticoagulants ) or a combination . Would see the notes (parity,medical problems,bleeding problems,obstetric problems like polyhydramnios), ask about the progress of labour(partogram) , conduct of delivery,placental examination by midwife, were genital tract injuries seen by midwife.Would examin abdomin and massage uterus if lax .
If uterus is still atonic despite resusitation and ecbolics would take patient consent for further management that may need hystrectomy if possible or act in patient best interest, transfere patient to operating theatre and measures to stop bleeding undertaken according to patient situation and according to unit protocoles.Bimanual compression should be tried and if successful but the uterus continue to relax when stopping it, a Lynch brace suture might be of value. Would cosider other measures if bleeding does not stop as bilateral ligation of uterine arteries and if vascular surgeon was called ,consider bilateral ligation of internal iliac arteries.Would not delay the decision of doing a hysterectomy if situation necessitates .
If uterus is well contracted and patient still bleeding examination under anesthesia done with suturing of cervical or vaginal lacerations. Rupture uterus should be considered in patients whom blood loss vaginally does not corespond to the degree of shock , in presence of a well contracted uterus.This will need laparoscopy with either repair or hysterectomy.
Presence of retained placental products are removed with help of ring forceps.
Presence of history of bleeding disorder ,need help of hematologist and given fresh frozen plasma or cryo precipitates.
Coagulopathy dealt with by fresh frozen plasma or fresh blood transfusion if available
Would write an incident report, debrief the patient of what happened,inform her GP and discuss plans for next pregnancy if uterus still intact.Post partum hemorrhage of atonic type can be recurrent.

Posted by Sahithi T.
I will alert lead midwife, team of obstetricians and anaesthetist on labour ward duty to seek more help. I will make sure that two wide bore vein flows are introduced and blood collected at the same time for investigations. I will ask to start i.v. fluids immediately. I will do her bimanual examination. If uterus is atonic then I will start massage. I will ask midwife to administer syntometrin if not given already. I will ask my assistant to start her on oxytocin 40 IU in 40 ml of normal saline drip with infusion pump. Blood should be sent for full blood count, clotting profile, and group and cross match. One team member should document the management and observations with time. I will make sure that somebody would explain the situation and reassure the woman and her relatives present in room. The woman should be continuously monitored for her pulse, BP and saturations preferably on automatic monitors if available.
If the woman continues to bleed and uterus relaxes in between, I will continue with uterine massage and ask for Prostagladin F 2 alfa preparation (injection hemabate) 250 mcg intra muscular. I will wait for prostagladins to act. Most cases of PPH respond well to these measures. If the woman shows signs of shock and continues to bleed, blood transfusion should be considered along with repeat dose of PGF2 alfa injection after 15 min of first dose. Simultaneously I will give her 800 mcg misoprostol ( PGE1 ) tablets per rectally. I will catheterise her. I will continue with fluid resuscitation and get anaesthetist involved in management. PGF2 alfa injection can be repeated upto maximum 8 times with 15 minute interval.
If above all management fails and woman continues to bleed with atonic uterus I will inform consultant and will shift woman to operation theatre. I will order for fresh frozen plasma continuing blood transfusion. I will check for clotting again. If the uterus is contracted but woman is still bleeding, then I will shift her to operation theatre and I will check for any cervical or vaginal tears under anaesthesia. If there are tears then they should be sutured. Vaginal lacerations with fragile tissue can be packed applying pressure packing. But if the woman continues to bleed with atonic uterus with failed medical measures needs exploratory laparotomy. I will explain the woman and her relatives about operative intervention needed and will consent her for laparotomy and if required hysterectomy as a last resort. With informed consent and normal clotting profile, I will take her to theatre. I will explore her uterine cavity for any remnants of placenta or clots. On laparotomy, brass sutures like B-Lynch would be tried as an initial attempt to make uterus compress and control bleeding. Conservative management like balloon can be used with consultant advice. But with all failed attempts to control bleeding, hysterectomy should be considered as a last resort with two consultants’ opinion. The fluid management and blood transfusion should be carefully monitored at the same time. The woman will be managed in high dependency unit and I will document all events carefully in her notes. I will explain her and her relatives about the steps taken in her care at appropriate time.
Posted by C P.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].
C
It is an acute emergency situation, I will rush in to the room quickly introduce myself to the patient and asses her airway, breathing and her circulation. Prefer to keep the patient in tilt position which improves after load. Briefly I will ask the midwife about the birth event to judge what could be the cause of the bleeding.
I will ask for senior help this includes consultant obstetrician, senior anaesthetist, midwife sister and my junior medical colleague. Even the porter should be summoned. In the same time I will inform the theatre staff that we may take this patient to the theatre in due time for exploration if the bleeding is not control with initial approach.
I will ask the midwife to give 15 lt O2/min by facial mass. Meanwhile I will insert two large bore ventflown one on either hands and start iv fluids. I will start with crystalloids. While inserting the ventflown I will take adequate blood for group and cross match and for investigation of FBC, and coagulation profile. Involve the haematologist and request for 6 units of group specific blood, if not immediately available O negative blood will be requiring first. Further fresh frozen plasma 4 units and platelets 4 units will be required.
Continues monitoring of heart rate, blood pressure, O2 saturation, and Respiratory rate and documenting is mandatory.
After explaining to the patient I will examine her abdomen and look for whether uterus has well contracted or it is still relaxed. If uterus is relaxed while massaging the uterus, I will ask one of the team member to start 40 units syntocinon in 500 ml of Normal saline to infuse at 125 ml/hour. Along with this ergometrin 500mg im should be given. If the uterus is not responded to this I will give 250 mic gram carbipros intra muscularly. This is a prostaglandin which will cause potent uterine contraction.
Further I will ask someone to continue massaging the uterus and I will examine the perineum for any perineal tear, cervical tear or uterine inversion. If uterine invasion I will try to reduce it as soon as possible.
As soon as blood arrives it should be started with blood warmer. Because this patient had bleed significantly more within a very short time, if the bleeding is not controlled she needs further exploration in the operation theatre with good analgesia, adequate light and good assistant with appropriate instruments.
Following informed consent I will shift her to the theatre. With the help of my anaesthetist colleague either regional or under general anaesthesia depends upon the patients condition. If she is hypotensive regional anaesthesia will be not suitable for her. I will examine to find out the bleeding point. If it is from perineum or cervical tear I will apply haemostatic sutures. If difficulties arises obstetric consultant’s help will be obtained.
If the bleeding from the uterus with the previously given medication further 250 mcg carbipros can be repeated every 15 minutes for total of 8 doses. Simultaneously 1000 mg misoprostol should be given PR. Following bimanual compression of the uterus I will check for the uterine contraction. If still not successful Ruch balloon can be inserted in to the uterus as tampon to stop the bleeding.
If interventional radiologist are available, I will summon them to come to the theatre to intervene. Not all the places have this facility.
If she is still bleeding the next step would be laparotomy and try to do B lynx suture, further uterine artery ligatiion, internal artery ligation can be tried. If one method fails to go to other. If I decide to do internal artery ligation I will get the help of the vascular surgeon.
I will not hesitate to do hysterectomy if the condition does not improve with all the above measures. Caesarean hysterectomy is a difficult procedure in a stressful situation. Consultant obstetrician would perform this procedure.
Post operatively I will document the events systematically. Fill the incident form. This patient should be managed in the intensive care unit until she recovers. I will debrief the patient and her partner about all the procedure we have done and the necessity of this. I will ask mid wife sister to organise for proper counselling before she leaves the hospital.

Posted by SUNDAY A.
Sunday\'s answers

The principle of management of this patient would centre around good communication, resuscitation, monitoring and investigation and arresting bleeding all of which be undertaken simultaneously to ensure good outcome. On arrival at the room, I would immediately call for help from the labour ward coordinator, on call anaesthetist, alert my consultant and consultant anaesthetist, heamologists . I would ensure that the unit protocol in followed with staff available to document the events and facilitate request of blood and blood products to and from the blood bank.
I would proceed to check the airway and commence high flow oxygen therapy (10-15L), check the breathing and gain iv access with 2 large bore cannula and also take blood for urgent FBC, U/Es, clooting profile and crossmatch 4 units of blood. Regular monotoring of BP, pulse rate and oxygen saturation would be comenced. I would make sure the patient is flat and quickly proceed to establish the likely cause of the bleeding. I would explain the need for the above mentioned intervention to the patient and also ensure that the family and relative are reassured and informed regarding progress. i would give upto 2 litres of hartmans + 1.5 litres of colloids depending on the clinical situation whiel waiting for blood to arrive. All efforts should be made to keep patient warm and ensure that fluids given are warm.
I would check for uterine contraction, ascertain any drugs that have been given- eg oxytocin or syntometrine. I would give a repeat dose of iv syntocinon 5units or sytometrine 10 units if no contraindication and ergometrine 0.5mg( if no C/I ie high BP). i would also commence iv syntocinon 40 units in a 500mls normal saline to run at 125mls/hr. I would proceed to vaginal examination to assess for perinal/vaginal/cervical tears and subsequently insert an indwelling foley\'s catheter. I would also ensure that the placenta and membranes are complete in which case the patient should be transfered to the theatre for EUA and further management if bleeding continues. Blood results would be checked promptly to rule out possiblity of a coagulopathy which would be corrected under the guidance of the heamatologist. Blood tansfusion would be commenced as soon as possible with possible use of other blood products such as platelets, fresh frozen plasma etc as dictated by the amount of blood transfused and patients clinical condition.
In theatre under good light and anaesthesia, a detailed examination would be carried out and any perineal/vaginal /cervical tear would be sutured. Manual removal of placenta made be indicated if retained products is suspected. If patients continue to bleed or with suspicion of uterine atony not responsive to the above remedies, a balloon tamponade can attempted to control the bleeding before resorting to surgical mangement such use of brace suture- B-lynch technique, internal iliac atery ligation can be used with help and guidance of my consultant. Uterine embolisation can be considered if facilities and personnel is available and a resort to hysterectomy may be made if all intervention fails. This ideally requires the agreement of another consultant if possible.
Once bleeding has been controlled , patient should be transferred to ITU or Labour ward HDU for close monitoring and obsrevation of vital signs, urine output and further bleeding or deterioration.
The patient and relatives and staff should be debriefed about the events and an incident form filled as per the unit protocol.i would ensure that a proper record of events and intervention is properly documented in the patient\'s notes.
Posted by Manoj M.

