Obstetric

Haemorrhage in a
Resource-poor
Setting

Max Brinsmead PhD FRANZCOG

July 2018
Obstetric haemorrhage is...

 The major cause of maternal death in

resource-poor countries

 The risk is increased by:

 Severe anaemia
 Other medical & obstetric conditions
 Poverty
 Transport problems
 Cultural & religious practices
Although the average gravida’s blood
volume is expanded by 1.5L and all clotting
factors are increased...

 Blood loss of 10% or >500ml →Tachycardia

 Loss of 25% or 1250ml→Vasoconstriction
 Pale & cold extremities
 Weak, thready pulse
 But systolic BP may be maintained
 Loss of 33% or 2000ml →Hypotension
 Sweating, pallor, thirst & oliguria
 Greater blood loss → Risk of organ damage
 Air hunger, restlessness & confusion
 DIC and ARDS
 >50% loss of blood volume → Cardiorespiratory
arrest
Beware of the patient who survives large PPH
elsewhere and arrives 24 – 48 hours later

 May have a Hyperkinetic Circulation…

 Rapid, full volume pulse

 Normal BP
 However JVP is raised and there are basal lung creps

 This is anaemic Congestive Cardiac

Failure…

 And requires careful transfusion with IV

Frusemide
After major obstetric haemorrhage the first priority
is adequate IV access

 14G peripheral line

 Use hot towels to vasodilate
 Ideally one in each arm
 Femoral vein puncture next best option

 Jugular vein line with CVP is even better

 Long saphenous cutdown next option

 Femoral Artery catheterisation may be

required

 Pressure suit may be a first aid

alternative
Jugular Vein Catheterisation
 Position supine with 15 degree head-down tilt, head
to the left
 Skin asepsis, Lignocaine 1%
 Identify the two heads of the sternomastoid muscle
 Incise the skin at the apex of these muscles
 The vein is deep to the clavicular head of this
muscle and lateral to the carotid artery at the level
of the cricoid cartilage
 Use 16G cannula attached to 5 ml syringe
 Advance subcutaneously at 30-degree angle
towards the nipple
 Aspirate until the vein is reached
 Attach manometer which should oscillate with resps.
 Complications:
 Pneumothorax
 Air embolism
 Arterial puncture
 Haematoma
 Sepsis & thrombosis
Femoral Vein Catheter
 Supine position, inguinal region exposed
 Skin antisepsis and drape
 Identify the inguinal ligament and femoral vein pulsations
 Mark a point 1 cm above the ligament & 0.5-1.0 cm
medial to the arterial pulsations
 Infiltrate with 1% Lignocaine
 With a 26G finder needle and 5 ml syringe
 Advance cephalically at an angle of 45 degrees
 When the vein is identified by the flash of blood use a
22G needle with catheter immediately above or below the
finder needle
 Advance the catheter when the vein is reached
 Secure
 OR
 Omit the finder needle and proceed with the larger
Intracath on a 10 ml syringe
 Complications:
 Arterial puncture
 Haematoma
 Femoral Nerve Damage
Femoral Vein Catheterisation
Saphenous vein cut down
 Position supine, leg restraint, tourniquet desirable
 Skin asepsis, Lignocaine 1%
 The vein is 2 cm above and 2 cm anterior to the
medial malleolus
 Incise the skin transversely
 Identify the vein by dissection with fine arterial
forceps, separate from adjacent nerve and strip
clean for 2 cm
 Place two loops of silk behind the vein
 Tie off the distal end and loose tie the proximal
 Open the vein with iris scissors or scalpel, using
traction on the distal suture
 Tourniquet release
 Introduce a blunt plastic cannula, advance and allow
blood to backflow, tighten the upper silk ligature
 Suture secure and close the skin
 Complications:
 Infection
 Delayed healing & keloid scar
Saphenous vein cut down
It is desirable to...
 Check that your cannula is in a vein before
commencing infusion
 Check by blood aspiration
 X-ray for CVP placement
 The zero mark of a CVP is aligned with the
level of the R. atrium
 5 – 8 cm of H20 is normal
 Begin infusion with Hartmanns
 But only 700 ml of each litre remains
intravascular
 Albumin is the best colloid but Gel-fusion is
a good substitute
 Blood is best
 May require delivery pressure
 Fluid warming desirable
Your patient is stabilised when...

