Transcript File
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
Deaths from haemorrhage could often be
avoided. (In SA, over 80% haemorrhage deaths are
avoidable)
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
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
Haemorrhage – signs
Pale
Confused
Increased HR, reduced BP
FH abnormalities
Reduced urine output
Obvious or hidden bleeding
WHEN SIGNS ARE THERE THEY ARE
SIGNIFICANT, HAVE HIGH SUSPICION
AND ACT QUICKLY!
Haemorrhage - management
Have an accessible protocol (poster form)
ABCs
C replace the volume and stop the
bleeding
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
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
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
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
Oxytocic agents for treating uterine atony
Drug
Dose
Max dose
Further
doses
Cautions
oxytocin
IM; 10 units
IV; slowly
IV; infusion
20-40iu/
IV bolus
2.5units
Litre
Avoid >3
litres of fluid
containing
oxytocin
ergometrine
IM: 0.5mgms Repeat dose Total 1.0mg
IV: 0.2mgms after 15
minutes
Hypertension,
pre-eclampsia,
heart disease
misoprostol
400600mcgms
sublingual or
rectal
pyrexia
PGF2alpha
Intramyometri
al; 5mgms in
10 mls saline.
Give 1ml
Repeat dose Total 2.0
after 10
mgms (4
mins.
doses)
Asthma, do not
give IV
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
Haemorrhage - Laparotomy
Compression of the aorta
Uterine compression suture (eg B-lynch)
Uterine vessel ligation
Hysterectomy
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
?
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RECAP
Recognising Obstetric Haemorrhage
Causes
Management
Protocol
ABC
Blood replacement
Diagnosis of cause of bleeding
Methods to arrest haemorrhage