M
(a)This is major PPH and I will commence simultaneously resuscitative measures, communicate with my team, commence continous monitoring with investigation and measures to arrest bleeding to reduce the risk of maternal mortality.
I will call for more help from senior midwife, anaesthetist oncall to help me with managing her and also alert my obstetric and anaesthetic consultant and haematologist.
I will assess her airway and breathing and simultaneously commence high flow O2 at 15 lts/m using facemask and also obtain 2 large IV acess(orange canula) and take 20mls of blood for FBC, clotting, U&E and cross match for 4 units as urgent.
I will position her flat on the bed and use bed warmers available to prevent hypothermia.
I will simultaneously commence fluid resuscitation untill blood available and use either crystalloids or colloids to a total of 3.5litrs.
If blood is not available then Onegative blood given untill cross matched blood available. For every 6 units blood use 4 units FFP(or if aPTT above 1.5 times control),if platelet count below 50 then platelet concentrate should be given and if fibrinogen below1g/l then cryoprecipitate should be considered.
Recombinant Factor 7a can be considered but is very expensive and fibrinogen level should not be below 1g/l and platelet above 20 for it to work.
I will continously monitor this patient with resuscitative measures using continous pulseoximeter, ECG monitor, automated continous BP recording. Temperature will be recorded every 15 minutes. I will insert a foleys catheter to measure her urinary output, an arterial line will be commenced with an experienced anaesthetist for monitoring of invasive blood pressures.
I will rapidly assess her to find the cause of PPH and initiate with rubbing uterine contraction if not stopping then bimanual compression of uterus to arrest bleeding with uterine atony.
Uterotonics will be used like oxytocin 5IU slow IV bolus and repeated or ergometrine 500micrograms slow IV or IM (contraindicated with hypertension and may causing vomiting).
Carboprost can be given 250micrograms as IM, every 15minutes apart for a total of 8 doses, Misoprostol 1000micrograms rectally can also be used as uterotonics.
If the above pharmacological measures fails to arrest bleeding then a baloon tamponade (e.g. Rusch balloon) is an effective measure to control bleeding, open surgical mesures include ligation of uterine artery, ligation of internal iliac artery, selective arterial embolisation(need specialist intervetinal radiologist) or hysterectomy (should be considered earlier if uterine rupture or invasive placenta is the cause of PPH)
Consultant and extra help will be summoned if continued bleeding at earlier stage before resorting to any surgical procedures and if needing more than 1 carboprost and resuscitation stabilished then patient will be moved to operating theatre.
Other causes of PPH like retained placenta should be explored and removed in theatre and any perineal/ vaginal/ cervical tears should be sutured, if thrombin coagulopathy is the cause then addition factors along with blood like FFP, cryo and platelet concentrate should be considered.
Once the patient is stabilished she should be further monitored in ITU/HDU.
All events should be documented simultaneously by an assistant on labour ward and then fully documented in notes.
A critical incident form filled for risk management and I will debrief the patient about the event and a 4-6week postnatal clinic organised.
Posted by G. K.
The first thing is to make sure that the patient is haemodynamically stable.This is checked by her blood pressure, pulse and state of conciousness.Call for additional help and inform the senior obstetrician and the anesthetist. Make sure that the patient has atleast two wide bore cannulas and is on IV syntocinon infusion and on crystalloids infusion.Draw blood for full blood count, group and cross match for 6 units of blood and take blood for baseline investigations including urea and electrolytes and liver function tests. Catheterise the patient to moniter her fluid intake and output.Inform the blood bank and the haematologists and the consultant obstetricians and the theatre staff of the situation.
Palpate the abdomen for utrine tone first since uterine atony is the most common cause of post partum hemorrhage. If atonic, try to rub up a contraction.
Carefully examine the lower genital tract for any vaginal or cervical lacerarations as the cause of bleeding.If found, they should be repaired immedietly.
Rule out inversion of uterus as the cause of bleeding.If found it should be replaced manually after stopping the syntocinon infusion. after replacement, the syntocinon infusion should be recommenced.
Explore uterine cavity for retained placental cotyledon.If found, remove the cotyledon and do bimanual compression.
The patient should receive uterotonics like ergometrine 250ug IM as a bolus dose. Carboprost (prostaglandin2 alpha ) should be given in a dose of 250ug every 15 minutes, upto a maximum of 3 doses.Misoprostol should be given per rectally in a dose of 800ug to augment the effects of other uterotonics.
If all these measures fail, the situation should be explained to the patient and she should be transferred to theatre.
In theatre the uterine bed can be compressed by the use of either a large foley catheter, senstaken blakemore cathere or Bakri SOS balloon to stop the bleeding.
The blood results should be back by now and they should be reviewed to rule out a superimposing picture of DIC compounding the problem.The results should be discussed with the haematolgist. If platelets are <50X 10 5, the patient should be transfused with platelets.If fibrinogen levels are less than 1g, the patient should receive fresh frozen plasma.
If patient is still bleeding, she should be made aware of the situation and consent obtained for laparotomy and further procedures if needed.
Further management options include, urgent uterine artery embolization if the facility is available.If this fails, laparotomy is performed and compression sutures to compress the placental bed are placed. If this fails, e ligation of uterinse arteries should be carried out to stop the bleeding.
If this measure fails to control the bleeding, the surgeons should be involved and the internal iliac arteries should be ligated.
A last resort is hysteredtomy if the above measures fail.
Postoperatively , the patient should be transferred to ICU for monitoring.
Postoperatively the patient and her family should be debriefed and the events leading to the hysterectomy explained.
All the notes should be carefully recorded in the chart since it can potentially be a medicolegal case.
An incident form should be filled.
Posted by H H.
sorry,rupture uterus treatment by laparotomy and not as I miswrote laparoscopy,I must have been drinking.I must revise what I wrote, the problem that some times one can\'t find the time
Posted by Shalini  M.
Shalini
This is an acute emergency with the lady having moderate PPH.I would begin by calling for help-Senior obstetrician and anaesthetist and informing the respective consultants,experienced midwife and midwife incharge,proters to carry samples,inform clinical hematologist on call and the blood transfusion laboratory.I would then assess her airway and breathing and start oxygen 12-15 lts / min if hypoxic.Intravenous access should be established with 2, 14or 16 gauge cannulas and 20ml blood should be taken and sent for Full blood count,urea ,electrolytes,liver function tests for baseline and coagulation profile for detecting any coagulopathy along with group and save for cross matching 4-6 units blood.Intravenous fluids like crystalloids(max 2.5 lts),colloids(1lt) should be warmed and rushed fast till crossmatched blood is available which should be then transfused rapidly after warming.Patient should be warmed.Then quickly i would assess the tone of the uterus and if atonic will chech if bladder is empty or not and would start bimanual massage alongwith administering oxytocin 5 IU slow IV.Syntometrine can be given if there is no hypertension.Also carpoprost 250ugm can be given intramuscularly and repeated every 15 min till a max of 8 doses.Also injection carboprost can be given intramyometrally thru the abdomen although it could precipitate an acute attack in asthamatics.Misoprostol 1000ugm can be given per rectally although it has not been found to be more effective than oxytocin.If uterus does not contract then balloon tamponade of the uterus can be done with foley\'s catheter,rusch balloon,etc which has been found to be very effective.Patient needs shifting to theater if bleeding continues after discussion with the anaesthetist about the anaesthesia(regional anaesthesia should be preferred).4 units FFP should be transfused after 6 units of blood that is given and hypocalcaemia should be looked for.Continous pulse,blood pressure and oxygen saturation monitoring should continue apart from temperature every 15 min.Output should be monitored by catherising the bladder .Platelets should be transfused if platelet count is less than 50x109/lt.Patient should be explored under good illumination in theater with appropriate analgesia in place.Swabs should be counted and instruments checked.Consultant obstetrician should be present as also the consultant anaesthetist for a thourough exploration of the genital tract.If no trauma is found then laprotomy for uterine artery.ovarian artery ligations,B-lynch mass suture,internal iliac ligation etc whatever is indicated.Uterine artery embolisation is still under research trials.Cesarean hysterectomy is indicated in cases of intractable PPH as an life saving measure and should be resorted to after opinion of a second obstetrician.
Posted by A A.
As the patient is having blood loss of 1500 ml and still bleeding so it is the major post partum haemorrhage (PPH) and prompt intervention is required to reduce maternal morbidity and mortality. I will call for assistance from anaesthetist ,experienced midwife, in-charge midwife, SHO and porter for delivery of specimen and blood. I will inform consultant obstetrician, consultant anaesthetist, consultant haematologist, blood transfusion laboratory and operation theatre staff. I will appoint one member of my team to record events, fluids, drugs and vital signs. I will follow unit protocols / guidelines for management of PPH. I will assess airway, breathing, and check pulse and blood pressure. I will give high concentration of oxygen by face mask 10-15 litre per minute, obtain venous access by passing two 14 gauge canulae and draw 20ml of blood at the same time for investigation. I will send blood for crossmatching (4 units minimum) and group, FBC, Coagulation screen including PT/APTT, thrombin time, fibrongen, renal function test and liver function test. Until blood available, I will transfuse 2 litres of warmed crystalloid Hartman’s solution and / or 1.5 l of colloid as rapidly as required. If cross match blood is not available, I will give RH negative group O blood or uncrossmatched group-specific blood. The most common cause of primary PPH is uterine atony. However I will do abdominal ad pelvic examination to exclude other or additional causes like RPOCs, genital tract trauma, uterine inversion and uterine rupture. Perceiving uterine atony is the cause I will rub up contraction and do bimanual uterine compression to stimulate contraction and ensure that bladder is empty. I will leave folleys catheter in place for further monitoring of urine. I will give syntocinon 5 units IV slowly, inj Ergometrine 0.5 mg by IM inj and will commence syntocinon infusion (40 units in 500 ml hartman’s solution at 120 ml p/hr).I will ask anesthetist to obtain CVP line not only for adequate fluid monitoring but also as a route for rapid fluid replacement. Monitoring of the patient will be continued comprising temperature every 15 min, continuous pulse, blood pressure recording , respiratory rate (using pulse oximetre, ECG and automated BP recording) and fluid input/output.It will be documented on a flow chart.I will try to keep women warm using appropriate available measures. I will ensure that woman and her partner/carer are kept informed clearly at each step of the situation.I will check for genital tract trauma(vulva,vagina or cervix).If there is no obvious trauma and bleeding hasn’t stopped, I will give injection carboprost 0.25 mg by IM injection and will put tab Misoprostol 1000 ug rectally.After discussing with anaesthetist consideration will be given for FFPs(4units for every 6units of Red blood cells or PT/APTT>1.5xl(12-15ml/kg),PLT count<50x10 9/l and fibrinogen<1g/l. Aim will be to maintain HB conc >8g /dl, plt conc > 75 X 10 (6) / l, PT < 1.5 X mean, APTT <1.5 x mean and fibrinogen > 1 g /l.
If bleeding still not stopped, consideration for surgical measures sooner than later will be given.I will explain women and her carer about need for examination under anesthesia in theatre,possibility for hysterectomy if bleeding does not stop as a last resort and will take informed consent.This(EUA) is also to ensure that there are no products of conception,even when placenta is thought to be complete.I will make sure that by the time consultant obstetrician and consultant anaesthetist have reached. Intrautrine balloon tamponade(using Sangstaken Blackmore tube,urological Rush balloon,Bakri balloon) is the first line surgical management for uterine atony as it provides tamponade effect without concealing bleeding. If bleeding is controlled it will be left for 4-6 hours and patient will be shifted to high dependency unit (HDU or ICU) for close monitoring. If bleeding still not controlled then laprotomy will be done and first B-lynch suture / modified compression suture will be considered, if it is unsuccessful then bilateral uterine artery ligation,bilateral internal Iliac artery ligation or subtotal hysterectomy will be performed sooner than later (especially if the uterus is ruptured). Once bleeding has controlled and initial resuscitation has been completed, continued close monitoring in ICU or HDU will be done. I will ensure for clear documentation of all events with timing date and signature. I will fill the incident form. As all of these events can be traumatic to women and her family,and likely to creat anxiety and psychological stress in woman I will arrange for debriefing of the woman by consultant obstetrician.Proper follow up and investigations like screening for coagulopathies if there are other indicators or for panhypopituitarism(sheehans syndrome)will also be done.Need for HRT in case of hysterectomy. I will provide the woman details of the support groups for PPH.
Posted by SANCHU R.
Sanchu
The management involves communication, resuscitation and measures to stop the bleeding all done simultaneously.
The patient and her partner are kept informed and supported. The consultant is alerted and the middle-grade anaesthetist is called. Further communication would be with the blood bank and Hematologist if needed.
The probable cause is atony.
Airway and Breathing are assessed. O2 by mask is started at 15L/min.
Continuous monitoring of BP, PR, SATS are done. 2 14 or 16 G IV cannulae are sited with blood sent for FBC, Coag profile and cross-matching.
IV crystalloids(Normal saline or Hartmann\'s)are rushed. The clinical situation indicates blood transfusion and time is not wasted waiting for lab results.IV fluids upto 3.5 litres can be given (2 l of crystalloids + 1.5 l colloid) until blood is ready. If cross-matched blood is still not ready, group-compatible uncrossmatched blood or O negative blood is started.
oxytocin infusion 40 units/ 500ml is started at 125 ml/hr. IV Syntometrine (0.5 ergometrine + 5 U oxytocin)IV is repeated. If she is still bleeding Hemabate 0.25 mg IM is given repeated every 15 min for a maximum of 8 doses.
When massage of the uterus is continued and bleeding not heavy, she is quickly examined to rule out traumatic PPH from cervix or vagina.
If she is bleeding heavily, she must be taken to theatre immediately. She is examined under anaesthesia. The causes of Tissue, (retained placental bits), Trauma is ruled out and Rusch balloon is used for tamponade which is removed after 6 hours. If bleeding is still not controlled or Rupture uterus or Broad ligament hematoma are suspected , Laparotomy with consent for hysterectomy is done. B-Lynch sutures, uterine A. ligation and Internal Iliac ligation, Uterine A. embolisation are the methods which can be tried before resorting to hysterectomy. If PPH is due to placenta accreta, hysterectomy is done sooner than later.
Blood, FFP, Cryoprecipitate and recombinant VII A are given according to Haemotologist\'s advice.
Posted by Sophia Y.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].

I will call for help - senior midwives, labour ward coordinator, consultant obstetricians and anaesthetist and juniour obstetric and midwivery colleagues and porters. I will ensure that her airway is patent, she is breathing & presence of circulation by checking her carotid artery. I will ensure she has two big bore intravenous cannula (size 14) inserted. Bloods will be sent urgently. This includes full blood count to exclude anaemia & thrombocytopenia, group & save & crossmatched her for at least 4 units of blood to correct anaemia due to bleeding. I will check baseline renal & liver function. I will check clotting to exclude disseminated intravascular coagulopathy. Results need to be followed up urgently.

I will give her oxygen up to 10 litres via facial oxygen. Her blood pressure, pulse, oxygen saturation will be monitored at least every 15 minutes until she becomes stable. She needs to be catheterised & urine output to be monitored every one hour in conjunction with temperature. All these observation monitoring should be recorded on the \"modified obstetric early warning score\". She should receive crystalloid (eg normal saline) infusion & colloid infusion while waiting for bloods. If there is no enough time to cross match & blood transfusion is needed urgently, O negative b lood should be given.

Cause of postpartum hamorrhage (PPH) needs to be identified. Uterine atony is the commonest cause. Continuous bimanual uterine compression and oxytocic can be used. The latter includes im sytocinon 5 units bolus intramuscularly (im) or slow intravenous (iv) bolus. 40units of iv syntocinon infusion (mixed with 500ml normal saline) running over 4 hours should be commenced. Ergometrine or syntometrine i ampule im can be given when there is not history of hypertensive episodes. Carboprost (prostangladin F2 alpha) 250 microgram can be given as im every 15 minutes up to 8 doses. Misoprostol 1g per rectum can also be considered.

Perineal, vaginal or cervical trauma needs to be excluded and immediate repair should be commenced. The placenta should be checked to exclude any retained placenta. Consultant haematologists should be discussed with should the blood results show any coagulopathy or significant thrombocytopenia where fresh frozen plasma, cryoprecipitate or platelets need to be given.

Should her PPH not respond to oxytocic treatment or retained placenta is suspected, she should be consented for examination under anaesthesia. It can be done under spinal or general anaesthesia. Patient should be counselled about hysterectomy should uterine atony do not respond to balloon tamponade, uterine compression sutures eg B-Lynch. A second opinion from consultant obstetrician should be obtained for hysterectomy. The woman should be considered to be transferred to high dependecy unit for close observation.

Good communication is important in cases of PPH. Staff should be allocated for monitoring recording observations, scribing the events, transporting equipments & medicines, looking after the woman & partner so that the team can work effectively.

Once she is stable, she should be debriefed about the incident. An incident form should also be completed due to PPH.
Posted by Leen K.
LEEN
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].

In such a situation, there are 4 components of management that should be done simultaneously - communication, resuscitation, monitoring and investigations, and arresting the bleeding.
I would make sure the consultant obstetrician, senior anaesthetists, laboratory (blood transfusion and haematology especially) and porters (to collect blood samples and blood products) are informed. Resuscitation should be commenced, and her airway, breathing and circulation should be assessed and secured. At least 2 large bore intravenous (IV) cannula (14 gauge minimum) should be inserted and bloods taken for full blood count, urea and electrolytes, liver function tests, coagulations screen (including fibrinogen) and group and crossmatch of at least 4 units. I would commence warmed crystalloids and/or colloids (at a fast rate) whilst awaiting the arrival of crossmatched blood. Her blood pressure and pulse should be observed continuously and temperature taken every 15 minutes. Facial oxygen (15litres) should be given.
I would check her fundus for signs of atony (the most common reason for post partum haemorrhage) and apply bimanual compression of the uterus if it is atonic. 5 units of syntocinon should be given IV and a syntocinon infusion (40iu in 500mls NaCl 0.9%, at 125 mls/hr) started. I would catheterise the patient and monitor her urine output. I would make sure there is a designated staff/person scribing and documenting all events, condition of the patient, interventions and timing.
Ergometrine should be given (if she has no history of hypertension) - 0.5mg intramuscularly (IM). If this does not stop her bleeding, I would give her carboprost 0.25mg IM (every 15 minutes, up to a maximum 8 doses) .
If crossmatched blood is still not available and she has had up to 2 litres of crystalloid and 1 litre of colloid, and she is still bleeding, I would give her O negative blood (which should be available on labour ward) whilst awaiting crossmatched blood.
I would also check for other causes of bleeding, and treat any causes found. I would look for any signs of trauma (vaginal/cervical tears), retained products of conception (get a midwife to check if the placenta is complete and examine her cervix to see if membranes are present) and signs of coagulopathy in the patient (coagulation screen and signs of blood not clotting).
If the medical management of arresting her bleeding does not work, I would transfer her to theatre and insert a Rusch catheter (intrauterine) to arrest bleeding. If this does not work, I would perform a laparotomy to apply a compressioin suture (eg B-Lynch). Failing that, ligation of the uterine arteries or internal illiac arteries can be attempted. If intervention radiology is available, I would involve them to consider internal iliac artery embolisation. These interventions are not shown to affect future fertility or pregnancy outcome. As a last resort, if she continues to bleed, a hysterectomy will need to be performed (usually 2 consultant obstetricians need to agree that it is the best course of action - as it is associated with increased morbidity and is a difficult operation in such a circumstance).
I would keep the patient and her family informed of the situation at all steps and reassure them if appropriate.

