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Obstetric Haemorrhage Aims To recognise Obstetric Haemorrhage To practise the skills needed to respond to a woman who is bleeding To achieve competence in those skills Haemorrhage is common Most common cause of maternal death worldwide Accounts for ~30% of maternal deaths Deaths from haemorrhage could often be avoided. (In SA, over 80% haemorrhage deaths are 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 often not recognized 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 Mother can lose up to 35% of circulating blood volume (2000 mls) before showing signs of hypovolaemia Haemorrhage – signs Pale Confused Increased HR, reduced BP FH abnormalities Reduced urine output Obvious or hidden bleeding WHEN SIGNS ARE THERE THEY ARE SIGNIFICANT, HAVE HIGH SUSPICION AND ACT QUICKLY! Haemorrhage - management Have an accessible protocol (poster form) ABCs C replace the volume and stop the bleeding Haemorrhage ABCs Circulation IV access by 2 large bore cannulae Send off blood samples Give iv fluids and blood if available Be aware of potential coagulation disorders NB: Establish the CAUSE of the Haemorrhage Pregnancy Abortion, ectopic, abruptio, praevia Labour Abruption, praevia, ruptured uterus After delivery (4Ts) uterine aTony, Trauma (cervical or perineal, or ruptured uterus) reTained placenta reTained products Post Caesarean bleeding Atony, trauma, placental site bleeding Any of the above +/- coagulation disorder 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 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 Oxytocic agents for treating uterine atony Drug Dose Max dose Further doses Cautions oxytocin IM; 10 units IV; slowly IV; infusion 20-40iu/ IV bolus 2.5units Litre Avoid >3 litres of fluid containing oxytocin ergometrine IM: 0.5mgms Repeat dose Total 1.0mg IV: 0.2mgms after 15 minutes Hypertension, pre-eclampsia, heart disease misoprostol 400600mcgms sublingual or rectal pyrexia PGF2alpha Intramyometri al; 5mgms in 10 mls saline. Give 1ml Repeat dose Total 2.0 after 10 mgms (4 mins. 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 - Laparotomy Compression of the aorta Uterine compression suture (eg B-lynch) Uterine vessel ligation Hysterectomy 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 ? ? RECAP Recognising Obstetric Haemorrhage Causes Management Protocol ABC Blood replacement Diagnosis of cause of bleeding Methods to arrest haemorrhage