Primary PPH

Question 1

task

Answer 1

This 25-year-old primigravida had a normal vaginal delivery by the midwife 20 minutes ago in a
country District Hospital in which you are a Hospital Medical Officer (HMO), and currently on call
for the Obstetric Unit. The pregnancy had been perfectly normal. The labour was of 14 hours
duration. Only one dose of analgesia had been required. The estimated blood loss at delivery
was only about 250 mL. However a further 1500 mL of bright blood has been passed in the last
15 minutes. The midwife has just phoned you to advise you of these facts, and to ask you to come
and help with the patient’s care.
YOUR TASKS ARE TO:
* Ask the midwife the appropriate questions to define the probable cause of the
haemorrhage and to assist you to define what care is now required. You should not take
more than four minutes to do this task.
* Advise the midwife of what she should do between now and when you will arrive in the
delivery suite. You are currently at your flat which is ten minutes from the hospital.
* Advise the examiner of the most probable cause of the haemorrhage, and what you will do
when you arrive in the delivery suite.

Question 2

questions to ask nurse?

Answer 2

-Vitals : BP pulse
-labour : duration, mode, size of baby
-blood loss : amount 1500, pouring bright red, is it clotting
-episiotomy, any lacerations, perineal tear
-is ergometrine or oxytocin given
-ask about placenta : size , completeness
* I have not passed a urethral catheter.
* The uterus is central in position.
* The uterus appears slightly lax and extends 2 cm above the umbilicus.
* Total measured blood loss: 1500 mL so far.
* Haemoglobin one week ago: 120 g/L.
* Blood group: O Rh positive.
* She does not have an intravenous drip running.

Question 3

d/d

Answer 3

• Uterine atony.
• Genital tract laceration — vagina, cervix, uterine rupture.
• Retained placental fragment, cotyledon or membranes.
• A coagulation disorder.

Question 4

instructions to midwife

Answer 4

• Massage the fundus,
• Gain intravenous access if you can.
• Give intravenous or intramuscular ergometrine (0.25 mg) or intramuscular ergometrine and
  oxytocin (Syntometrine®)10iu immediately. Some candidates may suggest the use of a
  prostaglandin preparation given per rectum.
• Start transfusion rapidly with saline, Hartmann solution, or Haemaccel®.
• Take blood for cross-matching (good candidates would also request blood should be taken for
  coagulation studies as well).
• Pass a urethral catheter to ensure the bladder is empty.
• Observe any blood which is being passed to check whether it is clotting. :check for DIC

Question 5

what i will do

Answer 5

• As soon as I arrive, I will do the following unless the bleeding has substantially decreased. CALL MY SENIOR
  ~ Insert an intravenous drip if not completed by midwife — and commence or continue
  crystalloid fluids or Haemaccel® until blood is available.
  ~ Inspect the placenta myself to ensure it looks complete and normal.
  ~ Do a speculum examination to ensure there is no vaginal or cervical laceration which
  may require suturing.
  ~ Regularly monitor the vital signs to check the patient’s condition.
  ~ Give oxygen by mask.
  ~ Give blood as soon as available and cross-matched.
  -if bleed continues>add syntocinoe 25-50u/L>inform consultant obs>may require EUA as uterus not inverted
  -only after EUA>intramyometrial PG>sx methods int iliac hysterectomy