(written in 26 minutes)
Posted by mm S.
call help from senior obstetric and anaesthetic . ensure two intravenous lines and do emergency hb.hct, and cross match ,urea &E ,LFT and clotting screen . I will check her bp p and resusscitate her following ABC . first thing then to check uterine contractility and the placenta and membranes to make sure nothing is left . then i will check her partogram and her antenatal notes . in case the uterus is not contracting i will start utertonics syntocinone , metergine ,hemabat. if the uterus is will contracted proceding to genital tract examination in theatre under good lightning and analgesia to identify any trauma or uterine rupture or inversion and manage it accordingly . when hb result come back i will start transfusion after taking consent from the patient . After controlling the bleeding i will observe the patient in ITU . filling incident form and explaining to the patient what has happened .
Posted by SA M.
This is an Obstetric Emergency with moderate post partum haemorrage associated with increased risk of maternal morbidity and mortality.Its management requires communication,resuscitation,monitoring of patient and treatment. I will follow my unit protocol in this situation. I will put emergency call for multi disciplinary team including consultant obstetrician,Anesthetist,senior midwives,alert haematologist,lab and porter. My first step would be to resuscitate the patient by securing her airways, breathing with oxygen inhalation, circulation by inserting 2 large bore canula ( atleast 14 gauge).Bloods to be sent for FBC,Coagulation U & E’s and LFT’s to screen for baseline liver and renal function, 4 units of Blood cross match. Her continuous BP,pulse,O2 saturation monitoring should be done.Folley’s Catheter for maintenance of intake & Ouput chart..Blood loss should be replaced by crystalloids and colloids upto 3.5 liters (2.0 liters of crystalloids & 1.5 liters of colloids) till the blood arrives or ‘O’ Rh Negative blood can be given till group specific cross match blood arrives.Abdomen should be palpated & if uterine atony ,start with rubbing up of uterus plus Bimanual compression to increase uterine tone and at the same time I will start Uterotonic agent like oxytocin 5 units I/V slowly or 0.5 mg of Syntometrine I/M if patient is not hypertensive and still bleeding 40 units of oxytocin in 500 ml of 0.9% Normal saline at rate of 125 ml/hour if still uterus is relaxed. I will give 0.25 mg of carboprost Injection I/M or 0.5 mg intramyometrial injection if bleeding continues & uterus still relaxed.I will ask the midwife to check if placenta is complete.Vaginal examination to rule out retained placental pieces membranes or trauma to genital tract which can be sutured by absorbable Vicryl 2.0 to stop bleeding.
If all these medical measures will not stop her bleeding I will shift her to operation theater and by that time her coagulation results will be ready and should be Reviewed to exclude coagulation defects.Under Anesthesia and good light I will exclude her genital tract trauma again and suture if needed. If her uterine atony is the cause then I will consider conservative surgical measures as uterine temponade by mean of rusch catheter or sengstaken tube or Bakri balloon.If still bleeding continues I will do uterine or internal iliac artery ligation.If facilities available I will consider internal Iliac artery embolisation as these interventions will save her future fertility by saving her uterus. If all these surgical conservative measures failed then as last resort with opinion from atleast 2 consultant obstetricians Hystrectomy should be done, preference will be subtotal hystrectomy and with preservation of ovaries if possible .During all this time I will keep patient’s partner & family informed of the situation.i will document all the events carefully,timing,medication & surgical measures taken.Patient should be councelled and informed of all the events as early as possible by consultant obstetricians present during that event.
Posted by SN  K.
SN

This is an Obstetric emergency. Patient should be first assessed for Airway (A)(if talking, airway is patent), Breathing(B), Circulation(C) (pulse, BP) and blood loss should be estimated simultaneously. If A, B, C is defective (e.g. if airway is not patent, may need intubation and artificial ventilation; fluid resuscitation with crystalloids and colloids). I will request another team member to call for help (e.g. Labour ward coordinating mid wife, SHO, Anaesthetist, Senior Obstetrician). Two large bore cannulas should be inserted and bloods should be sent for FBC, Renal profile, LFT, clotting profile. 4 units of blood should be cross matched urgently.
A quick history regarding antenatal complications, labour (e.g. slow progress, use of oxytocin for augmentation) and delivery should be taken (e.g. perineal lacerations, episiotomy, complete evacuation of placenta).
Uterus should be examined for hypotonicity. If not a well contracted, Oxytocin infusion 10 units/hour should be started. If patient has already had Syntometrine IM post delivery, Ergometroine 500mcg can be given IM while Oxytocin infusion is in preparation. IM carboprost 250mcg every 15 minutes up to 6 doses can be given until bleeding ceases in addition to bimanual compression of the uterus.
Other causes of PPH should be excluded (retained placental parts, genital tract lacerations (e.g. perineal, vaginal, cervical tears). As the patient has already had 1.5L blood loss, she should be taken to theatre for EUA (examination under anaesthesia). Consent should be taken for intra-uterine balloon insertion, laparotomy and additional suturing (Uterine brace sutures) and Hysterectomy. Under EUA, genital tract trauma should be sutured if causing the PPH. If there are placental parts or clots retained in uterus, these should be evacuated. If actively bleeding, an intra-uterine balloon catheter should be inserted and watch for further bleeding. If bleeding has not stopped, a laparotomy is indicated for uterine Brace sutures (e.g. B- lynch). If still bleeding, may need a hysterectomy.
The Haematologist should be contacted for blood products resuscitation simultaneously. Patient may need platelets, FFP in addition to whole blood. Factor VII has shown to reduced intractable bleeding and may be considered in liaison with the haematologist if all other procedures and uterotonics fail, prior to hysterectomy.
Patient should be debriefed regarding management done and clear documentation is important with regards to all actions taken (with times) and post operative management. An incident form should be filled for major PPH.
Posted by GHADA AHMAD  M.
GH M
Call for help include senior anaesthetist, senior obstetrician, haematologist and alert OR team for possible surgical interventions. Two wide pore IV lines (16G). CPR is initially required making sure that airway, breathing and circulation are stable. Rapid infusion of crystalloids and colloids. Cross-matched blood at least six units’ alert blood bank for the possible need for more blood and blood products. Rapid history regarding mode and duration of delivery and size of the fetus and prior Hx of PPH. rechecking that the placenta is completely removed. Keep the patient oriented by the procedure that would be taken if she is conscious or inform her next in kin. Treatment with that emergency should be rapid and step-wised. Initial treatment is uterine massage and medical administration of ergometrine, Oxytocin infusion / prostaglandin analogue- misopristol if the uterus is atony. Bimanual compression which is more invasive than uterine rub my be tried. Vaginal exploration of possible vaginal cervical tears under proper analgesia and repair the tears if present. If the placenta is not complete, ERPC is done under anaesthesia. If the bleeding not stanched while maintaining haemodynamic stability I will proceed to more invasive measure. Uterine artery embolisation can be done if intervention radiology is available aiming to preserve the uterus. If not surgical intervention is mandatory starting with simple manoeuvre like B-Lunch brace suture. If bleeding did not stop proceed to bilateral uterine artery ligation or internal iliac ligation. The last resort will be hysterectomy if bleeding is continuous and threatening the life of patient. I will document the procedure in details in the patient notes for care of patient and possible medicolegal issues. I will explain what happen to patient in personal before discharge in sensitive way.
Posted by shipra K.
The patient is having major post partum haemorrhage and needs immediate corrective measures. First and the foremost is call for help,a senior midwife,a middle grade obstetrician and anaesthetist should be called ,consultant obstetrician alerted.The blood bank & heamatologist should be alerted.Communication is very important and patients attendants should be regularly informed about patients condition and therapy being given.
Resuscitation started pulse rate BP,respiratory rate taken.patient put on oxygen at a rate of 15l/min. Two wide bore IV cannula placed(14 gauge )crystalloid approximately 2l and colloid upto 1.5l can be given safely till blood made available.
Patient catheterized with foley’s catheter .One person in the team made incharge to take note of input output and medication given and its timing.About 20 ml of blood taken and send for FBC,clotting screen,LFT,RFT baseline,ask for 4 units of group specific blood if not available then O –ve can be given.A central venous access to be put.
Look for cause ,atonia is seen in 70% patients ,uterine massage done,oxytocin 5 to 10 units slow intravenously bolus given.Drip with 40 units of syntocinon in 500 ml started.ergometrine upto 500 µg can be given .if bleeding still continuing then carboprost 250 µg given intramuscularly .upto 8 doses at an interval 15 min can be given safely.Carbetocin a long acting oxytocin recently made available can be given.Misoprost 1000 microgram can be inserted per rectally. If PPH continuing the balloon temponade with Rusch balloon or Sengstaken Blakemore tube can be tried whichever available, or patient can be taken up for surgical procedure like B lynch sutures or internal artery ligation.or a hysterectomy if deemed necessary.If facilities of an interventional radiologist present then uterine artery embolization can be done.
If trauma is suspected( like perineal ,vaginal, cervical tear)it would need exploration and under GA.If uterine rupture then laparotomy with repair or hysterectomy may be required.
In case there is retained placental bits or membrane (examining the placenta would tell) then ERCP should be done.
Lastly the patient could be having coagulation failure ,a clotting screen would tell us so and transfusing 4 FFP’s for every 6 units of packed cells would prevent this. Recombinant Factor VII a can be given life threatening PPH in consultation with a haematologist.
Once PPH treated patient to be transferred to high dependency unit.
Posted by Asa A.
asa
PPH of 1500 ml blood should trigger full protocol of PPH management and my role is to act as leader of the team till arrival of more senior staff as PPH could cause mortality or near miss morbidity. Communication ,resuscitation , assessment and trying to arrest the bleeding should all be done at the same time. I will ask for more staff , senior midwife , anesthetist ,porters and alerting consultant obstetrician clinical heamatologist and the blood bank .One member should be assigned to record all events including staff involved ,their timing of arrival , their role , medication given ,timing and doses , fluid therapy and blood transfused and the condition of the woman during the whole process. I will see first if she is shocked or no by her general condition ,her level of consciousness , assess air way and breathing and administer O2 10-15 L /min by face mask . Keep her flat and 2 14 gauge cannulas should be inserted ,20 ml of blood withdrawn for FBC,cloting studies including fibrinogen , LFT ,RFT and cross matching of 4 units of blood . Fluid in the form of 2.5 L of Ringers lactate and 1.5 L of colloid will be started immediately till arrival of blood . If the patient has stated before that she refuses blood transfusion I will discuss it with her again. The patient must be kept warm .Foleys catheter must be inserted also. The patient will be attached to electronic monitoring for BP ,pulse . Giving her warmed blood quickly is very important and we should not use special infusion sets as it will slow the transfusion process . Other blood products like FFP or platelets will be transfused if indicated in conjunction with heamatologist opinion and lab results . I will examine the uterus abdominally to check if it is contracted or no as the most common cause of PPH is uterine atony If the uterus can t be felt I will see if it is inverted . Examination of the placenta to see if it is complete or no must be done .During examination taking quick history about circumstances during delivery difficult or no (ruptured uterus) ,history of thrombophilia and if the placenta was low lying ( bleeding lower segment ) .Examination of the perineum and vagina for bleeding tears and lacerations will be done if possible otherwise she will be shifted to theater for examination under anesthesia . Definite treatment depends on the cause of bleeding either tone, tissue ,thrombin and trauma . Atony will be treated by applying first bimanual compression to the uterus while giving 40 iu oxytocin in infusion and 5 iu IV , ergometrine 500 ug im .Giving carboprost im 0.25 mg repeatedly /15 min for a total of 2 mg if she is not asthmatic will be the next step . Insuflation of intrauterine balloon (Bakri or Rusch) to give tamponade effect will be instituted. If bleeding continues the patient will be managed by brace sutures during laparotomy . In case no senior staff is present even aortic compression may be of help . Further decisions for ligation of vessels as uterine artery, internal iliac a or selective embolisation of vessels will depend on the circumstances and available experienced staff. It is important to remember that the patient life is more important than keeping her bleeding uterus intact so decision for hysterectomy should be offered quickly if necessary preferably in the presence of two consultants .
Other causes like bleeding tears , big heamatomas and uterine rupture will be dealt with under aneasthesia as well as removal of retained products inside the uterine cavity .
The patient should be monitored during the whole time and repeat blood testing done as necessary. After stabilization and stopping the bleeding she will be cared for in ITU or HDU till the risk resolves and heamatological correction done.
Professional attitude and calmness are essential in dealing with the situation as the other members of the staff and the patient and her relatives will be tense ,anxious and confused . Debriefing is important for psychological support of the patiet . Adressess and websites for support groups will be offered .
Incident reporting and keeping complete chronological record of all procedures and medication given is essential .

Posted by PAUL A.
Post partum haemorrhage is an emergency situation. I would call for help, senior obstetrician, anaesthetist, junior doctors, more midwives. Haematologist and blood bank would alerted (1) .
I would assess for resuscitation, airway breathing, circulation , oxygen by face mask how much? . Blood pressure and pulse would be measured. IV access with two wide bore cannular, blood would be taken for full blood count, coagulation profile, Group and crossmatch 4 to 6units of blood urgently (1) . I
IV fluids would be given normal saline to run fast how much fluid?? . Rub-up contraction of the uterus per abdomen, because uterine atony is the commonest cause of Post partum haemorrhage (1) . Oxytocin 5units would be given IV/IM. With normal blood pressure ergometrin would be given in addition. I would ask if placenta was inspected and complete. Prostaglandin F2[Carboprost] 250mcg Im or intramural. It can be repeated every 15minutes with maximum of 8doses (1)
Examination of the vulva for any perineal tear, vagina or cervical tear that may be causing bleeding. This would be sutured with absorbable stitches (1) . Foley\'s catheter would inserted. In presence of persistent bleeding Oxytocin infusion to flow at 10units per hour. Blood transfusion according to local protocol how will you transfuse in the acute situation?? . If the crossmatched blood is not immediately available, O rhesus negative would be transfused pending the availability of crossmatched blood (1) .
Patient and her family would be kept informed (1) of the situation and the intervention. Where bleeding persist, she would be transfered to theatre for examination under anaesthesia and proceed to laparatomy if required.
In theatre, uterine artery embolisation if facilities and expertise available. If not, laparatomy would be performed. B-lynch sutured can be effective in uterine atony. Ligation of Iliac artery would be performed. If bleeding is still persist, the last option is subtotal hysterectomy with conservation of the ovaries (1) .
Initial post operative care would be in Intensive care or high dependence unit (1) . Clear documentation of events with time and date and all staffs present who is going to document? .
She and her family would be debriefed about what happened and the reason for the procedure or intervention (1) . Thromboprophylaxis according to local protocol. Anti-D would be given if required. Breastfeeding would be encouraged.
Arrangement for counselling, with provision of support with this traumatised events. Discharge letter would be written to community midwife and GP. Follow up would be arranged to discuss further about the events and she would able to ask questions. Appropriate contraception if required.

