Obstetric Obstetric HaemorrhageHaemorrhage

AimsAims

To recognise Obstetric HaemorrhageTo recognise Obstetric Haemorrhage

To practise the skills needed to respond to To practise the skills needed to respond to a woman who is bleedinga woman who is bleeding

To achieve competence in those skillsTo achieve competence in those skills

Haemorrhage is commonHaemorrhage is common

Most common cause of maternal death Most common cause of maternal death worldwideworldwide

Accounts for ~30% of maternal deathsAccounts for ~30% of maternal deaths

Deaths from haemorrhage could often beDeaths from haemorrhage could often be avoided. avoided. (In SA, over 80% haemorrhage deaths are (In SA, over 80% haemorrhage deaths are avoidable)avoidable)

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

Haemorrhage is oftenHaemorrhage is often not not recognizedrecognized

Blood loss is underestimated because in pregnancy Blood loss is underestimated because in pregnancy signs of hypovolaemia do not show until the losses are signs of hypovolaemia do not show until the losses are largelarge

This is because mother compensates for blood loss by This is because mother compensates for blood loss by shutting off the blood supply to the fetoplacental unitshutting off the blood supply to the fetoplacental unit

Mother can lose up to 35% of circulating blood volume Mother can lose up to 35% of circulating blood volume (2000 mls) before showing signs of hypovolaemia(2000 mls) before showing signs of hypovolaemia

Haemorrhage – signsHaemorrhage – signs

PalePaleConfusedConfused

Increased HR, reduced BPIncreased HR, reduced BPFH abnormalitiesFH abnormalitiesReduced urine outputReduced urine outputObvious or hidden bleedingObvious or hidden bleeding

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

Haemorrhage - managementHaemorrhage - management

Have an accessible protocol (poster form)Have an accessible protocol (poster form)

ABCABCss

CC replace the volume and replace the volume and stop the stop the bleedingbleeding

Haemorrhage

ABCsABCsCirculationCirculation

IV access by 2 large bore cannulaeIV access by 2 large bore cannulaeSend off blood samplesSend off blood samplesGive iv fluids and blood if availableGive iv fluids and blood if availableBe aware of potential coagulation disordersBe aware of potential coagulation disorders

NB: Establish the CAUSE of the NB: Establish the CAUSE of the HaemorrhageHaemorrhage

PregnancyPregnancy Abortion, ectopic, abruptio, praeviaAbortion, ectopic, abruptio, praevia

LabourLabour Abruption, praevia, ruptured uterusAbruption, praevia, ruptured uterus

After delivery (4Ts)After delivery (4Ts) uterine aTony, uterine aTony, Trauma (cervical or perineal, or ruptured uterus)Trauma (cervical or perineal, or ruptured uterus) reTained placenta reTained placenta reTained productsreTained products

Post Caesarean bleeding Post Caesarean bleeding Atony, trauma, placental site bleedingAtony, trauma, placental site bleeding

Any of the above +/- coagulation disorderAny of the above +/- coagulation disorder

Haemorrhage – stop the bleedingHaemorrhage – 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

Suspected Uterine AtonySuspected Uterine Atony

Empty bladderGive Oxytocics (oxytocin,ergometrine,prostaglandin)

Massage uterus / bimanual compressionAortic compressionOngoing bleeding -- look for other causeOngoing bleeding– Uterine balloon tamponadeOngoing bleeding - EUA

- laparotomy

Oxytocic agents for treating uterine atony

Drug Dose Max dose Further doses

Cautions

oxytocin IM; 10 units

IV; slowly

2.5units

IV; infusion 20-40iu/

Litre

Avoid >3 litres of fluid containing oxytocin

IV bolus

ergometrine IM: 0.5mgms

IV: 0.2mgms

Repeat dose after 15 minutes

Total 1.0mg Hypertension, pre-eclampsia, heart disease

misoprostol 400-600mcgms sublingual or rectal

pyrexia

PGF2alpha Intramyometrial; 5mgms in 10 mls saline. Give 1ml

Repeat dose after 10 mins.

Total 2.0 mgms (4 doses)

Asthma, do not give IV

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

Haemorrhage - LaparotomyHaemorrhage - Laparotomy

Compression of the aortaCompression of the aorta

Uterine compression suture (eg B-lynch)Uterine compression suture (eg B-lynch)

Uterine vessel ligationUterine vessel ligation

HysterectomyHysterectomy

Prevention of PPHPrevention of PPH

Routine iron supplementation in pregnancyRoutine iron supplementation in pregnancy Anticipate / Be preparedAnticipate / Be prepared

Detect at risk women to deliver at referral hospitalDetect at risk women to deliver at referral hospital Available supplies - IV fluids, cannulae, oxytocics, Available supplies - IV fluids, cannulae, oxytocics,

misoprostol, blood transfusion servicesmisoprostol, blood transfusion services

Prevent prolonged labourPrevent prolonged labour Active management of third stage of labourActive management of third stage of labour Routine postpartum and post caesarean section Routine postpartum and post caesarean section

monitoring of vital signs and bleedingmonitoring of vital signs and bleeding

???

RECAPRECAPRecognising Obstetric HaemorrhageRecognising Obstetric Haemorrhage

CausesCauses

ManagementManagement

ProtocolProtocol

ABCABC

Blood replacementBlood replacement

Diagnosis of cause of bleedingDiagnosis of cause of bleeding

Methods to arrest haemorrhageMethods to arrest haemorrhage