Download Obs-Gyn OSCE Post Partum Haemorrhage: General inspection

Obs-Gyn OSCE Post Partum Haemorrhage:
General inspection:
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Time since parturition: is this an early or delayed PPH? Is this a still-open caesarean?
Vitals: Temp, Pulse, Respiration, BP, capillary refill
How much blood has already been lost? What management has already been attempted?
Call for help
Relevant history:
o Placenta location and nature (praevia, accrete)
o Medications, recent FBE / Hb
Examine:
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Assess for haemodynamic and emergency stability:
o Airway / Breathing / Circulation
o BP / HR
Ensure that blood samples have already been taken, check for group / hold / cross-match / prior Hb level
Examine and identify site of bleeding:
o Uterine (through the os)
Manage:
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Pressure on the uterus:
o External as fundal pressure / massage
o Internal as direct fist pressure. Bimanual compression
Ensure IV access: 2x 16-18G cannulas, cubital fossae.
Notify blood bank – prepare for massive transfusion if required.
Medical management to increase uterine tone:
o IV syntocinon
o IV prostaglandin F2a
o IV ergometrine
Clearance of any retained POC:
o Manual evacuation of uterus
Reassess for amount of blood loss:
o Get blood ready for transfusion if required
o Get blood sample to check coagulation factors and platelet count, consider platelet transfusion.
o Give IV bolus of crystalloid to ensure adequate perfusion
Bakri (intra-uterine) balloon placement, warn theatre that emergency operation may be required
Operative management:
o Ligation of specific isolated vessel(s)
o Endovascular embolization
o Ligation of multiple vessels
o Uterine strapping
o Hysterectomy
Other questions:
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Cause of early PPH: retained POC, coagulopathy, uterine / cervical / vaginal tear,
Cause of late PPH: coagulopathy, sloughing of scar, infection, retained POC
Risks of severe PPH: pituitary infarction, renal failure, ARDS
Risks of treatment: subfertility / infertility, loss of uterus, loss of ovaries (and resultant surgical menopause)
Definition: >500mls of haemorrhage, either first 24hrs, or beyond 24hrs
Risk factors for PPH:
o Twins, polyhydramnios, macrosomia
o Placenta praevia, placenta accrete (absence of decidua layer), retained products of conception
o Prolonged 1st or 2nd stage, instrumented delivery, natural 3rd stage of labour
o Uterine abnormalities or POC disrupting uterine contractions
o Pre-existing anaemia, coagulopathy, haemophilias
o Prior PPH, prior uterine procedures / instrumentation, uterine abnormalities