Suggest you read recent RCOG guidelines on PPH to see how you will be expected to structure your answer
Posted by PAUL A.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].
the woman has major primary postpartum hemorrhage (PPH) which is associated with risk of mortality / serious morbidity . my 4 main aims of treating this women would be communication with relevant staff, resuscitation, monitoring and investigations, arresting ongoing bleeding all of which would be simultaneously carried out. i would call for help and involve most experienced midwife on call, senior obstetrician and alert the consultant, senior anesthetist and alert the consultant ansthetist, involve the consultant haematologist (1) , alert the lab and blood bank(for atleast 4 units of red cells) summon the portors. one member of the team to record the events (1) , watch the vitals pulse blood pressure, fluid input, output, drugs administered.
assess the airway and breathing ? circulation??? This should be standard!! . administer 10-15l/min of oxygen (1) by face mask, if airway not patent due to reduced consciousness involve the anesthetist, 2 large bore (14 gauge) cannulas (1) to be inserted, about 20ml of blood drawn for investigations (FBC, coagulation screen, RFT LFT ? cross-match or will you do this at a different time?? ) indwelling urinary catheter (would not only help in monitoring the output but also aid in uterine contraction). rush in about 3.5 L of fluids till blood arrives, about 2 L of warmed colloid and 1.5L of warmedcrystalloid (1) should be rushed through the IV. if blood does not arrive by this time trasfuse O Negative blood or alternatively ABO and D antigen specific blood, till cross matched blood arrives (1) . deciding on the trasfusion of blood products should done inconsulatation with the hematologist. for every 6 units of red cells transfused or if prothrombin time / activated partial thromboplastin time >1.5 time control 4 units of fresh frozen plasma should be transfused (1) . platelet concentrate and cryoprecipitate would be transfused if platelet<50,000/ml or ,fibrinogen <1g/ml respectively. constant assessment of the degree of shock and coagulation screening would guide furthur management. the aim would be to maintain HB >8g/dl, platelets >75000/ml, fibrinogen >1g/L, prothrombin time and activated prothrombin times <1.5times the control. adequate measures to keep the mother warm are essential (like wraping the mother, using warmed fluids for transfusion).constant breifing the birthing partner of the women will help prevent panic.
assessment of the cause of bleeding and measures to arrest the bleeding would go hand in hand with the above measures. A brief review of the case notes and the drugs administered so far should noted examination of the uterus to feel for contraction .
a through local examination and cervical exploration of cervix if genital tract trauma is suspected and repair of cervical/ vaginal lacerations would arrest the bleeding can only be undertaken under anaesthesia .
if uterine atony is identified ( examine the expelled placenta for retained bits, if yes this is not helpful – you will not avoid exploring the uterus just because the placenta appears complete. The majority of women with RPOC have the placenta reported to be complete at the time of delivery explore the uterine cavity and do manual removel, if uterine inversion manual replacement )
are you going to administer uterotonic drugs before or after exploring the uterus? pharmacological treatment with 5 U of oxytocin slow IV, methergin IM ??? (contraindicated in preeclamsia and hypertension), carboprost 500mcg IM (contraindicated in asthma) every 15 mins not more than 8 doses, would be given till uterus is well contracted and bleeding stops (1) you are not going to keep giving carboprost till 8 doses if it is evident that the drug is ineffective , simultaneously 40 U of oxytocin in 500ml of saline by infusion at 125ml/hr would help maintain the contraction, measures like bimanual compression would aid and facilitate uterine contraction (1) . if the above measures fail, procedures like uterine ballon(rusch baloon) tamponade should be attempted. if bleeding is controlled this should be left insitu for 4-6 hrs most people will leave this in for at least 12 hours if not longer . failure of tamponade would be followed`by surgical measures likeBlynch suture, uterine artery ligation, internal iliac artery ligation. recourse to hysterectomy (1) (
take second opinion from experienced staff) would be
early than later (1) especially if rupture uterus is suspected. thromboprophylaxis would be considered
unless contraindicated as with altered coagulation profile.
adequate antibiotic cover with ampicillin and metronidazole would be given.patient would be transferred to ITU or HDU for minitoring (1) and debreifing at the earlieat opportunity (1) will help prevent or reduce psychological and medicolegal problems. information about support groups would be provided.
Posted by PAUL A.
Post partum heamorrage is a leading course of maternal mortality.The patient should be accessed for airway, breathing and circulation (1) . Oxygen should be commenced how much? and intravenous access established how many? Is one sufficient?? . Patient should be managed in a multidisciplunary setting and help summoned including the obstetrician, hematologist, aneasthetist, interventional radiologist will you be calling them at this stage?? and midwives. Blood should be obtained for full blood count, coaggulation screening and 8 units of blood crossmatched liver + renal function tests . intravenous fluid administration with colloids or crystalloids how much fluid? should be commenced and this replaced by compatible blood once available ? O Rh neg blood . Blood pressure, pulse and oxygen saturation should be continuously monitored. Atony of the uterus constitutes over 70 % of the causes of post partum haemorrage and the uterus should be rubbed up for contraction if atonic (1) . Placenta and membranes should be checked to ensure complete complete delivery. If uterus remains atonic despite rubbing up, oxytocics such as sytocinon, ergometrine and prostaglandins should be commenced based on unit protocol (1) . The vagina and cervix can be examined if appropriate anagesia is in place.
Futher bleeding will necessitate transfer to the theatre after explaining to patients and relatives of the necessity and possibilty of laparotomy and hysterectomy.
In theatre, the patient under general anaesthesia should be further examined for vaginal of cervical tears. A central line will beneficial to monitor fluid input do you need this to monitor fluid input? . An indwelling urinary catheter to monitor urine output (1) . Procedures that would be considered in theatre would include uterine artery embolisation, laparotomy, B-Lynch sutures, uterine artery or internal iliac artery ligation. Hysterectomy will be a last resort (1) but the decision should be taken promptly . Transfusion of fresh frozen plasma or cryoprecipitate if disseminated intravascular coagulation is suspected discuss this with haematologist . Patient should be closed up with staples and drain left intraperitoneally to monitor further bleeding.
Patient should be monitored post op in HDU (1) with continuous pulse, blood preesure monitor at least for the first few hours. Blood investigations including full, blood count and coagulatio screen would be repeated as is necessary. Low molecular weight heparin for thromboprophylaxis should be considered once bleeding settles otherwise thromboembolic deterrent stockings would help. Early mobilisation should be encouraged with adequate hydration. Breast feeding should be encouraged and Anti-D given as required.
Patient should be discharged postnatally with advice about contraception and post natal clinic appointment to review events that have occurred will you wait 6 weeks to discuss these events with her? . Ugo

see recent RCOG guidelines on PPH
Posted by PAUL A.
1500 ml blood loss is a massive haemorrhage, there is also a possibility of under estimation.There is increased risk of maternal morbidity and mortality (1) . Prompt resucitation ,rapid restoration of blood loss, identification of cause and immediate management is mandatory to save womans life . I will call for help of Anesthetist, SHO, Midwife ,Consultant, interventional radiologist will you be calling radiologist at this stage? What about blood bank / haematologist? if facility is available to manage the patient in a multi disciplinary team. I will follow the unit protocol for the management of massive hemorrhage . I will check her pulse and B.P ABC , if she is in shock cardiopulmonary resuscitation is started with the help of CPR team . Two wide bore cannulae are passed (1) , blood withdrawn for FBC, group and crossmatch, clotting profile, blood gases why??? Are you going to use venous blood? (-1) , U&E and LFTs (1) . I.V fluids commenced ,Ringers lactate solution ,saline drip or colloid how much? . O negative blood is started unless group specific blood is available (1) . Pulse oximetry is started .
I willl examine the abdomen for uterine atony and massage is started if it is atonic (1) . Bladder is catherised . I will examine placenta for any missing cotyledon . I will inquire about administration of uterotonics and if not given already oxytocin 10 units I.V is given slowly , or ergometrine 0.5 units given slow I.V. Another option is syntometrine a combination of syntocinon and ergometrine i.v. An infusion of syntocinon started , 40 i.u in 400ml of normal saline. If still bleeding prostaglandins are adminstered. PGF2 ( carboplast or hemabate ) alpha 250 ugm i.m (1) . PGE 1 analogue (dinoprostone ) orally or rectally oral medication to a woman having a massive PPH??? .
If still there is bleeding , other causes of hemorrhage like cervical, vaginal trauma, retained cotyleydon or coagulopathy should be ruled out . I will explain to the women about the urgent need of examination in theatre and possibility of hysterectomy (1) ., verbal consent is obtained and will confirm any resenment for blood and blood products .I will also ensure that the relatives are kept informed . I will inform the theatre staff and blood bank for urgent blood and blood products you only going to tell them at this late stage?? . Meanwhile I will apply bimanual compression by placing left hand on the abdomen and right hand in the posterior fornix pressing uterine arteries .
In operation theatre I will re-examine the women after anesthetising ,if uterus has contracted I will put her in lithotomy position ,examine any vaginal or cervical lacerations and will suture it . If the cause of PPH is atony and she is hemodynamically stable uterine packing is done with sterile gauze piece or uterine baloon tamponade using blackmore catheter ,Rusch urological baloon or Bakri baloon is used . Uterine tamponade is simple and effective and may avoid hysterectomy in 80-90 % of cases .
If these measure fails I will perform Laparotomy ,to save the uterus provided women is hemodynamicaly stable ,I will apply compression sutures like B lynch .Devascularisation like uterine , ovarian or internal iliac ligation or embolisation of vessels by interventional radiology if expertise are available (1) . In a hemodynamically unstable women I will not perform these time consuming procedures and will perform subtotal hysterectomy (1) .Blood loss should be replaced with group specific blood ideally cotomegalovirus and kell negative . If the women did not consent for blood transfusion cell salvage therapy should be considered and help of hematologist and those expert in cell salvage therapy should be called.
Post operatively antibiotics and thrombo prophylaxis given . women is shifted transferred to ITU or high dependency unit (1) . Debriefing about all the events after recovery (1) . incident report form is filled .FBC ,HB and clotting repeated . see recent RCOG guidelines on PPH
Posted by PAUL A.
This a case of primary post partum hemorrhage, which has a high risk of maternal mortality and morbidity if not managed properly (1) .There should be local guidelines and protocols in each medical facility for management, these should be regularly rehearsed and audited for best care of patients.I would follow these protocols.If patient shocked how will you know she is shocked? Will you only call for help if she is shocked? ,would call for help(midwives,anaesthetist,porters, consultant and alert the operating theatre) (1) ,put patient flat ,head down, see to her airway assess ABC ,see if breathing and give oxygen how much? , site 2 large bore IV lines (1) and run iv fluids how much / what? , send blood to lab and call hematologist for urgency of cross matching 4 units of blood (other blood tests done FBC, clotting screen ,urea and electrolytes (1) LFT) ,if urgently needed would give RH-ve group o blood. Would feel the abdomen for a lax uterus and would massage it if lax (1) and give ecbolics uterotonic is commonly used term with doses according to unit protocols which drugs will you use? .
While resuscitating I would assess the situation for possible cause of her bleeding , the commonest is an atonic uterus but may be due to trauma to genital tract, placental remnants , coagulation problem (coagulopathy,bleeding tendency, delivery while still on anticoagulants ) or a combination . Would see the notes (parity,medical problems,bleeding problems,obstetric problems like polyhydramnios), ask about the progress of labour(partogram) , conduct of delivery,placental examination by midwife, were genital tract injuries seen by midwife.Would examin abdomin and massage uterus if lax already written this .
If uterus is still atonic despite resusitation and ecbolics would take patient consent for further management that may need hystrectomy if possible or act in patient best interest, transfere patient to operating theatre and measures to stop bleeding undertaken according to patient situation and according to unit protocols which measures? Unit protocol is not good enough .Bimanual compression should be tried and if successful but the uterus continue to relax when stopping it, a B- Lynch brace suture might be of value. Would cosider other measures if bleeding does not stop as bilateral ligation of uterine arteries and if vascular surgeon was called ,consider bilateral ligation of internal iliac arteries (1) .Would not delay the decision of doing a hysterectomy if situation necessitates (1) .
If uterus is well contracted and patient still bleeding examination under anesthesia done with suturing of cervical or vaginal lacerations (1) . Rupture uterus should be considered in patients whom blood loss vaginally does not corespond to the degree of shock , in presence of a well contracted uterus.This will need laparoscopy with either repair or hysterectomy.
Presence of retained placental products are removed with help of ring forceps NO – you will explore the uterus manually. There is a very high risk of perforation if you instrument the uterus and you are unlikely to empty it (-1) .
Presence of history of bleeding disorder ,need help of hematologist and given fresh frozen plasma or cryo precipitates you need haematologist even in women without bleeding disorders .
Coagulopathy dealt with by fresh frozen plasma or fresh blood transfusion if available
Would write an incident report, debrief the patient (1) of what happened,inform her GP and discuss plans for next pregnancy if uterus still intact.Post partum hemorrhage of atonic type can be recurrent. see recent RCOG guideline on PPH
Posted by PAUL A.
I will alert lead midwife, team of obstetricians and anaesthetist on labour ward duty to seek more help haematologist / blood bank . I will make sure that two wide bore vein flows cannulae (1) are introduced and blood collected at the same time for investigations which investigations?? . I will ask to start i.v. fluids immediately which fluids / how much? . I will do her bimanual examination are you doing an examination as you would in a gynae patient?? . If uterus is atonic then I will start massage. I will ask midwife to administer syntometrin if not given already. I will ask my assistant to start her on oxytocin 40 IU in 40 ml of normal saline drip with infusion pump (1) at what rate?. Blood should be sent for full blood count, clotting profile, and group and cross match renal / liver function tests . One team member should document the management and observations with time (1) . I will make sure that somebody would explain the situation and reassure the woman and her relatives present in room. The woman should be continuously monitored for her pulse, BP and saturations preferably on automatic monitors if available.
If the woman continues to bleed and uterus relaxes in between, I will continue with uterine massage and ask for Prostagladin F 2 alfa preparation (injection hemabate) 250 mcg intra muscular. I will wait for prostagladins to act. Most cases of PPH respond well to these measures. If the woman shows signs of shock and continues to bleed, blood transfusion should be considered along with repeat dose of PGF2 alfa injection after 15 min of first dose. Simultaneously I will give her 800 mcg misoprostol ( PGE1 ) tablets per rectally. I will catheterise her (1) . I will continue with fluid resuscitation and get anaesthetist involved in management. PGF2 alfa injection can be repeated upto maximum 8 times with 15 minute interval.
If above all management fails and woman continues to bleed with atonic uterus I will inform consultant and will shift woman to operation theatre. I will order for fresh frozen plasma continuing blood transfusion. I will check for clotting again. If the uterus is contracted but woman is still bleeding, then I will shift transfer. You will transfer whether the uterus is contracted or not, so why set out these conditions? If she is still bleeding, you transfer to theatre her to operation theatre and I will check for any cervical or vaginal tears under anaesthesia (1) . If there are tears then they should be sutured. Vaginal lacerations with fragile tissue can be packed applying pressure packing. But if the woman continues to bleed with atonic uterus with failed medical measures needs exploratory laparotomy. I will explain the woman and her relatives about operative intervention needed and will consent her for laparotomy and if required hysterectomy as a last resort. With informed consent and normal clotting profile, I will take her to theatre you have already transferred to theatre – you need to move on!!! . I will explore her uterine cavity for any remnants of placenta or clots. On laparotomy, brass sutures like B-Lynch would be tried as an initial attempt to make uterus compress and control bleeding. Conservative management like balloon can be used with consultant advice (1) . But with all failed attempts to control bleeding, hysterectomy should be considered what else is there to consider? You should perform a hysterectomy and not waste further time considering as a last resort with two consultants’ opinion. The fluid management and blood transfusion should be carefully monitored at the same time. The woman will be managed in high dependency unit (1) and I will document all events carefully in her notes. I will explain her and her relatives about the steps taken in her care at appropriate time (1) .

