OSCE stations

Question 1

First thing to do when called to a PPH by midwife

Answer 1

Say “OK this is a medical emergency and we need to call for some help, can you stay here with me and get one of the other midwives to call the consultant on call and tell him Emma is in hypovolaemic shock from a PPH, also let theater know to prepare for EUA +- bimanual compression”

Question 2

First ACTIONS to take when called to PPH

Answer 2

LOITE
Legs, Oxygen, IV, tests, empty bladder (IDC), examine

Get the midwife to elevate patient’s legs and put oxygen on high flow. Get another nurse to monitor BP, HR, O2 and urine output
Ask if we have IV access and if not we need 2 large bore cannulas
Get an IDC in
Group and hold, cross match, FBP, clotting screen
Assess uterus (massage fundus), check completeness of placenta, check genital tract for trauma and repair

Question 3

Causes of PPH with prevalence

Answer 3

Tone- 70%
Trauma- 20% (perineal, vaginal, cervical)
Tissue- 10% (retained placenta)
Thrombin- <1% (coag defect)

Question 4

RFs for PPH

Answer 4

Grand multi (>6 kids)
Uterine overdistension- twins, polyhydramnios
Uterine exhaustion- long labour, precipitate labour
Assisted or operative delivery
History of APH
Abnormal placentation
Intra-amniotic infection
Previous PPH

Question 5

Best way to reduce PPH?

Answer 5

Anticipate and prevent-active management of 3rd stage reduces PPH by 2/3rds
In high risk patients- Prophylactic oxytocin infusion immediately after delivery (30 units of syntocinon in 500mL of Hartmann’s run at 120mls per hour)

Question 6

What is prophylaxis oxytocin dose for preventing PPH?

Answer 6

30 units in 500mL of hartmann’s run at 120mL/hour

Question 7

Important questions to ask when called to PPH?

Answer 7

How much blood do you think she has lost?
Has the placenta been passed? Is it complete?
Has she had syntocinin or ergometrine?
Have you massaged the uterus?
Does she have clotting disorder we know of?

Question 8

What do we need to examine

Answer 8

Vital signs
Assess uterus for tone- massage fundus
Check initial prophylactic oxytocin given
Check completeness of placenta
Check genital tract for trauma and repair
Empty bladder- IDC

Question 9

What drugs do we order in PPH?

Answer 9

Synot, Ergo Miso

Question 10

What is dose of Misoprostol in PPH?

Answer 10

1000mcg PR

Question 11

What is dose of syntoconin in PPH?

Answer 11

30 units of synto in 500mL hartmann’s at 240MmL/hr

Question 12

When is ergometrine contraindicated?

Answer 12

In hypertension

Question 13

What is the dose of ergo in PPH?

Answer 13

500mcg

250 IM stat and 250 added to synto infusion

Question 14

Oxygen dose in PPH?

Answer 14

8L/min

Question 15

When to go to theatre in PPH?

Answer 15

> 1000mL haemorrhage or does not stop/cause not obvious

Placenta retained >30 minutes

Question 16

Extra management of PPH in theatre?

Answer 16

BPELT

Bimanual palpation
Prostaglandin F2 alpha
Tamponade with balloon catheter (BAKRI)- filled 30mL saline
Laparotomy- B-lynch suture, ligation uterine/internal iliac arteries, hysterectomy
Embolisation of uterine arteries

Question 17

What is the name of the balloon catheter and how does it work?

Answer 17

Bakri- large balloon opposes lining of uterus and downward traction then helps stop bleed.

Question 18

How long do you leave bakri in for?

Answer 18

24 hours

Question 19

How common is PPH

Answer 19

5%

Question 20

What is appropriate fluid management in PPH?

Answer 20

1L of blood loss= 1L colloid replacement

Up to 3.5L is max fluid admin (blood should then be available)

Question 21

name two types of crystalloid?

Answer 21

Normal saline and Hartmanns

Question 22

Name two types of colloid?

Answer 22

gelofusion, volvulen

Question 23

What is difference between coloid and crystalloid?

Answer 23

Colloids exert oncotic pressure but are far more expensive

Need 4L of crystalloid to replace 1L of blood but only 1L of colloid