Post-partum evacuation

Scenario A 24 year old patient delivers a 3,2kg healthy boy. 10 iu Oxytocin is administered IMI and breast feeding is initiated together with delayed cord clamping. The placenta is delivered. You notice that the patient is bleeding heavily vaginally. What do you do?

Shake and shout: The patient is alert Call a CAB Circulation: Pulse rate 100 bpm, BP 90/60 mmHg Airway: Patient is talking spontaneously Breathing: Breathing rate is 16 bpm Call for help IV access with 2 large bore IV cannulas (18 G or bigger) 20 iu Oxytocin in 1 litre Ringers lactate to run at 125 ml/hr Rub up uterine fundus. The uterus contracts Insert a urinary catheter Inspect the genital tract for local trauma causing bleeding. Nothing is found Inspect the placenta

Cotyledon missing

What do you do now? Prepare for evacuation in theatre Call a CAB: Circulation: Pulse rate 101 bpm, BP 115/70 mmHg Airway: Patient is talking spontaneously Breathing: Breathing rate is 16 bpm Face mask O2 Keep the patient warm Secondary survey

Big 5 CNS: alert CVS: BP 110/70 mmHg P 90 bpm Resp: RR 16 bpm Hepatic and GIT: Normal Renal: Clear urine in urine bag Forgotten 4 Haematological: ward Hb 7,0 g/dL thus order blood Immunological: Temp 36.5 Keep patient warm Endocrine: Glu 4.2 mmol/L Musculoskeletal: calves soft and not tender Core 1 Still bleeding actively

Discuss patient with the anaesthetist and theatre team Counsel and obtain informed consent for manual removal of placenta and evacuation in theatre Discuss patient with the anaesthetist and theatre team Preoperative medication: Metaclopramide 10mg IVI Antacid eg Sodium Bicarbonate po Single dose prophylactic antibiotic, preferably second generation Cephalosporin Type and screen blood for transfusion Take patient to theatre

In theatre Patient has spinal anaesthesia Illustrate how you will do the evacuation

After the evacuation the patient continues to bleed heavily. What do you do now?

Documentation