see recent RCOG guideline on PPH
Posted by PAUL A.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].
C
It is an acute emergency situation, I will rush in to the room quickly introduce myself to the patient not necessary and asses her airway, breathing and her circulation (1) . Prefer to keep the patient in tilt position ? meaning which improves after load. Briefly I will ask the midwife about the birth event to judge what could be the cause of the bleeding.
I will ask for senior help this includes consultant obstetrician, senior anaesthetist, midwife sister and my junior medical colleague (1) blood bank / haematologist. Even the porter should be summoned. In the same time I will inform the theatre staff that we may take this patient to the theatre in due time for exploration if the bleeding is not control with initial approach.
I will ask the midwife to give 15 lt O2/min by facial mass (1) . Meanwhile I will insert two large bore ventflown (1) cannulae one on either hands and start iv fluids. I will start with crystalloids. While inserting the ventflown I will take adequate blood for group and cross match and for investigation of FBC, and coagulation profile renal / liver function . Involve the haematologist and request for 6 units of group specific blood, if not immediately available O negative blood (1) will be requiring first. Further fresh frozen plasma 4 units and platelets 4 units will be required under which circumstances will these be administered? .
Continues monitoring of heart rate, blood pressure, O2 saturation, and Respiratory rate and documenting is mandatory who is going to document? .
After explaining to the patient I will examine her abdomen and look for whether uterus has well contracted or it is still relaxed. If uterus is relaxed while massaging the uterus, I will ask one of the team member to start 40 units syntocinon in 500 ml of Normal saline to infuse at 125 ml/hour. Along with this ergometrin 500 mg ??? im should be given. If the uterus is not responded to this I will give 250 mic gram carbipros intra muscularly. This is a prostaglandin which will cause potent uterine contraction (1) .
Further I will ask someone to continue massaging the uterus and I will examine the perineum for any perineal tear, cervical tear or uterine inversion ? analgesia / anaesthesia . If uterine invasion I will try to reduce it as soon as possible.
As soon as blood arrives it should be started with blood warmer. Because this patient had bleed significantly more within a very short time, if the bleeding is not controlled she needs further exploration in the operation theatre with good analgesia, adequate light and good assistant with appropriate instruments.
Following informed consent I will shift transfer her to the theatre. With the help of my anaesthetist colleague either regional or under general anaesthesia depends upon the patients condition in a woman with massive haemorrhage, what is the most appropriate mode of anaesthesia?? . If she is hypotensive regional anaesthesia will be not suitable for her. I will examine to find out the bleeding point. If it is from perineum or cervical tear I will apply haemostatic sutures (1) . If difficulties arises obstetric consultant’s help will be obtained.
If the bleeding from the uterus with the previously given medication further 250 mcg carbipros can be repeated every 15 minutes for total of 8 doses. Simultaneously 1000 mg misoprostol should be given PR. Following bimanual compression of the uterus I will check for the uterine contraction. If still not successful Ruch balloon can be inserted in to the uterus as tampon to stop the bleeding.
If interventional radiologist are available, I will summon them to come to the theatre to intervene. Not all the places have this facility.
If she is still bleeding the next step would be laparotomy and try to do B lynx ??? look it up suture, further uterine artery ligatiion, internal artery ligation can be tried. If one method fails to go to other. If I decide to do internal artery ligation I will get the help of the vascular surgeon.
I will not hesitate to do hysterectomy (1) if the condition does not improve with all the above measures. Caesarean hysterectomy is a difficult procedure in a stressful situation. Consultant obstetrician would perform this procedure.
Post operatively I will document the events systematically. Fill the incident form. This patient should be managed in the intensive care unit (1) until she recovers. I will debrief (1) the patient and her partner about all the procedure we have done and the necessity of this. I will ask mid wife sister to organise for proper counselling before she leaves the hospital. see recent RCOG guidelines on PPH
Posted by nilasha A.
AGN
Recognise that post partum haemorrage(PPH) is an obstetric emergency.Prompt assessment and intervention is needed to avoid maternal morbidity and mortality.Common cause fo PPH is uterine atony.Other causes include genital tract injury,retained product of conception,uterine invertion and rare causes are bleeding disorders.
I will call for help from senior obstetrician and anasthetic.Also inform the attendan (for sending investigations and collect blood products).Inform the haematologist, may need more blood and blood produts.I will assess the patients vital sign(BP,PR.SO2) and start resusitation.Give face mask oxygenation,Fix 2 large bore iv lines(if not done) and take blood for FBC,LFT,U&E,coagulation profile and grossmatch 6 units of blood.Resussitate with cristaloid,colloid or blood o -ve while awaiting for grossmath blood.
I will assess the uterine contraction, if not well contracted ,rub uterus with hand and give iv syntometrine(if no contraindication,if contraindicated give iv syntocinon) or Im carboprost. repeat uterotonic after 15 minutes.Most off the PPH will stop within this simle procedure.If the uterus is not able to be felt or feel dimple per abdoman,suspect uterine inversion.Repeat BP,PR every 15minutes.Inform the woman regading PPH and procedure undertaking.If uterus well contracted and still has PV bleeding , check for genital tract injury under good lightning and analgesia and repair it. If there is no genital track injury causing PPH ,check for retained product of conception with abdominal ultrasound.If still has PV bleeding ,do bimanual compression and arrage for laparatomy.Othar option is uterine artery embolisation which need experinced radiologist and instrument(not available in most of the hospitals).
Councel patient and partner regarding the PPH and further plan including hysterectomy.Get written consent include for hysterectomy and blood transfusion.Try uterine artery ligation,B-lynch sutures and internal iliac vessel ligation.Can give intra myometral injection of carboprost.If still have uterine atony or PV bleeding,proceed with hysterectomy.Incert abdominal drain if suspected DIVC.Keep family members informed.know the limits for conservative management.Confidential enquiry into maternal death shows increase maternal morbidity and mortality due to delay in decision on hysterectomy.Massive blood transfussion can couse DIVC,hyperkalemia,hypocalcamia and hypotermia.Correct anaemia,hyperkalemia and hypocalcaemia.
Assess the need for thrombophylaxis post op.Avoid immobilization and dehydration.Remove abdominal drain once minimal drainage.
Post op counsel the patient and partner regarding the events and procedure undertaken.Offer formal counselling.Fill up incident form.Clear documentation including time called,time arrived,finding,persons involveded and procedurs undertaken.On disharge give f/up appointment 6 weeks post op.
Posted by PAUL A.
Sunday\'s answers

The principle of management of this patient would centre around good communication, resuscitation, monitoring and investigation and arresting bleeding all of which be undertaken simultaneously to ensure good outcome. On arrival at the room, I would immediately call for help from the labour ward coordinator, on call anaesthetist, alert my consultant and consultant anaesthetist, heamologists (1) . I would ensure that the unit protocol in followed with staff available to document the events and facilitate request of blood and blood products to and from the blood bank (1) .
I would proceed to check the airway breathing & circulation – this is standard and commence high flow oxygen therapy (10-15L / min (1) ), check the breathing and gain iv access with 2 large bore cannula (1) and also take blood for urgent FBC, U/Es, clooting profile and crossmatch 4 units of blood (1) LFT . Regular monotoring every half hour??? What is regular? of BP, pulse rate and oxygen saturation would be comenced. I would make sure the patient is flat and quickly proceed to establish the likely cause of the bleeding. I would explain the need for the above mentioned intervention to the patient and also ensure that the family and relative are reassured and informed regarding progress. i would give upto 2 litres of hartmans + 1.5 litres of colloids depending on the clinical situation whiel waiting for blood to arrive (1) warm fluids . All efforts should be made to keep patient warm and ensure that fluids given are warm.
I would check for uterine contraction, ascertain any drugs that have been given- eg oxytocin or syntometrine. I would give a repeat dose of iv syntocinon 5units or sytometrine 10 units is there any thing as 10u syntometrine?? Which drug will you give? if no contraindication and ergometrine 0.5mg( if no C/I ie high BP). i would also commence iv syntocinon 40 units in a 500mls normal saline to run at 125mls/hr (1) . I would proceed to vaginal examination to assess for perinal/vaginal/cervical tears and subsequently insert an indwelling foley\'s catheter. I would also ensure that the placenta and membranes are complete in which case the patient should be transfered to the theatre ? meaning for EUA and further management if bleeding continues. Blood results would be checked promptly to rule out possiblity of a coagulopathy which would be corrected under the guidance of the haematologist (1) . Blood tansfusion would be commenced as soon as possible with possible use of other blood products such as platelets, fresh frozen plasma etc as dictated by the amount of blood transfused and patients clinical condition ? use of O neg blood .
In theatre under good light and anaesthesia, a detailed examination would be carried out and any perineal/vaginal /cervical tear would be sutured (1) . Manual removal of placenta made be indicated if retained products is suspected (1) . If patients continue to bleed or with suspicion of uterine atony not responsive to the above remedies, a balloon tamponade can attempted to control the bleeding before resorting to surgical mangement such use of brace suture- B-lynch technique, internal iliac atery ligation can be used with help and guidance of my consultant (1) . Uterine embolisation can be considered if facilities and personnel is available and a resort to hysterectomy may be made if all intervention fails (1) decision should be mane promptly . This ideally requires the agreement of another consultant if possible.
Once bleeding has been controlled , patient should be transferred to ITU or Labour ward HDU (1) for close monitoring and obsrevation of vital signs, urine output and further bleeding or deterioration.
The patient and relatives and staff should be debriefed (1) about the events and an incident form filled as per the unit protocol.i would ensure that a proper record of events and intervention is properly documented in the patient\'s notes. good answer
Posted by PAUL A.
M
(a)This is major PPH and I will commence simultaneously resuscitative measures, communicate with my team, commence continous monitoring with investigation and measures to arrest bleeding to reduce the risk of maternal mortality.
I will call for more help from senior midwife, anaesthetist oncall to help me with managing her and also alert my obstetric and anaesthetic consultant and haematologist (1) .
I will assess her airway and breathing ? circulation and simultaneously commence high flow O2 at 15 lts/m (1) using facemask and also obtain 2 large IV acess (1) (orange canula) and take 20mls of blood for FBC, clotting, U&E and cross match for 4 units as urgent (1) LFT .
I will position her flat on the bed and use bed warmers available to prevent hypothermia (1) .
I will simultaneously commence fluid resuscitation untill blood available and use either crystalloids or colloids to a total of 3.5litrs (1) warm fluids .
If blood is not available then Onegative blood given untill cross matched blood available. For every 6 units blood use 4 units FFP (1) (or if aPTT above 1.5 times control),if platelet count below 50 then platelet concentrate should be given and if fibrinogen below1g/l then cryoprecipitate should be considered.
Recombinant Factor 7a can be considered but is very expensive and fibrinogen level should not be below 1g/l and platelet above 20 for it to work.
I will continously monitor this patient with resuscitative measures using continous pulseoximeter, ECG monitor, automated continous BP recording. Temperature will be recorded every 15 minutes. I will insert a foleys catheter to measure her urinary output (1) , an arterial line will be commenced with an experienced anaesthetist for monitoring of invasive blood pressures at this stage, there are more pressing issues than inserting an art line and you want to get to a position where you can do an EUA and stop the bleeding .
I will rapidly assess her to find the cause of PPH and initiate with rubbing uterine contraction if not stopping then bimanual compression of uterus to arrest bleeding with uterine atony (1) .
Uterotonics will be used like oxytocin 5IU slow IV bolus and repeated or ergometrine 500micrograms slow IV or IM (contraindicated with hypertension and may causing vomiting).
Carboprost can be given 250micrograms as IM, every 15minutes apart for a total of 8 doses, Misoprostol 1000micrograms rectally can also be used as uterotonics (1) .
If the above pharmacological measures fails to arrest bleeding then a baloon tamponade (e.g. Rusch balloon) is an effective measure to control bleeding, open surgical mesures include ligation of uterine artery, ligation of internal iliac artery, selective arterial embolisation(need specialist intervetinal radiologist) (1) or hysterectomy (1) (should be considered earlier if uterine rupture or invasive placenta is the cause of PPH)
Consultant and extra help will be summoned if continued bleeding at earlier stage before resorting to any surgical procedures and if needing more than 1 carboprost and resuscitation stabilished then patient will be moved to operating theatre.
Other causes of PPH like retained placenta should be explored and removed in theatre and any perineal/ vaginal/ cervical tears should be sutured (1) , if thrombin coagulopathy is the cause then addition factors along with blood like FFP, cryo and platelet concentrate should be considered discuss with haematologist .
Once the patient is stabilished she should be further monitored in ITU/HDU (1) .
All events should be documented simultaneously by an assistant on labour ward and then fully documented in notes.
A critical incident form filled for risk management and I will debrief (1) the patient about the event and a 4-6week postnatal clinic organised. Good answer
Posted by PAUL A.
The first thing is to make sure that the patient is haemodynamically stable.This is checked by her blood pressure, pulse and state of conciousness Assess ABC .Call for additional help From who? and inform the senior obstetrician and the anesthetist. Make sure that the patient has atleast two wide bore cannulas (1) and is on IV syntocinon infusion ? dose and on crystalloids infusion how much? .Draw blood for full blood count, group and cross match for 6 units of blood and take blood for baseline investigations including urea and electrolytes and liver function tests (1) . Catheterise the patient to moniter her fluid intake and output.Inform the blood bank and the haematologists and the consultant obstetricians and the theatre staff of the situation (1) .
Palpate the abdomen for utrine tone first since uterine atony is the most common cause of post partum hemorrhage. If atonic, try to rub up a contraction (1) ? bi-manual compression.
Carefully examine the lower genital tract for any vaginal or cervical lacerarations as the cause of bleeding.If found, they should be repaired immedietly may require EUA .
Rule out inversion of uterus as the cause of bleeding.If found it should be replaced manually after stopping the syntocinon infusion. after replacement, the syntocinon infusion should be recommenced.
Explore uterine cavity for retained placental cotyledon ? any anaesthesia? .If found, remove the cotyledon and do bimanual compression.
The patient should receive uterotonics like ergometrine 250ug IM as a bolus dose. Carboprost (prostaglandin2 alpha ) should be given in a dose of 250ug every 15 minutes, upto a maximum of 3 doses.Misoprostol should be given per rectally in a dose of 800ug to augment the effects of other uterotonics (1) will you give these drugs before or after exploring the uterus?.
If all these measures fail, the situation should be explained to the patient and she should be transferred to theatre So you are exploring the uterus in the delivery room??? (-1) .
In theatre the uterine bed can be compressed by the use of either a large foley catheter, senstaken blakemore cathere or Bakri SOS balloon to stop the bleeding.
The blood results should be back by now and they should be reviewed to rule out a superimposing picture of DIC compounding the problem.The results should be discussed with the haematologist (1) . If platelets are <50X 10 5, the patient should be transfused with platelets.If fibrinogen levels are less than 1g, the patient should receive fresh frozen plasma.
If patient is still bleeding, she should be made aware of the situation ?? logic – you have already taken her to theatre and presumably given a GA and consent obtained for laparotomy and further procedures if needed.
Further management options include, urgent uterine artery embolization if the facility is available.If this fails, laparotomy is performed and compression sutures to compress the placental bed are placed. If this fails, e ligation of uterinse arteries should be carried out to stop the bleeding.
If this measure fails to control the bleeding, the surgeons should be involved and the internal iliac arteries should be ligated (1) .
A last resort is hysteredtomy if the above measures fail (1) decision should be made without delay .
Postoperatively , the patient should be transferred to ICU for monitoring (1) .
Postoperatively the patient and her family should be debriefed (1) and the events leading to the hysterectomy explained.
All the notes should be carefully recorded in the chart since it can potentially be a medicolegal case.
An incident form should be filled. The sequence of events you describe is not logical. See good answers above
Posted by PAUL A.
Shalini
This is an acute emergency with the lady having moderate PPH what is moderate PPH? .I would begin by calling for help-Senior obstetrician and anaesthetist and informing the respective consultants,experienced midwife and midwife incharge,proters to carry samples,inform clinical hematologist (1) on call and the blood transfusion laboratory.I would then assess her airway and breathing ? circulation and start oxygen 12-15 lts / min if hypoxic how will you know if she is hypoxic? If SO2 is 99%, will you not give oxygen?? .Intravenous access should be established with 2, 14or 16 gauge cannulas (1) and 20ml blood should be taken and sent for Full blood count,urea ,electrolytes,liver function tests for baseline and coagulation profile for detecting any coagulopathy along with group and save for cross matching 4-6 units (1) blood.Intravenous fluids like crystalloids(max 2.5 lts),colloids(1lt) should be warmed and rushed fast (1) till crossmatched blood is available which should be then transfused rapidly after warming ? O neg blood .Patient should be warmed.Then quickly i would assess the tone of the uterus and if atonic will chech if bladder is empty or not and would start bimanual massage (1) alongwith administering oxytocin 5 IU slow IV.Syntometrine can be given if there is no hypertension.Also carpoprost 250ugm can be given intramuscularly and repeated every 15 min till a max of 8 doses (1) .Also injection carboprost can be given intramyometrally thru the abdomen although it could precipitate an acute attack in asthamatics.Misoprostol 1000ugm can be given per rectally although it has not been found to be more effective than oxytocin. If uterus does not contract then balloon tamponade ? in the delivery room? of the uterus can be done with foley\'s catheter,rusch balloon,etc which has been found to be very effective.Patient needs shifting transferring to theater if bleeding continues after discussion with the anaesthetist about the anaesthesia (regional anaesthesia should be preferred) ?? regional anaesthesia in major PPH??? (-1) .4 units FFP should be transfused after 6 units of blood that is given and hypocalcaemia should be looked for.Continous pulse,blood pressure and oxygen saturation monitoring should continue apart from temperature every 15 min (1) .Output should be monitored by catherising the bladder .Platelets should be transfused if platelet count is less than 50x109/lt.Patient should be explored under good illumination in theater with appropriate analgesia in place.Swabs should be counted and instruments checked.Consultant obstetrician should be present as also the consultant anaesthetist for a thourough exploration of the genital tract.If no trauma is found then laprotomy for uterine artery.ovarian artery ligations,B-lynch mass suture,internal iliac ligation (1) do not bother with etc – there are no marks for it etc whatever is indicated.Uterine artery embolisation is still under research trials. Cesarean fetus has been delivered vaginally!! hysterectomy (1) is indicated in cases of intractable PPH as an life saving measure and should be resorted to after opinion of a second obstetrician. see recent RCOG guidelines on PPH
Posted by A H.
AH

