1. Major Obstetric haemorrhage Miss Melanie Tipples

2.  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

3.  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

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

5.  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

6.  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

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

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

9.  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

10.  Bimanual compression of uterus  Empty bladder Management -Tone

11.  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

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

13.  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

14.  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

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

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

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