You are caring for Rhyla following an induction of labour for past dates. Rhyla is a Para 1+0, single mother who had a Syntocinon infusion and required to have a forceps delivery. Following delivery of the placenta Rhyla feels dizzy and unwell. You check her sanitary pad, and it is soaked with blood. You check her blood pressure and pulse. The blood pressure is 80/50 mmHg and the pulse is tachycardic at 115bpm.
- What is the most likely cause of this bleed?
A postpartum haemorrhage.
- What factors led you to this conclusion?
She had 2 risk factors, a syntocinon infusion during induction of labour and a forceps delivery. She feels dizzy and unwell, her sanitary pad is soaked with blood. She’s also hypotensive and tachycardic.
- Demonstrate and discuss how you would manage this situation.
Help
Hi Rhyla, my name is Ayesha and I’m of the student midwifes. Is it okay if I check down below? You are bleeding more than we would like so I’m going to press the emergnecy buzzer for help. It will get busy in here but try not to panic as everyone is here to take care of you.
I want to press my emergency buzzer and put a double 2 double 2 call out as this is an obstetric emergency. Multi-professional management is important, so I want an obstetrician, senior midwife, anaesthetist, porter, haematologist, I want to make sure blood transfusion labs are aware and any other available staff.
SBAR and. flat
When the medical staff arrive in the room, I want to give them an SBAR. I’m going to say this is Rhyla, she’s having a postpartum haemorrhage. She is a para 1+0, a postdates induction of labour who recently delivered with a forceps. The placenta has also been delivered. Rhyla has soaked a pad and is feeling dizzy and unwell. She has a blood pressure of 80/50 and her pulse is 115.
I recommend that we assess using an ABCDE approach, AVPU and find the cause of the bleeding. So if someone could get the emergency trolley and PPH drugs.
I’m going to stay by Rhyla’s side and reassure her and her birth partner. I will calmly communicate what is happening. Demonstrate flattening the bed and removing pillows from underneath Rhyla.
I want to flatten the bed and remove all, but one pillows from underneath Rhyla to support venous return.
AB
I’m going to use the ABCDE approach to assess Rhyla and I want to secure her airway, breathing and circulation and assess the cause of the PPH. Airway
- How are you feeling Rhyla? Ive done my AVPU, Rhyla is talking and responding to the assessment. From this I know that her airway is clear. If she wasn’t managing her airway I could do a head tilt chin lift or a jaw thrust or I could insert a geudul airway.
Breathing
I’m then going to move on to breathing: so, I’m going to look, listen and feel for breath for 10 seconds. I’m thinking about the effort, the effect and efficiency of Louise’s breathing, so I’m going to apply a pulse oximeter. Her oxygen saturations should be between 96-99% on air.
- I’m also going to count Louise’s respiratory rate, so counting for 1 minute, observing the pattern, depth and symmetry of her breathing.
- I’m listening for inspiration and expiration sounds, any stridor or wheeze.
- As Louise is breathing, I’m going to administer oxygen through a trauma mask at 15 litres per minute. I want her oxygen saturations to be at 94-99% on oxygen.
- If she was not breathing, I would use a bag and mask to ventilate and administer artificial breaths.
C
o I’m going to specifically think of the cause of bleeding. I want to think about the 4 T’s:
for tone, I’m going to palpate rhylas uterus to see if its atonic.
For trauma, I’m going to thoroughly examine for trauma as Rhyla has had a forceps, so she likely has an episiotomy. I would ensure any trauma was sutured promptly to prevent infection and further bleeding.
For tissue, I know the placenta and membranes have been delivered so I’m going to ask someone to double check that they are complete to ensure there are no retained products preventing Rhyla’s uterus from contracting.
For thrombin, the blood appears to be clotting on the bed so I don’t think its thrombin, but that would be double checked with the blood results.
C - tone
I’m told that Rhyla’s uterus is boggy, broad, and high. I know that she is tachycardic, hypotensive and feeling dizzy. That’s going to suggest to me that an atonic uterus is the cause.
o I’m going to ‘rub up’ a contraction by massaging the fundus of the uterus in a gentle but firm motion with the fingers. This stimulates the uterus to contract down and aids expulsion of uterine contents of blood clots (if they are present) but also prevents bleeding from the living ligatures as they are constricted. I would have someone rubbing up contractions throughout this emergency but for the purpose of the OSCE im going to move away.
catheter and iv access
- Fluids
o I know that the placenta has been delivered so my next step is to ensure that her bladder is empty as this will encourage the uterus to contract. With consent, I will catheterise using an aseptic non touch technique. I’m inserting a 10-12 chanel foleys catheter and attaching a urometer, ensuring an output of more than 25 mls an hour. I don’t need to obtain a specimen of urine. I want to closely monitor fluid input and output for fluid balance. - IV access
o I also want to obtain IV access. With consent I’m going to insert 2 14–16-gauge cannulas using an aseptic non touch technique. I will apply a sterile dressing that will be dated, timed and the cannula will be flushed by a trained professional.