This patient is experiencing major obstetric haemorrhage. Haemorrhage was the third cause of direct maternal mortalityaccording to the last Confidential enquiry (2002-2005).and urgent action by appropriately experiencd staff is essential.
Help will be summoned while assessment and resuscitation is commenced.
The midwife in charge, a senior midwife, the consultant obstetrician, and the anaesthetic registrar will be summoned. The consultant anaesthetist, the consultant haematologist,and blood transfusion laboratory will be alerted. The laboratory porter will be called to collect blood specimens.
Thepatient and her birthing partner will be counselled about the massive haemorrhage and measures will be taken to arrest the bleeding and resuscitate her.
While the above is taking place the patient will be quickly assassed.
Airway and breathing will be assessed and if the airway is compromised the anaesthetist will manage this. High flow oxygen (10-15 L/min)via face mask will be commenced.
Circulation will be assessed and 2 large bore cannulae will be inserted at which time blood (apporximately 20 ml) will be taken and sent to the lab for determination of haemoglobin and platelet concentration, coagulation screen, urea and electrolytes, and at least 4 units of crossmatcthched blood will be requested. Intravenous fluids will be commenced with warmed crystalloids transfused quickly to a maximum volume of 3.5 litres or colloids up to 2 litres while awaiting blood.
The patient will be kept warm and placed lying flat. A Foley\'s catheter will be inserted and left on free drainage for monitoring urine output. Pulse rate, respiratory rate, blood pressure and oxygen saturation will be continuously monitored via oximeter, automated blood pressure monitor and ECG. Blood will be transfused as soon asit is available. If cross matched blood is not available, group specific or O RhD negative blood will be requested with guidance from the haematologist. A dedicated member of staff will be assigned to record all events, drugs used, vital signs fluids and urine output.
A cause for the bleeding will be sought. The most common cause is uterine atony but other causes must be ruled out. These include retained products (placenta, membranes, clots) trauma to the genital tract, especially lacerations to the cervix and vagina, and uterine inversion.
Trauma to the genital tract will be repaired in theatre, uterine inversion will be managed according to departmental protocol.
Uterine atony will be managed initially by conservative measures. Bimanual compression of the uterus and \'rubbing up\' of the uterine fundus to stimulate contraction will be done.
Oxytocics will be administered. Initially 5 iu of oxytocin will be given by slow intravenous injection and repeated if necessary.
Ergometrine 0.5 mg by slow intravenous injection will be given if necessary if the patient is not hypertensive. Other pharmacological agents which can be employed if the uterus does not remain contracted include a syntocinon infusion of 40 units in 500 ml Lactated Ringers (Hartmann\'s solution), or prostaglandins. Carbaprost (prostaglandin F2alpha derivative) 0.25 mg intamuscularly or intramyometrially; the latter under direct consultant advice as this route of administration is not approved. Another option is misoprostol 1000 mg per rectally.
Early recourse to surgical management is necessary to prevent severe morbidity or mortality if the bleeding is not controlled.
Conservative measures include intrauterine bollon tamponade. If this is successful, the patient can be monitored for 4 to 6 hours . If the bleeding continues, the B-Lynch brace suture is effective and can be inserted by a suitably competent surgeon. Other options are bilateral uterine artery or internal iliac artery ligation,or, if facilities and staff for interventional radiology are available, uterine or iliac artery embolisation.
The definitive treatment when all else fails is hysterectomy. An early decision will be taken by the consultant preferably in consultation with another consultant.
Anaesthetic input by the consultant anaesthetist is necessary to determine type of anaesthesia. Epidural anaesthesia is preferable, but if an epidural is not in place, and there is thrombocytopaenia or deranged coagulation, general anaesthesia will be the preferred option.
The patient would be monitored in HDU or ITU depending on her condition. The family will be debriefed and an incident form will be filled.
Posted by Maayka ..
maayka


This is a case of massive postpartum haemorrhage. My initial management would be to ensure the patient has a patent airway and is breathing and then manage her circulatory problems. She is likely to be in hypovolaemic shock or soon develop such, so 2 large bore IV cannulae ( size 14 gauze) will be sited and blood taken off for full blood count, Xmatching 6 units of blood and PT/PTT. Also bloods can be taken for urea and electrolytes and liver function to have as a baseline as she may have a complication of disseminated intravascular coagulation (DIC). Crystalloids like Ringer’s lactate or 0.9% saline will be started immediately. A call for help will be made and the senior midwife and anaesthetist should be present. Someone should be assigned to documentation of events and time of administration of fluids/drugs. I would ask for her history from the midwife while the catherization of bladder and abdomen is palpated. Of relevance would be her parity and any history of previous C/Section , her booking Hb value and the birth weight of her baby. The patient should be briefed and asked if she is Jehovah Witness or has any objections to blood transfusion if needed.

All the while the patient’s vital signs should be monitored continuously, that is of blood pressure, pulse, oxygen saturation and urine output.

If the uterus is not contracted , I would check with the midwife if there is a possibility of retained placental tissue – ask her to check placenta again if necessary. If the likely cause is uterine atony then Syntometrine one vial as a bolus should be administered IV or IM. A Syntocinon infusion with 40units in 500mls Ringer’s can be started. If uterus still not contracted then Carboprost can be administered and if necessary Misoprostol 800ug in the uterus or per rectally.

If the uterus was contracted on examination then it is important to inspect the perineum and cervix for any lacerations to be repaired.

If there has been no control of the bleeding with all the above measures and especially if still atonic, then the patient needs to be taken to theatre and under general anaesthesia, attempt to stop the bleeding. Uterine artery ligation then B-lynch suture is normally attempted by the senior obstetrician and if this fails subtotal hysterectomy performed.
Embolization of the uterine artery is only an option if the facilities are closeby in the hospital and the experienced interventional radiologist is available.

Whatever the outcome and at whatever stage the bleeding was arrested, the patient and her family must be debriefed thereafter and an incident form filled out.
Posted by PAUL A.
As the patient is having blood loss of 1500 ml and still bleeding so it is the major post partum haemorrhage (PPH) and prompt intervention is required to reduce maternal morbidity and mortality (1) . I will call for assistance from anaesthetist ,experienced midwife, in-charge midwife, SHO and porter for delivery of specimen and blood. I will inform consultant obstetrician, consultant anaesthetist, consultant haematologist (1) , blood transfusion laboratory and operation theatre staff. I will appoint one member of my team to record events (1) , fluids, drugs and vital signs. I will follow unit protocols / guidelines for management of PPH. I will assess airway, breathing, and check pulse and blood pressure (1) . I will give high concentration of oxygen by face mask 10-15 litre per minute (1) , obtain venous access by passing two 14 gauge canulae (1) and draw 20ml of blood at the same time for investigation. I will send blood for crossmatching (4 units minimum) and group, FBC, Coagulation screen including PT/APTT, thrombin time, fibrongen, renal function test and liver function test (1) . Until blood available, I will transfuse 2 litres of warmed crystalloid Hartman’s solution and / or 1.5 l of colloid as rapidly as required (1) . If cross match blood is not available, I will give RH negative group O blood or uncrossmatched group-specific blood (1) . The most common cause of primary PPH is uterine atony. However I will do abdominal ad pelvic examination to exclude other or additional causes like RPOCs how can you exclude this without anaesthesia? , genital tract trauma, uterine inversion and uterine rupture how will you exclude rupture on examination?? . Perceiving uterine atony is the cause I will rub up contraction and do bimanual uterine compression to stimulate contraction and ensure that bladder is empty (1) . I will leave folleys catheter in place for further monitoring of urine. I will give syntocinon 5 units IV slowly, inj Ergometrine 0.5 mg by IM inj and will commence syntocinon infusion (40 units in 500 ml hartman’s solution at 120 ml p/hr). I will ask anesthetist to obtain CVP line not only for adequate fluid monitoring but also as a route for rapid fluid replacement are you going to occupy the anaesthetist with CVP line while the woman is bleeding? If you need more lines, insert a 3rd peripheral line . Monitoring of the patient will be continued comprising temperature every 15 min, continuous pulse, blood pressure recording , respiratory rate (using pulse oximetre, ECG and automated BP recording) (1) and fluid input/output.It will be documented on a flow chart.I will try to keep women warm using appropriate available measures. I will ensure that woman and her partner/carer are kept informed clearly at each step of the situation (1) .I will check for genital tract trauma(vulva,vagina or cervix) best done under anaesthesia .If there is no obvious trauma and bleeding hasn’t stopped, I will give injection carboprost 0.25 mg by IM injection and will put tab Misoprostol 1000 ug rectally.After discussing with anaesthetist haematologist consideration will be given for FFPs(4units for every 6units of Red blood cells or PT/APTT>1.5xl(12-15ml/kg),PLT count<50x10 9/l and fibrinogen<1g/l. Aim will be to maintain HB conc >8g /dl, plt conc > 75 X 10 (6) / l, PT < 1.5 X mean, APTT <1.5 x mean and fibrinogen > 1 g /l.
If bleeding still not stopped, consideration for surgical measures sooner than later will be given.I will explain women and her carer about need for examination under anesthesia should have been done a lot earlier – you cannot identify / exclude genital tract trauma / RPOC without an EUA in theatre,possibility for hysterectomy if bleeding does not stop as a last resort and will take informed consent.This(EUA) is also to ensure that there are no products of conception,even when placenta is thought to be complete.I will make sure that by the time consultant obstetrician and consultant anaesthetist have reached. Intrautrine balloon tamponade(using Sangstaken Blackmore tube,urological Rush balloon,Bakri balloon) is the first line surgical management for uterine atony as it provides tamponade effect without concealing bleeding. If bleeding is controlled it will be left for 4-6 hours It will be very brave, almost fool-hardy to face this situation, insert a balloon which is effective and then remove it after 4 or 6 hours and patient will be shifted transferred to high dependency unit (HDU or ICU) (1) for close monitoring. If bleeding still not controlled then laprotomy will be done and first B-lynch suture / modified compression suture will be considered, if it is unsuccessful then bilateral uterine artery ligation,bilateral internal Iliac artery ligation or subtotal hysterectomy why sub-total? will be performed sooner (1) than later (especially if the uterus is ruptured). Once bleeding has controlled and initial resuscitation has been completed, continued close monitoring in ICU or HDU will be done. I will ensure for clear documentation of all events with timing date and signature. I will fill the incident form. As all of these events can be traumatic to women and her family,and likely to creat anxiety and psychological stress in woman I will arrange for debriefing (1) of the woman by consultant obstetrician.Proper follow up and investigations like screening for coagulopathies if there are other indicators or for panhypopituitarism(sheehans syndrome) ? in the absence of clinical features? will also be done.Need for HRT in case of hysterectomy will you be removing the ovaries? . I will provide the woman details of the support groups for PPH ? example??

Your answer is almost too long because you lost focus half way through it and went into too much detail. You also delayed taking her to theatre for EUA and seemed to suggest that you can do fairly invasive procedures in the room
.
Posted by PAUL A.
Sanchu
The management involves communication, resuscitation and measures to stop the bleeding all done simultaneously.
The patient and her partner are kept informed and supported. The consultant is alerted and the middle-grade anaesthetist is called. Further communication would be with the blood bank and Hematologist if needed how / when will you decide that this is needed? .
The probable cause is atony.
Airway and Breathing ? circulation are assessed. O2 by mask is started at 15L/min (1) .
Continuous monitoring of BP, PR, SATS are done. 2 14 or 16 G IV cannulae are sited (1) with blood sent for FBC, Coag profile and cross-matching renal / liver function tests .
IV crystalloids(Normal saline or Hartmann\'s)are rushed ? vol . The clinical situation indicates blood transfusion and time is not wasted waiting for lab results.IV fluids upto 3.5 litres can be given (2 l of crystalloids + 1.5 l colloid) until blood is ready (1) . If cross-matched blood is still not ready, group-compatible uncrossmatched blood or O negative blood is started (1) .
oxytocin infusion 40 units/ 500ml is started at 125 ml/hr. IV Syntometrine (0.5 ergometrine + 5 U oxytocin)IV is repeated. If she is still bleeding Hemabate 0.25 mg IM is given repeated every 15 min for a maximum of 8 doses (1) .
When massage of the uterus is continued and bleeding not heavy, she is quickly examined to rule out traumatic PPH from cervix or vagina.
If she is bleeding heavily, she must be taken to theatre immediately. She is examined under anaesthesia. The causes of Tissue, (retained placental bits), Trauma is ruled out repair bleeding tears and Rusch balloon is used for tamponade which is removed after 6 hours why rush to remove it? . If bleeding is still not controlled or Rupture uterus or Broad ligament hematoma are suspected , Laparotomy with consent for hysterectomy is done. B-Lynch sutures, uterine A. ligation and Internal Iliac ligation, Uterine A. embolisation are the methods which can be tried (1) before resorting to hysterectomy. If PPH is due to placenta accrete question says placenta delivered , hysterectomy is done sooner than later (1) .
Blood, FFP, Cryoprecipitate and recombinant VII A are given according to Haemotologist\'s advice (1) .
Posted by PAUL A.
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].

I will call for help - senior midwives, labour ward coordinator, consultant obstetricians and anaesthetist and juniour obstetric and midwivery colleagues and porters haematologist / blood transfusion . I will ensure that her airway is patent, she is breathing & presence of circulation (1) by checking her carotid artery. I will ensure she has two big bore intravenous cannula (size 14) inserted (1) . Bloods will be sent urgently. This includes full blood count to exclude anaemia & thrombocytopenia, group & save & crossmatched her for at least 4 units of blood to correct anaemia due to bleeding. I will check baseline renal & liver function (1) . I will check clotting to exclude disseminated intravascular coagulopathy. Results need to be followed up urgently.

I will give her oxygen up to 10 litres / min (1) via facial oxygen. Her blood pressure, pulse, oxygen saturation will be monitored at least every 15 minutes continuously until she becomes stable. She needs to be catheterised & urine output to be monitored every one hour in conjunction with temperature. All these observation monitoring should be recorded on the \"modified obstetric early warning score (1) \". She should receive crystalloid (eg normal saline) infusion & colloid infusion ? volume while waiting for bloods. If there is no enough time to cross match & blood transfusion is needed urgently, O negative b lood should be given (1) .

