Major Obstetric haemorrhage Miss Melanie Tipples

 Understand the definition and causes of major haemorrhage  Recognise and manage a collapse from haemorrhage  Understand the surgical and pharmacological options for management of haemorrhage Objectives

 Major cause of morbidity and mortality for all pregnant women through pregnancy and in post partum period  Reduction in deaths in last triennial report but still major cause of death  Substandard care found in 3 out of five cases (no obs, concealed bleeding not considered)  MEOWS charts for 24 hours post section and need for action where abnormalites found Haemorrhage

 Major Obstetric Haemorrhage is defined as the loss of more than 1000mls of blood either antepartum or post partum Definition

 T – Tone (multiple causes both fetal and maternal)  T – Tissue Retained tissue (placenta or products)  T - Trauma Genital tract injury, broad ligament haematoma, uterine rupture  T- Thrombin ie coagulopathy secondary to haemorrhage, abruption, sepsis, eclampsia or dead fetus, amniotic fluid embolus  It can be caused by one or more of the above Causes

 Identifying you have a problem – look for signs of shock (concealed or revealed)  Pulse, respiratory rate, peripheral perfusion, urine output  Remember blood pressure drops late  Acidosis and confusion/drowsy Management

 Communication and documentation  Call for help  Resuscitation (ABC)  Fluid replacement  Arresting the bleeding and obstetric intervention  Monitoring and investigation  Anaesthetic inpurt Management

 MAJOR OBSTETRIC HAEMORRHAGE CALL  Make sure you know what that means in your hospital  Allocate a team leader TEAM APPROACH

 A – Oxygen  B – Assess  C – two large bore cannulas (grey) and take bloods for FBC, u&es, coag, and cross match. Commence ward colloid infusion  Place on oximeter, BP cuff, Insert catheter Rescucitation

 Bimanual compression of uterus  Empty bladder Management -Tone

 Syntocinon 5 units  Ergometrine 0,5mg iv/im  Sytocinon 40 in 500mls n/saline  Carboprost 0.25mg im every 15 minutes to a max of 8 injections  Misoprostol 600 microgrammes oral or pr (asthma or home deliveries) Tone - pharmocology

 Tamponade balloon  Haemostatic brace lynch suture  Selective arterial embolization Tone – surgical tecniques

 Failure to respond to pharmolocogical techniques, intermittent relaxation or suspicion that the placenta is incomplete should prompt examination of the uterine cavity under anaesthetic Management - Tissue

 Surgical exploration and repair  If repair not possible Hysterectomy may be indicated  Timely definitive surgery has been shown to be associated with best outcome Management - Trauma

 Involve Haematologist and MLSO early  Update them regularly  Remember to stand them down Management - Thrombin

 Documentation  Datix  Debrief  Follow up patient and arrange support Post Haemorrhage

 Systematic approach and team working has been shown to improve outcome in the most recent CMACE report Summary