E
temperature and examining rhyla’s colour. She could be pale or clammy due to the haemorrhage.
Drugs
I want to administer uterotonic drugs to stimulate contraction of the uterus and stop the bleeding. Firstly, I’ll check what uterotonic drugs have already been given. I want to check that Rhyla has no allergies or contraindications prior to administering the drugs.
I could administer synotcinon 5iu IV or 10IU IM, syntometrine 1ml IM. I could give 500mcgs of ergometrine.
I want to be aware of any contraindications to ergometrine which are hypertension and cardiac disease.
I could also give 1-2g tranexamic acid IV slowly over 10 minutes.
(Carboprost/Haemabate 250 micrograms IM in thigh or uterine muscle repeated every 15 minutes to maximum of 8 doses / Misoprostol 800 micrograms rectally).
bloods and fluids
Bloods
o From the cannula I want to obtain FBC, urates, coagulation for clotting factors, Us and Es for kidney function, LFTs, and I want to crossmatch 4-6 units of bloods in case a blood transfusion is required.
o I want to think about fluid replacement as she is losing blood. I’ll commence an IV fusion of normal saline or Hartmann’s. A litre running stat.
o I want to start an IV infusion of synotocin at 40iu and 500ml of hartmans solution running at 125mls per hour. I’m checking the date on the bag.
observations
I also want to monitor rhyla’s observations every 5 minutes. Her blood pressure, temperature, pulse, respirations, oxygen saturations as well as the fluid balance. I’m going to document this on the MEWS chart to observe for any deterioration or improvement. I would want her oxygen sats to be above 94%, checking if her pulse is bounding which would suggest she is compromised, looking at her overall colour, her capillary refill should be no more than 2 seconds.
further measures
If the bleeding continued and Rhyla continued to feel unwell, and her blood pressure and pulse didn’t improve, I would move on to my emergency measures. When doing these I want to be aware that his will be painful for Rhyla so considering pain relief and reassuring her.
external bimanual compression.
We could do external bimanual compression. One hand is placed on the abdomen behind the uterus and one hand is placed on the abdomen on the front of the uterus. The uterus is then compressed and pulled up into the abdomen. This will compress the area of bleeding and it will straighten the uterine veins to allow blood to flow out and decrease congestion.
internal bimanual compression
If that didn’t work, we would move onto internal bimanual compression. That is conducted preferably if rhyla has anasthetic. One hand is inserted into the vagina in a cone shape and is directed up towards the anterior fornix of the uterus in a fist. The other hand is placed on the abdomen and the uterus is brought forwards and together towards the symphysis pubis. Both hands are compressed, and the uterus is squashed down at the placental site. This pressure is maintained until the uterus contracts or until taken to theatre.
abdominal aortic compression
We could also do abdominal aortic compression. This is very rarely used but I would use a fist above the woman’s abdomen at the top of the fundus and below the level of the uterine artery. Strong pressure is applied. The aim is to press the aorta against the spine and then decrease the blood flow to the uterus. If this manoeuvure was effective, you wouldn’t be able to feel femoral pulses. This is used in very severe haemorahges.
theatre
If that didn’t work, I would need to prepare Rhyla for theatre for surgical management.
I would use the MOVE acronym for moving to theatre.
This could include surgical measures, so you have a uterine tamponade using a rouge balloon or it could be done with packing. We could use compression sutures, eg b line sutures. Arterial ligation. Or a full hysterectomy.
Radiolocgial management could include a uterine artery embolization or internal iliac balloon catheters.
documentation
I want to acruately document
* Date and time of PPH.
* Cause of the PPH which was tone.
* Amount of blood loss.
* Key times actions were taken for example catheterisation or calling for help.
- Manoeuvres and the effects of these, as well as manouevres in theatre if she went to theatre and time of transfer to theatre.
* Time of drugs administered – name, dose, amount, and effect.
* Intravenous fluids administered – type and amount.
* All fluid output recorded – urinary and blood loss.
* Names of all staff involved in the care, when help was called for and when they arrived.
* Rhyla’s outcome.
* Future care.
* Legible signatures of midwife and medical staff.
