PPH Flashcards
Scenario
You are caring for Rhyl’s following an induction of labour for past dates. Rhyla is a Para 1+0,single mother who has a syntocinon infusion an 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 bP is 80/50 and the pulse is tachycardic at 115bpm.
What is the most likely cause of this bleed
PPH
What factors led you to this conclusion
Indication of labour
Forceps delivery
Unwell and dizzy
Pad socked with blood
Low BP
Tachycardic
demonstrate and discuss how you would manage this situation
introduce myself
check pads- confirm PPH
Push emergency buzzer
Call 2222- obstetric team, charge midwife, anaesthetist, hemotogist and inform blood bank.
Give SBAR to the team- recommendation- ABCDE ,cannulation, catheterise, stop bleeding
Get emergency trolly
PPE
Lie her flat and remove pillow to help blood circulation
Begin to rub up a contraction continuously- fro purpose of osce this isn’t possible
AVPU and ABCDE
AVPU- ask how she’s feeling an asses if she’s alert and talking or of not is she reacting to pain or if she’s unconscious.
Airway- if she’s talking she must be maintaining her own airway
If this wasn’t the case i can do a head chin tilt lift, i can do a tongue sweep if there was an obvious obstruction.
Can insert a guadel but sizing up, putting in upside i down as a tongue depressor and then turning don to insert fully
Breathing
Look listen and feel
Look fro chest wall movement and that is it symmetrical.
Listen for any strider or wheezing
Feel the breaths on the side of your cheek
Administer 15l of oxygen through a trauma mask
Count respiration between 12-20
4 TS
while rubbing up the uterus asses 4 Ts
Trauma check is she has any tears- there was a 2nd degree but has been sutured
Tone- check if the uterus feels a tonic- it is and uterus is sitting broad and high ( cause of the PPH)
Tissue- check placenta and membranes are complete and there is no retained placenta in situ.
Thrombin- there is clotting as blood is coming out so unlikely to be the cause however will be check when bloods sand sent
Circulation
due to suspected tone causing PPH
Venous access is required- grey wide bore 14/16 gauge cannulas, both arms, sterile non touch technique, sterile dressing ,date and times, flushed by trained professional
Take bloods off the back of the cannula- full blood count (hemoglobin, white cell count and platelets) group and save, lft, coagulation, us and es, cross match. Sent to labs
Take a full set of observation- BP, sats, rasps, pulse, colour, capillary refil- on mews chart every 5mins
Hang two bags of hartmans- check they are in date and not contaminated- running stat
Insert a catheter- size 10-12 in dwelling, non touch a septic technique, with consent and attach a uromieter fro fluid output- over 25mls per hour and document of fluid balance chart.
Administer drugs- uteri tonic drugs- 10IU IM of syntocinon, can also give 500mg or ergomentrin
or a 1ml of syntometrin ( can’t give these if any high BP problems). Administer transamix 1g slow IV bolos. Hang a bag of syntocinon 40IU in a 500 ml bag of heartmans at 125mls per hour. Can also give mysoprostil 800mcg PR and carboprost 250mcg ( can be given up to 8 doses 15 mins apart)
Continuously checking blood loss- can give a bag that’s been cross match or a at of 0- in emergency.
Emergency manoeuvres
IF drugs aren’t helping uterus contract need to go onto emergency manoeuvres.
External bi manual compression- one hand o top of uterus and one underneath, compress in and up towards the abdomen, trying to straighten uterine veins to stem bleeding.
Internal bi manual compression- put my hand in a cone shape, insert my whole hand and then create a first when entered and up to the anterior fosixs , use my other hand to hold the fundus down on top of my first to compress placenta site- only used as a temporary measure until into theatre.
Abdominal aortic compression- above fundal above l1 an l2 and push my first down directly onto the aorta- would stop blood flow- can check this is working by checking there is no femeral pulses
If none of the above worked- prepare rhyla for theatre
MOVE
Move- on the bed
Oxygen- use a portable tank as she has 15 litres on
Venous- already have venous access
Expertise- will all be ready in theatre for arrival
Emergency procedure in theatre
Uterine tamponade using a rush ballon to compress placenta site.
uterine Gauze packing
Uterine suture- suture round the uterine to stop bleeding
Pelvic vessel ligation
Hysterectomy
Radiological procedure
Uterine artery embolisation
internal iliac ballon catheter
Disability
continuously asking her questions to ensure she is alert and not unconscious
Exposure
Check her temperature- document on mews chart
Check how she feels
Her colour
Documentation
When PPH was diagnosed- date and time and cause
when help was called
emergency buzzer
who attended
when they attended
what roles they did
When cannulation and catheter was insterted
fluids
Drugs- name, dose, route, effect
observation on mew chart
Fluid balance chart
Measured blood loss
Manoeuvres carried out
maternal outcome- future care
Time dated and signed
