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Obstetric Haemorrhage

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

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Obstetric Haemorrhage

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  1. Obstetric Haemorrhage

  2. Aims • To recognise Obstetric Haemorrhage • To practise the skills needed to respond to a woman who is bleeding • To achieve competence in those skills

  3. Haemorrhage is common • Most common cause of maternal death worldwide • Accounts for ~30% of maternal deaths • Deaths from haemorrhage could often beavoided. (In SA, over 80% haemorrhage deaths are avoidable)

  4. 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

  5. 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

  6. Haemorrhage – signs • Pale • Confused • Increased HR, reduced BP • FH abnormalities • Reduced urine output • Obvious or hidden bleeding

  7. WHEN SIGNS ARE THERE THEY ARE SIGNIFICANT, HAVE HIGH SUSPICION AND ACT QUICKLY!

  8. Haemorrhage - management • Have an accessible protocol (poster form) • ABCs • C replace the volume and stop the bleeding

  9. 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

  10. 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

  11. 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

  12. 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

  13. Oxytocic agents for treating uterine atony

  14. 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

  15. Haemorrhage - Laparotomy • Compression of the aorta • Uterine compression suture (eg B-lynch) • Uterine vessel ligation • Hysterectomy

  16. 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

  17. ? ?

  18. RECAP • Recognising Obstetric Haemorrhage • Causes • Management • Protocol • ABC • Blood replacement • Diagnosis of cause of bleeding • Methods to arrest haemorrhage

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