1. Obstetric haemorrhage
ESMOE

2. Aims To recognise obstetric haemorrhage
To understand the causes of haemorrhage
To practise the skills needed to respond to a woman who is bleeding
To achieve competence in those skills

3. Haemorrhage is Common Most common cause of maternal death worldwide
Accounts for ~30% of maternal deaths
Deaths from haemorrhage could often be avoided. (In RSA, over 80% of haemorrhage deaths are avoidable)

4. SA: NUMBERS, RATES, TRENDS
Haemorrhage MMR
(per 100,000 LBs)
442
19.5
491
18.8
688
24.9
684
24.3

5. Causal sub-categories of Obstetric Haemorrhagen %
Bleeding at/after C section
221
32.3
Abruptio placenta
108
16.1
Ruptured uterus
103
15.1
“other PPH” 84
12.3
Retained &/or adherent placenta 62
9.1
Atonic uterus 50
7.3
Vaginal/cervical trauma 25
3.7
Placenta praevia 16
2.3
“other APH” 8
1.2
Inverted uterus 5
0.7
TOTAL
684
100

6. Prevention of Haemorrhage
Routine iron supplementation in pregnancy
Anticipate / be prepared
Detect women at risk and deliver at referral hospital
Available supplies - IV fluids, cannulae, oxytocics, misoprostol, internal tamponade, blood transfusion services
Prevent prolonged labour (use of the partogram)
Active management of third stage of labour
Routine postpartum and post caesarean section monitoring of vital signs and bleeding. Use Early Warning Chart (EWC)

7. Haemorrhage is Often Not Recognized
Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are large
Mother can lose up to 35% of circulating blood volume (2000 mls) before showing clinical signs of hypovolaemia

8. Haemorrhage – Signs Pale Confused Increased HR, reduced BP (late sign)
FH abnormalities
Reduced urine output
Obvious or hidden bleeding

9. WHEN THE SIGNS ARE THERE, THEY ARE SIGNIFICANT, SO DO NOT IGNORE THEM AND ACT QUICKLY

10. All Cases of Haemorrhage
Call-a-C A B
Circulation
IV access by 2 large bore canulae
Send off blood samples
Give iv fluids and blood if available
Catheterise the patient and monitor output
Be aware of potential coagulation disorders 10

11. Skills station: Blood Loss Volume Demonstration

12. Antepartum Haemorrhage (APH)
Abruptio placentae Placenta praevia APH of unknown origin (APHUO)

13. Is a clinical diagnosis
Abruptio Placentae
Is a clinical diagnosis
Signs:
Tender tense enlarged uterus
Degree of shock not always proportional to revealed blood loss
Fetal distress or demise and can develop complications – renal failure, clotting problems and anticipate a PPH

14. Abruptio Placentae- Management
Call-a-CAB!
Resuscitate
Make a diagnosis
Control the bleeding
Mx is delivery 14

15. Management Abruptio Placentae
Live Baby
Rupture membranes
Resuscitate mother and as soon as stable emergency delivery
Dead Baby
Resuscitate mother and induce labour by rupture of membranes
Refer immediately

16. Skills Station: Abruptio Placentae

17. Placenta Praevia (PP)
All other APHs must undergo ultrasound to exclude PP
All PPs must be referred
It is essential that the most senior surgeon performs any surgery
It is advisable to have some form of tamponade available at surgery

18. APHUO
PV bleed in the absence of placenta praevia, abruptio or local causes Danger – atypical abruptio (50%) Refer Mx: admit for 6 hourly CTG Earliest sign of abruptio – spont decels → immediate CD

19. Postpartum Haemorrhage (PPH)

20. Haemorrhage - Management
Call-a-CAB!
Resuscitate
Control the bleeding
Make a diagnosis
Treat!

21. Approach – After Vaginal Delivery
Is the uterus contracted?
If not – atony or retained products
Contract the uterus
Is the uterus empty?
If not – empty the uterus
The uterus is contracted?
Trauma – find site
Is the uterus there?
No = uterine inversion – correct stat

22. Uterine Atony Massage uterus / bimanual compression
Give oxytocics (oxytocin,ergometrine,prostaglandin)
Empty bladder
Aortic compression
Ongoing bleeding - look for other causes
Ongoing bleeding - uterine balloon tamponade
Ongoing bleeding – EUA
laparotomy
Do not delay

23. Bimanual Compression (Source: B-lynch. A Textbook of PPH.2006)

24. Oxytocic Agents for Treating Uterine Atony
Drug
Dose
Max dose
Further doses
Cautions
Oxytocin
IM; 10 units,
IV; 2.5 units slowly
IV; infusion 20-40iu/ Litre
Avoid >3 litres of fluid containing oxytocin
IV bolus
Ergometrine
IM: 0.5mgs
IV: 0.2mgs
Repeat dose after 15 minutes
Total 1.0mg
Hypertension, pre-eclampsia, heart disease
Syntometrine
1 amp
(0.5 mg ergomentrine + 5iu oxytocin)
Misoprostol
mcgms orally or per rectum
Pyrexia

26. Rusch hydrostatic balloon catheter Source: B-Lynch, Textbook of PPH,2006.

27. Skills station : Uterine Tamponade Assembly

28. Retained Placenta
Should ideally be removed in theatre under anaesthesia If not possible or patient bleeding heavily Remove in labour ward with analgesia

29. Manual Removal of Placenta

30. Skills station : Postpartum Haemorrhage & Skills Station : Manual Removal of Placenta

31. Retained Placental Products
Should be removed in theatre under anaesthesia First explore the uterus manually Beware of perforation with instrument use If needed – curettage with the largest curette available Uterine contraction with ↓ bleeding = empty uterus

32. Examine perineum visually Examine vagina digitally
Genital Tract Trauma
Examine perineum visually Examine vagina digitally

33. Unknown Cause
If the cause is not obvious early resort to examination under anaesthesia in theatre is essential

34. Observations Post-haemorrhage
1st 2 hours post-op/event: ½ hourly observations Next 4 hours: 2 hourly observations Then 4 hourly

35. Observations to Be Recorded
Pulse rate Blood pressure Vaginal bleeding (pad checks) (Urine output and temperature)

36. Observations
Should be performed in an area where health care professionals can do the observations regularly EARLY RECOURSE BACK TO THEATER DO NOT WAIT AND SEE!

38. Transfer of Unstable Patients ?
District hospital; Transfer or treat?
Importance of resuscitation measures to have been commenced and some temporising measures to arrest bleeding initiated before and continued during referral.
Temporising measures:
Uterine tamponade

39. ?

40. Recap Recognising Obstetric Haemorrhage Causes Management
Protocol
CAB
Blood replacement
Diagnosis of cause of bleeding
Methods to arrest haemorrhage