Cause of postpartum hamorrhage (PPH) needs to be identified. Uterine atony is the commonest cause. Continuous bimanual uterine compression and oxytocic can be used. The latter includes im sytocinon 5 units bolus intramuscularly (im) or slow intravenous (iv) bolus. 40units of iv syntocinon infusion (mixed with 500ml normal saline) running over 4 hours should be commenced. Ergometrine or syntometrine i ampule im can be given when there is not history of hypertensive episodes. Carboprost (prostangladin F2 alpha) 250 microgram can be given as im every 15 minutes up to 8 doses (1) . Misoprostol 1g ? dose?? per rectum can also be considered why consider it rather than give it? what is there to consider? .

Perineal, vaginal or cervical trauma needs to be excluded how? and immediate repair should be commenced. The placenta should be checked to exclude any retained placenta just because the placenta appears complete does not mean RPOC have been excluded . Consultant haematologists should be discussed with should the blood results show any coagulopathy or significant thrombocytopenia where fresh frozen plasma, cryoprecipitate or platelets need to be given (1) .

Should her PPH not respond to oxytocic treatment or retained placenta is suspected, she should be consented for examination under anaesthesia you need this if you are to identify cervical tears . It can be done under spinal will you give spinal to a woman who is having major haemorrhage??? or general anaesthesia. Patient should be counselled about hysterectomy should uterine atony do not respond to balloon tamponade, uterine compression sutures eg B-Lynch (1) . A second opinion from consultant obstetrician should be obtained for hysterectomy (1) . The woman should be considered to be transferred to high dependecy unit (1) for close observation.

Good communication is important in cases of PPH. Staff should be allocated for monitoring recording observations, scribing the events (1) , transporting equipments & medicines, looking after the woman & partner so that the team can work effectively.

Once she is stable, she should be debriefed about the incident (1) . An incident form should also be completed due to PPH.
Posted by PAUL A.
LEEN
A healthy 35 year old woman is having heavy vaginal bleeding following the delivery of her baby and the placenta. The estimated blood loss is 1,500ml at the time you arrive (15 minutes after delivery) and she is still bleeding. Describe your management of this patient [20 marks].

In such a situation, there are 4 components of management that should be done simultaneously - communication, resuscitation, monitoring and investigations, and arresting the bleeding.
I would make sure the consultant obstetrician, senior anaesthetists, laboratory (blood transfusion and haematology especially) and porters (to collect blood samples and blood products) are informed ? midwives . Resuscitation should be commenced, and her airway, breathing and circulation should be assessed (1) and secured. At least 2 large bore intravenous (IV) cannula (1) (14 gauge minimum) should be inserted and bloods taken for full blood count, urea and electrolytes, liver function tests, coagulations screen (including fibrinogen) and group and crossmatch of at least 4 units (1) . I would commence warmed crystalloids and/or colloids ? volume (at a fast rate) whilst awaiting the arrival of crossmatched blood ? O neg blood . Her blood pressure and pulse should be observed continuously and temperature taken every 15 minutes resp rate, SO2 . Facial oxygen (15litres / min (1) ) should be given.
I would check her fundus for signs of atony (the most common reason for post partum haemorrhage) and apply bimanual compression of the uterus if it is atonic. 5 units of syntocinon should be given IV and a syntocinon infusion (40iu in 500mls NaCl 0.9%, at 125 mls/hr) started ? other uterotonic agents?? . I would catheterise the patient and monitor her urine output. I would make sure there is a designated staff/person scribing and documenting all events (1) , condition of the patient, interventions and timing.
Ergometrine should be given (if she has no history of hypertension) - 0.5mg intramuscularly (IM). If this does not stop her bleeding, I would give her carboprost 0.25mg IM (every 15 minutes, up to a maximum 8 doses) (1) .
If crossmatched blood is still not available and she has had up to 2 litres of crystalloid and 1 litre of colloid (1) ?? answer plan – you have already discussed fluids. It may not cost you marks now but you are wasting time & space , and she is still bleeding, I would give her O negative blood (1) again, discussed earlier (which should be available on labour ward) whilst awaiting crossmatched blood.
I would also check for other causes of bleeding, and treat any causes found. I would look for any signs of trauma (vaginal/cervical tears how? EUA ), retained products of conception (get a midwife to check if the placenta is complete and examine her cervix to see if membranes are present) majority of women with RPOC have placenta recorded as complete at the time of delivery – checking the placenta is of little use. IF SHE IS BLEEDING, YOU EXPLORE THE CAVITY and signs of coagulopathy in the patient (coagulation screen and signs of blood not clotting).
If the medical management of arresting her bleeding does not work, I would transfer her to theatre and insert a Rusch catheter (intrauterine) to arrest bleeding. If this does not work, I would perform a laparotomy to apply a compressioin suture (eg B-Lynch). Failing that, ligation of the uterine arteries or internal illiac arteries can be attempted. If intervention radiology is available, I would involve them to consider internal iliac artery embolisation (1) . These interventions are not shown to affect future fertility or pregnancy outcome. As a last resort, if she continues to bleed, a hysterectomy will need to be performed (1) (usually 2 consultant obstetricians need to agree that it is the best course of action - as it is associated with increased morbidity and is a difficult operation in such a circumstance you will get greater morbidity / mortality if you delay hysterectomy waiting for an opinion from someone else ).
I would keep the patient and her family informed of the situation at all steps and reassure them if appropriate. ? debriefing – this is different from keeping them informed

(written in 26 minutes)
Posted by PAUL A.
call help from senior obstetric and anaesthetic ? midwife, haematologist . ensure two intravenous lines wide bore and do emergency hb.hct, and cross match ,urea &E ,LFT and clotting screen (1) how many units of blood? . I will check her bp p and resusscitate her following ABC will you do this before or after getting iv access and taking blood? . first thing then to check uterine contractility and the placenta and membranes to make sure nothing is left just checking placenta and membranes is not helpful. Majority of women with RPOC have placenta reported as complete at delivery . then i will check her partogram and her antenatal notes for what? Why?? . in case the uterus is not contracting i will start utertonics syntocinone , metergine ,hemabat (1) . if the uterus is will contracted proceding to genital tract examination in theatre under good lightning and analgesia (1) anaesthesia more appropriate to identify any trauma or uterine rupture or inversion and manage it accordingly . when hb result come back i will start transfusion will you wait for Hb results before transfusing a woman who is actively bleeding? She could bleed to death before results are available(-1) after taking consent from the patient . After controlling the bleeding i will observe the patient in ITU (1) . filling incident form and explaining to the patient what has happened .

You have 20 marks and have used a fraction of the space / time provided. See good answers above and RCOG guidelines on PPH
Posted by PAUL A.
This is an Obstetric Emergency with moderate major post partum haemorrage associated with increased risk of maternal morbidity and mortality.Its management requires communication,resuscitation,monitoring of patient and treatment. I will follow my unit protocol in this situation. I will put emergency call for multi disciplinary team including consultant obstetrician,Anesthetist,senior midwives,alert haematologist,lab and porter (1) . My first step would be to resuscitate assess first then resuscitate the patient by securing her airways, breathing with oxygen inhalation how much? , circulation by inserting 2 large bore canula (1) ( atleast 14 gauge).Bloods to be sent for FBC,Coagulation U & E’s and LFT’s to screen for baseline liver and renal function, 4 units of Blood cross match (1) . Her continuous BP,pulse,O2 saturation monitoring should be done.Folley’s Catheter for maintenance of intake & Ouput chart (1) ..Blood loss should be replaced by crystalloids and colloids upto 3.5 liters (2.0 liters of crystalloids & 1.5 liters of colloids) till the blood arrives (1) or ‘O’ Rh Negative blood can be given till group specific cross match blood arrives (1) .Abdomen should be palpated & if uterine atony ,start with rubbing up of uterus plus Bimanual compression to increase uterine tone and at the same time I will start Uterotonic agent like oxytocin 5 units I/V slowly or 0.5 mg of Syntometrine ?? dose I/M if patient is not hypertensive and still bleeding 40 units of oxytocin in 500 ml of 0.9% Normal saline at rate of 125 ml/hour if still uterus is relaxed. I will give 0.25 mg of carboprost (1) Injection I/M or 0.5 mg intramyometrial injection if bleeding continues & uterus still relaxed.I will ask the midwife to check if placenta is complete does not exclude RPOC . Vaginal examination to rule out retained placental pieces membranes or trauma to genital tract requires EUA which can be sutured by absorbable Vicryl 2.0 to stop bleeding.
If all these medical measures will not stop her bleeding I will shift transfer her to operation theater and by that time her coagulation results will be ready may take an hour – she should not be in the room for that long if she is bleeding and should be Reviewed to exclude coagulation defects.Under Anesthesia and good light I will exclude her genital tract trauma again such an examination should not have occurred without anaesthesia and suture if needed (1) . If her uterine atony is the cause then I will consider conservative surgical measures as uterine temponade by mean of rusch catheter or sengstaken tube or Bakri balloon.If still bleeding continues I will do uterine or internal iliac artery ligation.If facilities available I will consider internal Iliac artery embolisation as these interventions will save her future fertility by saving her uterus (1) . If all these surgical conservative measures failed then as last resort with opinion from atleast 2 consultant obstetricians Hystrectomy should be done (1) although the RCOG guidelines say this, you should recognise that it is not safe to delay hysterectomy while waiting for a colleague to come and give an opinion – this could result in unnecessary morbidity / mortality , preference will be subtotal hystrectomy why?? and with preservation of ovaries if possible why should it not be possible to conserve the ovaries? .During all this time I will keep patient’s partner & family informed of the situation (1) .i will document all the events carefully,timing,medication & surgical measures taken.Patient should be councelled and informed of all the events as early as possible by consultant obstetricians (1) present during that event.
Posted by PAUL A.
SN

This is an Obstetric emergency. Patient should be first assessed for Airway (A)(if talking, airway is patent), Breathing(B), Circulation(C) (pulse, BP) (1) and blood loss should be estimated simultaneously. If A, B, C is defective (e.g. if airway is not patent, may need intubation and artificial ventilation; fluid resuscitation with crystalloids and colloids). I will request another team member to call for help (e.g. Labour ward coordinating mid wife, SHO, Anaesthetist, Senior Obstetrician) ? haematologist / blood bank . Two large bore cannulas (1) should be inserted and bloods should be sent for FBC, Renal profile, LFT, clotting profile. 4 units of blood should be cross matched (1) urgently.
A quick history regarding antenatal complications, labour (e.g. slow progress, use of oxytocin for augmentation) and delivery should be taken (e.g. perineal lacerations, episiotomy, complete evacuation of placenta). ? facial O2 / Fluid resuscitation; monitoring T,P,BP,SO2, Resp rate
Uterus should be examined for hypotonicity. If not a well contracted, Oxytocin infusion 10 units/hour should be started. If patient has already had Syntometrine IM post delivery, Ergometroine 500mcg can be given IM while Oxytocin infusion is in preparation. IM carboprost 250mcg every 15 minutes up to 6 doses can be given until bleeding ceases in addition to bimanual compression of the uterus (1) .
Other causes of PPH should be excluded how? what will you do? (retained placental parts, genital tract lacerations (e.g. perineal, vaginal, cervical tears). As the patient has already had 1.5L blood loss, she should be taken to theatre for EUA (examination under anaesthesia) (1) . Consent should be taken for intra-uterine balloon insertion, laparotomy and additional suturing (Uterine brace sutures) and Hysterectomy. Under EUA, genital tract trauma should be sutured (1) if causing the PPH. If there are placental parts or clots retained in uterus, these should be evacuated. If actively bleeding, an intra-uterine balloon catheter should be inserted and watch for further bleeding. If bleeding has not stopped, a laparotomy is indicated for uterine Brace sutures (e.g. B- lynch) (1) . If still bleeding, may need a hysterectomy (1) .
The Haematologist should be contacted for blood products resuscitation simultaneously. Patient may need platelets, FFP in addition to whole blood (1) when should FFP be given?. Factor VII has shown to reduced intractable bleeding and may be considered in liaison with the haematologist if all other procedures and uterotonics fail, prior to hysterectomy. transfer to ITU / HDU
Patient should be debriefed (1) regarding management done and clear documentation is important with regards to all actions taken (with times) and post operative management. An incident form should be filled for major PPH. SEE RCOG GUIDELINES ON PPH
Posted by Ron C.
RnRn