 Systolic BP is > 100 mm

AND

 Pulse rate is < 100 / min

 Put in a bladder catheter to monitor urine output

 CVP is better, of course

Placenta Previa
 After appropriate resuscitation delivery is indicated
when…
 The fetus is mature
 The fetus is dead or severely malformed
 Continuing haemorrhage threatens
 The patient is unwilling or resources prevent continuing
hospitalisation
 Examination under anaethesia → Caesarean if…
 The placenta is palpable through 2 or more fornices
 The presenting part cannot be brought into the pelvic brim
 During Caesarean Section…
 Lower segment preferred
 Consider ligation of major vessels
 Go above the placenta to perform ARM & delivery
 Use Green-Armytage to control bleeding after incision
 A place for bipolar version and bringing down a leg
 Requires > 4 cm dilation of the cervix
 Attach a 1.5 Kg weight to the ankle
 The buttock compresses the placenta
 While the thigh dilates the cervix
 Don’t attempt delivery until fully dilated
Placental Abruption
 If the Uterus is > Dates or…
 The fetus is dead then…
 Assume major blood loss
 As a guide to fluid replacement:
 If the BP is 100 mm give 1,000 ml
 If the BP is <80 mm give 2,000 ml
 Plan delivery if >36 weeks
 Examination under anaesthesia may be required
 An early recourse to CS maybe life saving for the fetus
 But do not begin CS until resuscitation is complete and
coagulation has been checked
 A rapid infusion of cryoprecipitate and platelets is desirable
 Aim for vaginal delivery by amniotomy and oxytocin
infusion when there has been fetal death
 But monitor coagulation and
 Prepare for PPH
Postpartum Haemorrhage
 Begin aggressisve Rx earlier when there is…
 Severe anaemia (HB <7.0)
 Severe pre eclampsia
 Prolonged labour
 Principles:
 Secure adequate IV access ASAP
 Empty the uterus
 Contract the uterus by oxytocics
• Ergometrine, Heat-stable Carbetocin, Rectal Misoprostol
 Bimanual uterine compression or
 Aortic compression
 Compress the bleeding site
• Pack the vagina
• Intrauterine balloon tamponade
 Surgical options
 Internal iliac artery ligation
 B-Lynch suture
 Hysterectomy
 Uterine artery embolisation
Intrauterine Balloon Tamponade
BJOG Review May 2009
 Was effective in 91.5% of cases
• Combined retrospective and prospective studies
• But only a total of 106 patients
 Types of balloons
• Sengstaken Blakemore (GI use)
• Rusch (Urological)
• Foley (often multiple)
• Bakri (Specifically designed for obstetrics)
• Condom (+/- Foley)
 But there remain many unanswered
questions
Questions concerning intrauterine balloon
tamponade
BJOG Review May 2009
 Is it effective
• There are no RCTs
 Risks and contraindications
 Which balloon to use, how to insert it
and what volume to inflate it
 Is a vaginal pack required
 Is an oxytocin infusion required
 Antibioitics and analgesia
 When to deflate and or remove it
B-Lynch Suture

 Use lithotomy in order to assess vaginal bleeding

 Empty the bladder
 GA and laparatomy
 Expose the lower segment
 Exteriose the uterus – open CS incision if present
 Tie off any obvious bleeders
 Compress the uterus manually to assess likely response
 Use 70 mm needle and No. 2 chromic catgut or Vicryl
 Go in anteriorly 3 cm above right lower edge and 3 cm towards
midline, through the uterine cavity and up vertically 3 cm
 Go through the posterior uterine wall – now 4 cm from the
lateral edge of uterus
 Take the suture posteriorly over the top of the uterine fundus
 Bring the suture to the same UPPER point anteriorly
B-Lynch Suture (2)

 Re enter the uterine cavity and go laterally then out posteriorly

at a corresponding point on the left side
 Go over the top of the uterus on the left side
 Re enter the uterine cavity at the corresponding upper anterior
point
 Then out at the corresponding lower anterior point.
 Tie anteriorly below the CS incision with manual compression of
the uterus
 Re suture the CS incision
 For bleeding from the lower uterine segment (after placenta
previa) put figure of 8 sutures anteriorly and or posteriorly
BEFORE the B-Lynch suture
B-Lynch Suture Technique
When a patient presents with a retained placenta
of >24 hours...

 First resuscitate, transfuse and give antibiotics

 Delay placental removal (for up to 48 hrs if required)
 Prepare for morbid adherence of the placenta

 During EUA after PPH always consider…

 The possibility of uterine rupture

 For secondary PPH up to 7 days after birth…

 Uterine “curage” with 2 fingers is safer

 For secondary PPH more than 7 days after birth…

 Suction is safer than traditional curette
 And remember to give antibiotics for sufficient time
before EUA to control generalised sepsis
Renal Failure after Obstetric Haemorrhage
 Diagnosis…
 Less than 400 ml urine in 24 hours

 Beware of toxicity from any drugs usually

excreted by the kidneys

 Avoid fluid and sodium overload during the

oliguric phase
 Strict fluid balance
 Mannitol or Frusemide
 Bicarbonate infusion for acidosis
 Ion exchange resin, insulin & glucose or dialysis for
hyperkalaemia

 Avoid dehydration in the diuretic phase

 Strict fluid balance
 May require up to 10 litres/day
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