Post-partum haemorrhage

Question 1

What are the 4 Ts of PPH?

Answer 1

The differential diagnoses for PPH cause:

1. Tone - uterine atony
2. Tissue - retained placenta/products
3. Trauma - genital tract or cervical tear
4. Tendency to bleed - coagulopathy, amniotic fluid embolism

Question 2

What is the preferred anaesthetic technique for PPH?

Answer 2

GA with RSI is often indicated

A functioning epidural top-up could be appropriate if the patient is haemodynamically stable

For pts with a retained placenta who are otherwise stable - a spinal may be appropriate

Question 3

Outline possible induction agent choices and give dosages

Answer 3

Thiopentone for classic RSI -> 3mg/kg

Propofol RSI -> 2.5mg/kg

Ketamine (esp if haemodynamically unstable) -> 2mg/kg

Question 4

What are the first steps in management of a PPH once notified by O&G team?

Answer 4

1. Call for senior help
2. Review patient in birth suite and commence preparation - can start epidural top-up
3. 100% O2
4. Secure large bore IV access x2 and ensure X-match has been sent
5. Request insertion of IDC if not already insitu
6. Rapid anaesthetic assessment
7. Give sodium citrate 30mLs
8. Return to OT and prepare (if not topping up epidural)

Question 5

What drugs should be ready in OT?

Answer 5

• Warmed fluids - crystalloid or colloid
• Induction agent
• Suxamethonium (or Rocuronium)
• Oxytocics - Oxytocin, Ergometrine, Dinoprost, Misoprostol
• Vasopressors - Ephedrine, Metaraminol, Phenylephrine, Adrenaline
• Antibiotics - Cephazolin, Metronidazole
• Analgesia
• Anti-emetic/Prokinetic

Question 6

Outline management once patient arrives in OT

Answer 6

1. Calm the room
2. Continue fluid resuscitation
3. RSI if planned for GA
4. Contact blood bank and arrange for delivery of blood or activation of MTP
5. Monitor temperature and keep warm
6. Consider IAL and CVL if time allows
7. Replace factors/FFP/platelets as required
8. Ongoing monitoring of resuscitation success
9. Transfer to ICU/HDU or specialled on birth suite once stable