Quality Education for a Healthier Scotland

Multidisciplinary

Obstetric Haemorrhage

Promoting multiprofessional education and development in Scottish maternity care

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MultidisciplinaryContent

• Antepartum haemorrhage

• Abruption• Placenta Praevia• Vasa praevia• Uterine rupture

• Postpartum haemorrhage

• Uterine inversion

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Antepartum haemorrhage

• Consider

• Abruption• Placenta Praevia• Vasa praevia• Uterine rupture

• Idiopathic

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MultidisciplinarySaving Mothers’ Lives 2011

9 women died due to haemorrhage in 2006 – 2008, incidence of 0.39 per 100,000 maternities.

Severe Haemorrhage occurs in 1:200-250 deliveries

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Contributing Causes

6 (66%) of these women received sub-standard care in due to failures in:

• Ultrasound had not been performed despite previous history of Caesarean section

• Multiprofessional management of placenta percreta.

• Women who have a C/S must be on a MEOWS chart and abnormal recordings acted upon

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Placenta percreta/accreta

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MultidisciplinaryCauses: Placental abruption

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MultidisciplinaryCauses: Placenta praevia

Grade 1 Grade 2 Grade 3 Grade 4

Minor Major

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Causes: Vasa Praevia

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MultidisciplinaryCauses: Uterine Rupture

• Virtually never occurs in primigravidae.

• Associated with:• obstructed labour in multiparous patients • induction using prostaglandins• following previous cesarean section

(9:1000 VBAC)• Obesity

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MultidisciplinaryCauses: Uterine Rupture

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MultidisciplinaryManagement of APH

Dependent on:

• amount of bleeding

• maternal and fetal condition.

Major haemorrhage:

• Resuscitate mother

• Immediate delivery

• LUSCS if fetus alive

• Vaginal delivery may be appropriate if fetus dead.

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Risk Factors:

Grand multiparityMultiple pregnancyProlonged labour FibroidsPlacenta praevia Placenta accretaAPH Previous PPHRetained placenta Bleeding disorder.

Postpartum Haemorrhage

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Recognise

Act on clinical signs – do not wait for laboratory results.

Look for shock (pallor, tachycardia, hypotension). Note: hypotension may not be apparent until approx 1.5 litres lost

Beware the “trickle”

Measure blood loss accurately!

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MultidisciplinaryPPH Management

• Call Help – most senior available• Nurse flat• Airway (facial O2)• Breathing (Respiratory rate, SaO2)• Circulation (HR, BP, refill time)• 2 wide bore cannulae Bloods FBC, XM,• IV crystalloid 2 litres – fast• Compression

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MultidisciplinaryPPH (Continued)

• Syntocinon 5 units slow bolus + Infusion• Ergometrine 500 micrograms IM/IV slowly• Carboprost (Hemabate) 250 micrograms IM (not

IV) max 8 doses• Misoprostol 800 micorgrams PR• Bloods FBC, XM,• Coagulation screen• Catheter

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MultidisciplinaryPPH

Consider cause 4Ts

• Tone

• Trauma

• Tissue

• Thrombus

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MultidisciplinaryPPH

Consider alternative measures to arrest bleeding

• Rusch Balloon• Vaginal pack• B-Lynch• Hysterectomy• Embolisation

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MultidisciplinaryRusch Balloon

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MultidisciplinaryB-Lynch Suture

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MultidisciplinaryEmbolisation

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MultidisciplinaryUterine Inversion

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MultidisciplinaryUterine Inversion

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Any Questions?

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Key Points

React ahead of loss - think big

Get big people involved early

Beware the postpartum ‘trickle’.