1. Obstetric Haemorrhage

2. Aims To recognise Obstetric Haemorrhage To recognise Obstetric Haemorrhage To practise the skills needed to respond to a woman who is bleeding To practise the skills needed to respond to a woman who is bleeding To achieve competence in those skills To achieve competence in those skills

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

4. SAVING MOTHERS REPORT FOR SOUTH AFRICA, 2005 – 2007 OBSTETRIC HAEMORRHAGE Accounted for 491 maternal deaths in South Africa during 2005 – 2007. ( 12.4% of total deaths and the third most common cause of maternal death) Most common causes of haemorrhage deaths were: APH: Abruptio placentae PPH: uterine atony (prolonged labour) retained placenta ruptured uterus bleeding associated with caesarean section

5. Haemorrhage is often not recognized Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are large Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are large This is because mother compensates for blood loss by shutting off the blood supply to the fetoplacental unit This is because mother compensates for blood loss by shutting off the blood supply to the fetoplacental unit Mother can lose up to 35% of circulating blood volume (2000 mls) before showing signs of hypovolaemia Mother can lose up to 35% of circulating blood volume (2000 mls) before showing signs of hypovolaemia

6. Haemorrhage – signs Pale Pale Confused Confused Increased HR, reduced BP Increased HR, reduced BP FH abnormalities FH abnormalities Reduced urine output Reduced urine output Obvious or hidden bleeding Obvious or hidden bleeding

7. WHEN SIGNS ARE THERE THEY ARE SIGNIFICANT, HAVE HIGH SUSPICION AND ACT QUICKLY! WHEN SIGNS ARE THERE THEY ARE SIGNIFICANT, HAVE HIGH SUSPICION AND ACT QUICKLY!

8. Haemorrhage - management Have an accessible protocol (poster form) Have an accessible protocol (poster form) ABCs ABCs C replace the volume and stop the bleeding C replace the volume and stop the bleeding

9. Haemorrhage ABCs ABCs Circulation Circulation IV access by 2 large bore cannulae IV access by 2 large bore cannulae Send off blood samples Send off blood samples Give iv fluids and blood if available Give iv fluids and blood if available Be aware of potential coagulation disorders Be aware of potential coagulation disorders

10. NB: Establish the CAUSE of the Haemorrhage Pregnancy Pregnancy  Abortion, ectopic, abruptio, praevia Labour Labour  Abruption, praevia, ruptured uterus After delivery (4Ts) After delivery (4Ts)  uterine aTony,  Trauma (cervical or perineal, or ruptured uterus)  reTained placenta  reTained products Post Caesarean bleeding Post Caesarean bleeding  Atony, trauma, placental site bleeding Any of the above +/- coagulation disorder Any of the above +/- coagulation disorder

11. Haemorrhage – stop the bleeding Good history and systematic examination to determine cause CALL for help: Resuscitation and diagnosis of cause of bleeding plus treatment must occur concurrently. How to stop bleeding for most causes will be covered in breakout sessions Stepwise approach in case of uterine atony

12. Suspected Uterine Atony Empty bladder Give Oxytocics (oxytocin,ergometrine,prostaglandin) Massage uterus / bimanual compression Aortic compression Ongoing bleeding -- look for other cause Ongoing bleeding– Uterine balloon tamponade Ongoing bleeding - EUA - laparotomy

13. Oxytocic agents for treating uterine atony DrugDoseMax doseFurther doses Cautions oxytocinIM; 10 units IV; slowly 2.5units IV; infusion 20-40iu/ Litre Avoid >3 litres of fluid containing oxytocin IV bolus ergometrineIM: 0.5mgms IV: 0.2mgms Repeat dose after 15 minutes Total 1.0mgHypertension, pre-eclampsia, heart disease misoprostol400- 600mcgms sublingual or rectal pyrexia PGF2alpha Intramyometri al; 5mgms in 10 mls saline. Give 1ml Repeat dose after 10 mins. Total 2.0 mgms (4 doses) Asthma, do not give IV

14. Treatment of PPH from other causes Retained placenta…. Manual removal. (Efficacy of Intraumbilical cord oxytocin injection not proven) Suspected retained placental products…. uterine evacuation under anaesthesia Cervical and vaginal trauma…..Repair with good light/ understanding of the anatomy. Ruptured uterus ….Laparotomy Unknown cause…Early recourse to Examination under Anaesthesia and possible laparotomy

15. Haemorrhage - Laparotomy Compression of the aorta Compression of the aorta Uterine compression suture (eg B-lynch) Uterine compression suture (eg B-lynch) Uterine vessel ligation Uterine vessel ligation Hysterectomy Hysterectomy

16. Prevention of PPH  Routine iron supplementation in pregnancy  Anticipate / Be prepared  Detect at risk women to deliver at referral hospital  Available supplies - IV fluids, cannulae, oxytocics, misoprostol, blood transfusion services  Prevent prolonged labour  Active management of third stage of labour  Routine postpartum and post caesarean section monitoring of vital signs and bleeding

17. ? ?

18. RECAP Recognising Obstetric Haemorrhage Recognising Obstetric Haemorrhage Causes Causes Management Management  Protocol  ABC  Blood replacement  Diagnosis of cause of bleeding Methods to arrest haemorrhage Methods to arrest haemorrhage