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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Multidisciplinary
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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Multidisciplinary
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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Multidisciplinary
Any Questions?
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Multidisciplinary
Key Points
React ahead of loss - think big
Get big people involved early
Beware the postpartum ‘trickle’.