Case scenario 1

1. Immediate management
 Ensure a safe environment
 Take charge.
 Have one person go get senior obstetrician & have another person gather emergency
equipment & supplies (eg, emergency kit)
 Follow A-E approach
 Assess the airway – open the airway, check for obstruction, jaw thrust and chin lift. Add high
flow oxygenation (15L/min) as soon as possible and early intubation when a skilled person is
available
 Assess breathing by looking at movement of chest, listening and feeling for the movement of
air(no longer than 10 seconds). If the women is not breathing spontaneously then the next step
is to initiate assisted ventilation by facemask and ambu bag then later tracheal intubation can
be done .if spontaneous breathing is confirmed then she should be placed in the left lateral
position.
 Assess circulation – assess pulse, BP , capillary return .

- two large bore IV assess should be taken. Bloods should be taken and sent
-for hemoglobulin estimation, urea & electrolyte , liver function test , coagulation screen ,
blood culture and glucose.

 Disability –monitor patients GCS.

 Exposure – adequate exposure of a collapsed woman is essential for full assessment to avoid
missing vital information to make definitive diagnosis, which should include a vaginal
examination to exclude pathology. thus expose the patient to identify the bleeding sources.

2. Possible causes of mothers collapse

Causes Clinical features Determine cause

Hypovolemia -cold or clammy skin, Pale
skin, rapid, shallow
breathing, rapid heart rate,
little or no urine output.,
confusion, weakness.
Hypoxia -Shortness of breath, Fast
heartbeat, Coughing,
Wheezing, Confusion,
Bluish color in skin,
fingernails, and lips
Hemorrhage -Hypotension ,
tachycardia , visible
hemorrhage , reduced
consciousness , abdominal
-full body examination can
be done to find any
concealed bleeding &
electrolyte level can be
checked
-Check the spO2 by the
pulse oximeter
-Arterial blood gas test
-Full history and physical
examination to detect any
visible bleeding or CT scan
to check internal bleeding.
 pain or tenderness
(concealed bleeding)
Thromboembolism -Pulmonary embolism – PE- wells criteria &
chest pain , dyspnea , D- dimer test
tachycardia, hypotension Amniotic fluid
-Amniotic fluid embolism embolism – check
– profound hypotension, for coagulation
dyspnea , loss of profile , lung CT ,
consciousness, cardiac ECG.
arrest, tachycardia
Eclampsia -Grand mal convulsion -do dipstick urinalysis ,
,post ictal drowsiness, protein creatinine ratio,
hypertension, check the BP , u& E, serum
hyperreflexia urate

1. Etiology of vaginal bleeding

Causes Examination findings Intervention

1.Tone– atonic uterus -Immediate PPH 1.bimanual compression of uterus –
-70% -Uterus soft and not wear disinfected gloves, insert a
contracted , hand into the vagina and form a fist
-place the fist into the anterior
fornix, and apply pressure against the
anterior wall of the uterus. -with the
other hand, press deeply into the
abdomen behind the uterus, applying
pressure against the posterior wall of
the uterus
-maintain compression until bleeding
is controlled and the uterus
contracts.

2.pharmacologic measures – start

oxytocin infusion to maintain uterus
contraction- IV infuse 20units in 1 L
in N/S - infuse 500ml over 10mins
then 250ml/ hr.
-give 0.2mg- IM or IV (slowly)-
Ergometrine – to enhance uterine
contraction.