Being an obstetric emergency, multidisciplinary approach involving senior colleagues & midwives, consultant on call, anesthetist, hematologist and blood bank staff. They must be informed right away and extra help must be arranged, including someone to note times and events. On being confronted with the situation, most important information is what pre-delivery Hb was, whether there is an i.v. canulla and sample for group & save present, whether placenta is complete, what drugs (uterotonics) have been given so far and whether there is an episiotomy or vaginal/cervical tears (as possible cause for bleeding). Her parity and previous deliveries must be noted as well, as in a previous caesarean there may currently be a scar rupture.
Initial assessment will focus on vital signs; blood pressure, pulse rate, saturation (pulse-oximeter) are noted and continuous monitoring is justified. Uterine tone and fundal height are assessed as atonic uterus is the most common cause. Urine-output most be noted and if not done yet, catheterization with a urimeter will allow better assessment whilst it will remove a full bladder as contributing factor to atonic uterus. Bloods are sent off for full blood count to assess hemoglobin & platelets and coagulation including fibrinogen to guide transfusion, and liver function tests and renal function test are taken as baseline. Blood for X-match is sent if not done yet and as further blood loss is anticipated 6 units of packed cells are ordered, as well as cross-matching 4 units FFP. If blood can’t be released on a short notice, group-specific or even 0-Rhesus-negative blood must be considered. Further transfusion can be partially guided by haemacue Hb values and the anesthetist may decide to place a CVP line to facilitate monitoring.
While one staff member is arranging all investigations and a porter will get blood, simultaneously initial resuscitation has started, arranging i.v. access with 2 large bore canula’s (14 gauge) and transfusing 2 litres of hartmans and 1.5 litres of colloids, using pressure cuffs and warming devices. Early transfer to operating theatre must be arranged to facilitate further management in a better equipped environment. It will also allow for easier assessment of any cervical/vaginal/vulval trauma as cause of bleed. If an atonic uterus is present this is the most likely cause. It is treated with uterine massage, bimanual compression and uterotonics, initially an i.v. bolus oxytocine 5 units (which can be repeated). If ineffective, next step is ergomethrin 500 mcg i.m. Subsequently a continuous infusion of oxytocine 10 iu/hr is started. If bleeding continues, haemabate 250 mcg i.m. can be used every 15 minutes if needed. Additional misoprostol 100 mcg per rectum can help as well. If nevertheless bleeding continues and placenta is complete on re-check, placing a Rusch catheter or equivalent such as Senstaken balloon in the uterine cavity is a way of stopping bleeding from within. By that time any alternative cause of ongoing bleed such as trauma to tissues or coagulation problems must have been ruled out. If this reduces the bleed, it can be left in for 6 hours and thereafter gradually deflated (ideally day time), leaving the catheter in situ. If it doesn’t result in reduction of bleed, decision for laparotomy is made and at that time broad ligament hematoma may be identified. B-lynch suture can be attempted and experienced clinicians can try ligation of internal iliac artery. The latter can also be done by an interventional radiologist, but this expertise is not present in every hospital. In life-threatening scenarios the decision for hysterectomy must however not be left too long and made by a senior consultant (preferably 2).
Afterwards further monitoring in an intensive care unit is appropriate. Further monitoring of full blood count and coagulation to guide transfusion and renal function tests & liver function tests to early identify (multi-) organ failure is important. Much later further tests such as thyroid hormones, LH, FSH may identify Sheehan syndrome, though not very common. Following soon after the event patient and partner must be debriefed, and several further opportunities must be offered to discuss and go through all events and decisions.
Posted by PAUL A.
GH M
Call for help include senior anaesthetist, senior obstetrician, haematologist and alert OR team for possible surgical interventions ? midwife . Two wide pore IV lines (16G) (1) not a sentence. CPR WHY IS CPR required? is initially required making sure that airway, breathing and circulation are stable this is not CPR . Rapid infusion of crystalloids and colloids ? vol . Cross-matched blood at least six units’ any other blood tests? alert blood bank for the possible need for more blood and blood products. Rapid history regarding mode and duration of delivery and size of the fetus and prior Hx of PPH. rechecking that the placenta is completely removed how? Inspecting placenta does not exclude RPOC . Keep the patient oriented by the procedure that would be taken if she is conscious or inform her next in kin. Treatment with that emergency should be rapid and step-wised. Initial treatment is uterine massage and medical administration of ergometrine, Oxytocin infusion / prostaglandin analogue- misopristol (1) if the uterus is atony. Bimanual compression which is more invasive than uterine rub my be tried. Vaginal exploration of possible vaginal cervical tears under proper analgesia and repair the tears (1) if present. If the placenta is not complete, ERPC is done under anaesthesia the majority of women re-admitted with RPOC have the placenta reported as complete at delivery. So the fact that the placenta appears complete should not stop you exploring the uterus if she is bleeding . If the bleeding not stanched while maintaining haemodynamic stability I will proceed to more invasive measure. Uterine artery embolisation can be done if intervention radiology is available aiming to preserve the uterus. If not surgical intervention is mandatory starting with simple manoeuvre like B-Lunch brace suture. If bleeding did not stop proceed to bilateral uterine artery ligation or internal iliac ligation (1) ? balloon tamponade . The last resort will be hysterectomy (1) if bleeding is continuous and threatening the life of patient. I will document the procedure in details in the patient notes for care of patient and possible medicolegal issues. I will explain what happen to patient in personal before discharge in sensitive way (1) See RCOG guidelines on PPH and good answers above .
Posted by PAUL A.
The patient is having major post partum haemorrhage and needs immediate corrective measures. First and the foremost is call for help,a senior midwife,a middle grade obstetrician and anaesthetist should be called ,consultant obstetrician alerted.The blood bank & heamatologist should be alerted (1) .Communication is very important and patients attendants should be regularly informed about patients condition and therapy being given.
Resuscitation started pulse rate BP,respiratory rate taken (1) assess ABC .patient put on oxygen at a rate of 15l/min (1) . Two wide bore IV cannula placed (1) (14 gauge )crystalloid approximately 2l and colloid upto 1.5l can be given safely till blood made available (1) .
Patient catheterized with foley’s catheter .One person in the team made incharge to take note (1) of input output and medication given and its timing.About 20 ml of blood taken and send for FBC,clotting screen,LFT,RFT baseline,ask for 4 units of group specific blood (1) why not cross-matched blood? if not available then O –ve can be given. A central venous access to be put why? What is the benefit in the acute situation? There are more pressing issues for the anaesthetist .
Look for cause ,atonia is seen in 70% patients ,uterine massage done,oxytocin 5 to 10 units slow intravenously bolus given.Drip with 40 units of syntocinon in 500 ml started.ergometrine upto 500 µg can be given .if bleeding still continuing then carboprost 250 µg given intramuscularly .upto 8 doses at an interval 15 min (1) can be given safely. Carbetocin a long acting oxytocin recently made available can be given ? evidence that it is useful in management of PPH .Misoprost 1000 microgram can be inserted per rectally. If PPH continuing the balloon temponade with Rusch balloon or Sengstaken Blakemore tube can be tried whichever available will you do this in the room or in theatre? , or patient can be taken up for surgical procedure like B lynch sutures or internal artery ligation (1) .or a hysterectomy (1) ?? EUA and repair of tears if deemed necessary.If facilities of an interventional radiologist present then uterine artery embolization can be done.
If trauma is suspected( like perineal ,vaginal, cervical tear)it would need exploration and under GA ? logic – are you looking for tears AFTER you have used balloon / brace sutures / hystsrectomy?? .If uterine rupture then laparotomy with repair or hysterectomy may be required.
In case there is retained placental bits or membrane ( examining the placenta would tell this will not tell you – most women re-admitted with RPOC have the placenta reported as complete at delivery ) then ERCP should be done.
Lastly the patient could be having coagulation failure ,a clotting screen would tell us so and transfusing 4 FFP’s for every 6 units of packed cells would prevent this. Recombinant Factor VII a can be given life threatening PPH in consultation with a haematologist (1) .
Once PPH treated patient to be transferred to high dependency unit (1) ? debriefing .
Posted by PAUL A.
asa
PPH of 1500 ml blood should trigger full protocol of PPH management and my role is to act as leader of the team till arrival of more senior staff as PPH could cause mortality or near miss morbidity. Communication ,resuscitation , assessment and trying to arrest the bleeding should all be done at the same time. I will ask for more staff , senior midwife , anesthetist ,porters and alerting consultant obstetrician clinical heamatologist and the blood bank (1) .One member should be assigned to record all events (1) including staff involved ,their timing of arrival , their role , medication given ,timing and doses , fluid therapy and blood transfused and the condition of the woman during the whole process. I will see first if she is shocked or no by her general condition ,her level of consciousness , assess air way and breathing (1) ? circulation and administer O2 10-15 L /min (1) by face mask . Keep her flat and 2 14 gauge cannulas (1) should be inserted ,20 ml of blood withdrawn for FBC,cloting studies including fibrinogen , LFT ,RFT and cross matching of 4 units (1) of blood . Fluid in the form of 2.5 L of Ringers lactate and 1.5 L of colloid will be started immediately till arrival of blood (1) . If the patient has stated before that she refuses blood transfusion I will discuss it with her again. The patient must be kept warm .Foleys catheter must be inserted also. The patient will be attached to electronic monitoring for BP ,pulse resp rate, SO2 . Giving her warmed blood quickly is very important and we should not use special infusion sets as it will slow the transfusion process . Other blood products like FFP or platelets will be transfused if indicated in conjunction with heamatologist (1) opinion and lab results . I will examine the uterus abdominally to check if it is contracted or no as the most common cause of PPH is uterine atony If the uterus can t be felt I will see if it is inverted . Examination of the placenta to see if it is complete or no must be done does not exclude RPOC – the majority of women with RPOC have the placenta reported as complete at delivery .During examination taking quick history about circumstances during delivery difficult or no (ruptured uterus) ,history of thrombophilia and if the placenta was low lying ( bleeding lower segment ) .Examination of the perineum and vagina for bleeding tears and lacerations will be done if possible otherwise she will be shifted transferred to theater for examination under anesthesia (1) you are half way through your answer and transferring her to theatre without giving any uterotonic agents . Definite treatment depends on the cause of bleeding either tone, tissue ,thrombin and trauma . Atony will be treated by applying first bimanual compression to the uterus should have been started before transfer to theatre while giving 40 iu oxytocin in infusion and 5 iu IV , ergometrine 500 ug im .Giving carboprost im 0.25 mg repeatedly /15 min for a total of 2 mg (1) if she is not asthmatic will be the next step . Insuflation of intrauterine balloon (Bakri or Rusch) to give tamponade effect will be instituted. If bleeding continues the patient will be managed by brace sutures during laparotomy . In case no senior staff is present even aortic compression may be of help . Further decisions for ligation of vessels as uterine artery, internal iliac a or selective embolisation of vessels will depend on the circumstances and available experienced staff (1) . It is important to remember that the patient life is more important than keeping her bleeding uterus intact so decision for hysterectomy (1) should be offered quickly if necessary (1) preferably in the presence of two consultants .
Other causes like bleeding tears (1) , big heamatomas and uterine rupture will be dealt with under aneasthesia as well as removal of retained products inside the uterine cavity .
The patient should be monitored during the whole time and repeat blood testing done as necessary. After stabilization and stopping the bleeding she will be cared for in ITU or HDU (1) till the risk resolves and heamatological correction done.
Professional attitude and calmness are essential in dealing with the situation as the other members of the staff and the patient and her relatives will be tense ,anxious and confused . Debriefing (1) is important for psychological support of the patiet . Adressess and websites for support groups will be offered .
Incident reporting and keeping complete chronological record of all procedures and medication given is essential . Good answer – the sequence of events is vital. For instance: you do not get marks for bi-manual compression if you are only going to do it when she is in theatre
Posted by PAUL A.
AGN
Recognise that post partum haemorrage(PPH) is an obstetric emergency.Prompt assessment and intervention is needed to avoid maternal morbidity and mortality (1) .Common cause fo PPH is uterine atony.Other causes include genital tract injury,retained product of conception,uterine invertion and rare causes are bleeding disorders.
I will call for help from senior obstetrician and anasthetic.Also inform the attendan (for sending investigations and collect blood products).Inform the haematologist (1) , may need more blood and blood produts.I will assess the patients vital sign(BP,PR.SO2) (1) and start resusitation.Give face mask oxygenation how much? ,Fix 2 large bore iv lines (1) (if not done) and take blood for FBC,LFT,U&E,coagulation profile and grossmatch 6 units (1) of blood.Resussitate with cristaloid,colloid how much? or blood o -ve while awaiting for grossmath blood (1) .
I will assess the uterine contraction, if not well contracted ,rub uterus with hand and give iv syntometrine(if no contraindication,if contraindicated give iv syntocinon) or Im carboprost (1) more detail – time intervals. repeat uterotonic which one? after 15 minutes.Most off the PPH will stop within this simle procedure.If the uterus is not able to be felt or feel dimple per abdoman,suspect uterine inversion. Repeat BP,PR every 15minutes continuously .Inform the woman regading PPH and procedure undertaking.If uterus well contracted and still has PV bleeding , check for genital tract injury under good lightning and analgesia and repair it (1) . If there is no genital track injury causing PPH ,check for retained product of conception with abdominal ultrasound ?? value – uterus likely to contain blood clots and this will only delay intervention .If still has PV bleeding ,do bimanual compression and arrage for laparatomy.Othar option is uterine artery embolisation which need experinced radiologist and instrument(not available in most of the hospitals) ? balloon tamponade .
Councel patient and partner regarding the PPH and further plan including hysterectomy.Get written consent include for hysterectomy and blood transfusion.Try uterine artery ligation,B-lynch sutures and internal iliac vessel ligation (1) .Can give intra myometral injection of carboprost.If still have uterine atony or PV bleeding,proceed with hysterectomy (1) .Incert abdominal drain if suspected DIVC.Keep family members informed.know the limits for conservative management.Confidential enquiry into maternal death shows increase maternal morbidity and mortality due to delay in decision on hysterectomy (1) therefore prompt intervention needed .Massive blood transfussion can couse DIVC,hyperkalemia,hypocalcamia and hypotermia.Correct anaemia,hyperkalemia and hypocalcaemia.
Assess the need for thrombophylaxis post op.Avoid immobilization and dehydration.Remove abdominal drain once minimal drainage.
Post op counsel the patient and partner regarding the events and procedure undertaken (1) .Offer formal counselling.Fill up incident form.Clear documentation including time called,time arrived,finding,persons involveded and procedurs undertaken.On disharge give f/up appointment 6 weeks post op.
Posted by PAUL A.
AH

This patient is experiencing major obstetric haemorrhage. Haemorrhage was the third cause of direct maternal mortalityaccording to the last Confidential enquiry (2002-2005).and urgent action by appropriately experiencd staff is essential.
Help will be summoned while assessment and resuscitation is commenced.
The midwife in charge, a senior midwife, the consultant obstetrician, and the anaesthetic registrar will be summoned. The consultant anaesthetist, the consultant haematologist,and blood transfusion laboratory will be alerted (1) . The laboratory porter will be called to collect blood specimens.
Thepatient and her birthing partner will be counselled about the massive haemorrhage and measures will be taken to arrest the bleeding and resuscitate her.
While the above is taking place the patient will be quickly assassed.
Airway and breathing will be assessed (1) and if the airway is compromised the anaesthetist will manage this. High flow oxygen (10-15 L/min) (1) via face mask will be commenced.
Circulation will be assessed and 2 large bore cannulae (1) will be inserted at which time blood (apporximately 20 ml) will be taken and sent to the lab for determination of haemoglobin and platelet concentration, coagulation screen, urea and electrolytes, and at least 4 units of crossmatcthched (1) blood will be requested. Intravenous fluids will be commenced with warmed crystalloids transfused quickly to a maximum volume of 3.5 litres or colloids up to 2 litres (1) while awaiting blood.
The patient will be kept warm and placed lying flat. A Foley\'s catheter will be inserted and left on free drainage for monitoring urine output. Pulse rate, respiratory rate, blood pressure and oxygen saturation will be continuously monitored via oximeter, automated blood pressure monitor and ECG (1) . Blood will be transfused as soon asit is available. If cross matched blood is not available, group specific or O RhD negative blood (1) will be requested with guidance from the haematologist decision to use O neg blood is yours, not the haematologist’s . A dedicated member of staff will be assigned to record all events (1) , drugs used, vital signs fluids and urine output.
A cause for the bleeding will be sought. The most common cause is uterine atony but other causes must be ruled out. These include retained products (placenta, membranes, clots) trauma to the genital tract, especially lacerations to the cervix and vagina, and uterine inversion.
Trauma to the genital tract will be repaired in theatre (1) , uterine inversion will be managed according to departmental protocol.
Uterine atony will be managed initially by conservative measures. Bimanual compression of the uterus and \'rubbing up\' of the uterine fundus to stimulate contraction will be done.
Oxytocics will be administered. Initially 5 iu of oxytocin will be given by slow intravenous injection and repeated if necessary.
Ergometrine 0.5 mg by slow intravenous injection will be given if necessary if the patient is not hypertensive. Other pharmacological agents which can be employed if the uterus does not remain contracted include a syntocinon infusion of 40 units in 500 ml Lactated Ringers (Hartmann\'s solution), or prostaglandins. Carbaprost (prostaglandin F2alpha derivative) 0.25 mg intamuscularly or intramyometrially; the latter under direct consultant advice as this route of administration is not approved. Another option is misoprostol 1000 mg per rectally (1) .
Early recourse to surgical management is necessary to prevent severe morbidity or mortality if the bleeding is not controlled.
Conservative measures include intrauterine bollon tamponade. If this is successful, the patient can be monitored for 4 to 6 hours . If the bleeding continues, the B-Lynch brace suture is effective and can be inserted by a suitably competent surgeon. Other options are bilateral uterine artery or internal iliac artery ligation,or, if facilities and staff for interventional radiology are available, uterine or iliac artery embolisation (1) .
The definitive treatment when all else fails is hysterectomy (1) . An early decision (1) will be taken by the consultant preferably in consultation with another consultant.
Anaesthetic input by the consultant anaesthetist is necessary to determine type of anaesthesia. Epidural anaesthesia is preferable in a woman experiencing major haemorrhage??? (-1) , but if an epidural is not in place, and there is thrombocytopaenia or deranged coagulation, general anaesthesia will be the preferred option NO – GA is preferred in major haemorrhage irrespective of coagulopathy .
The patient would be monitored in HDU or ITU depending on her condition (1) . The family will be debriefed (1) and an incident form will be filled.