1. Post-partum evacuation

2. Scenario A 24 year old patient delivers a 3,2kg healthy boy.
10 iu Oxytocin is administered IMI and breast feeding is initiated together with delayed cord clamping.
The placenta is delivered.
You notice that the patient is bleeding heavily vaginally. What do you do?

3. Shake and shout: The patient is alert Call a CAB
Circulation: Pulse rate 100 bpm, BP 90/60 mmHg
Airway: Patient is talking spontaneously
Breathing: Breathing rate is 16 bpm
Call for help
IV access with 2 large bore IV cannulas (18 G or bigger)
20 iu Oxytocin in 1 litre Ringers lactate to run at ml/hr
Rub up uterine fundus. The uterus contracts
Insert a urinary catheter
Inspect the genital tract for local trauma causing bleeding. Nothing is found
Inspect the placenta

4. Cotyledon missing

5. What do you do now? Prepare for evacuation in theatre
Call a CAB: Circulation: Pulse rate 101 bpm, BP 115/70 mmHg
Airway: Patient is talking spontaneously
Breathing: Breathing rate is 16 bpm
Face mask O2
Keep the patient warm
Secondary survey

6. Big 5
CNS: alert
CVS: BP 110/70 mmHg P 90 bpm
Resp: RR 16 bpm
Hepatic and GIT: Normal
Renal: Clear urine in urine bag
Forgotten 4
Haematological: ward Hb 7,0 g/dL thus order blood
Immunological: Temp 36.5 Keep patient warm
Endocrine: Glu 4.2 mmol/L
Musculoskeletal: calves soft and not tender
Core 1
Still bleeding actively

7. Discuss patient with the anaesthetist and theatre team
Counsel and obtain informed consent for manual removal of placenta and evacuation in theatre
Discuss patient with the anaesthetist and theatre team
Preoperative medication:
Metaclopramide 10mg IVI
Antacid eg Sodium Bicarbonate po
Single dose prophylactic antibiotic, preferably second generation Cephalosporin
Type and screen blood for transfusion
Take patient to theatre

8. In theatre Patient has spinal anaesthesia
Illustrate how you will do the evacuation

9. After the evacuation the patient continues to bleed heavily.
What do you do now?

11. Documentation