Surgical measures- if the bleeding

does not settle with the above
 measures then further options are
uterine artery embolization or
laparotomy with B-lynch hemostatic
suture, uterine artery ligation or
hysterectomy.
2.Trauma- tears of -Immediate PPH -examine the woman carefully and
cervix, vagina or -complete placenta repair tears to the cervix or vagina
perineum -20% -uterus contracted and perineum.
-if bleeding continues, assess clotting
status using a bedside clotting test.
Failure of a clot to form after 7
minutes or a soft clot that breaks
down easily suggests coagulopathy.
3.Tissue- retained -Portion of maternal -administer IV oxytocin
placental fragments - surface of placenta -manual removal of placenta with
10% missing or torn regional or general anesthetic and
membranes with prophylactic antibiotics in theatre.
vessels -Start IV oxytocin infusion after
-immediate PPH removal.
-uterus contracted
4.Thrombin – -immediate PPH Management of coagulopathy
coagulopathies (von consists of treating the underlying
Willebrand, disease process, serially evaluating
hemophilia A/ B) – 1% the coagulation status, replacing
appropriate blood components and
supporting intravascular volume,
using a massive transfusion protocol
if indicated.

Part 3
Additional blood products to transfuse
massive transfusion protocol to decrease the risk of dilutional coagulopathy and other
postpartum hemorrhage complications have been established. These protocols typically
recommend the use ratios of four units of fresh frozen plasma and one unit of platelets for
every four to six units of PRBCs.

Strategies to prevent PPH

The best preventative strategy is active management of the third stage of labor. This includes :
 1. administering oxytocin (10 IU IM or 5-10 IU IV bolus) with or soon after the
delivery of the anterior shoulder and
2. Cutting the cord after a delay of 1to 3 minutes
3. Controlled cord traction to deliver the placenta – to perform CCT, grasp the cord
with one hand and gently apply traction while simultaneously applying
suprapubic (not fundal) pressure with one hand (called brandt maneuver).
4. Uterine massage after delivery of the placenta.

Long term complications for this patient

Postpartum hypopituitarism (Sheehan syndrome)
PPH, especially that associated with prolonged hypotension and/or shock, can lead to pituitary
ischemia and necrosis. This can result in loss of function of the pituitary gland. Failure of breast
milk production is noted first. Other symptoms include: fatigue, amenorrhea, loss of pubic and
axillary hair, and low blood pressure. Lack of adrenocorticotropic hormone (ACTH) can lead to
adrenal failure, a life-threatening condition. Symptoms may not develop for years after
delivery. Lifelong supplementation with hormones: estrogen, progesterone, thyroid and
corticosteroids is the mainstay of therapy.

Case scenario 2

1. Retained placenta, defined as the failure of the placenta to deliver within 30

minutes after birth, occurs in less than three percent of vaginal deliveries.
Injecting the umbilical vein with saline and oxytocin (UVI) does not reduce the
risk of retained placenta. If the placenta does not deliver after 30 minutes,
manual removal of the placenta should be considered. If the patient is stable,
taking time to establish adequate analgesia is strongly recommended. This will
make the procedure easier to perform and will reduce the patient’s emotional
and physical distress.
This patient is in health center thus they should be stabilized and transferred to main
hospital for treatment.
To manually remove the placenta:
1. Cease uterine massage and allow the uterus to relax. Subcutaneous or
intravenous terbutaline 0.25 mg, intravenous nitroglycerin 100 to 200 mcg, or
general anesthesia may infrequently be required to relax the uterus. When
medications for uterine relaxation are administered the patient can lose large
 amounts of blood, so it becomes imperative to accomplish the removal rapidly
and then reverse the relaxation with oxytocic agents.
2. Identify the cleavage plane between the placenta and the uterine wall.
Advance your finger-tips in the plane until the entire placenta is free.
3. Cup the separated cotyledons into your palm. Deliver the placenta intact if
possible.
4. After examining the uterine cavity and the placenta to ensure that the entire
placenta and membranes have been removed, massage the uterus and give
oxytocin.If the cleavage plane cannot be identified or parts of the plane
cannot be developed completely, prepare for surgical removal of the placenta:
 Ensure that the patient has oxygen, two large bore intravenous catheters with
replacement fluids running, adequate anesthesia started, proper surgical
setup available, and appropriately trained providers present. Then, remove
placental tissue either by vacuum or blunt curettage.
 Curette the uterine cavity with a large blunt curette or large suction catheter.
Take care to pre-vent perforating the soft, postpartum uterus
 Use ring forceps to grasp and remove placental tissue.