A mother may experience life-threatening haemorrhage after delivery of her baby. What can the resuscitation doctor do?
Rosen’s Emergency Medicine describes four main differential diagnoses: uterine atony, genital tract trauma, retained placental tissue, and coagulopathies, or the “four Ts”: tone, trauma, tissue, and thrombin.
As well as resuscitation with fluid and blood products and urgent obstetric and anaesthetic referral, efforts should be made to restore uterine tone with manual and pharmacological means, and consider tamponade of the haemorrhage.
The MOET (Management of Obstetric Emergencies & Trauma) Course outlines the following interventions for major obstetric haemorrhage:
- Empty uterus: deliver fetus if undelivered / remove placenta or retained products (this may need to be done digitally according to Rosen)
- Oxytocin / ergometrine / prostaglandin
- Massage & bimanual compression of uterus
- Repair genital tract injury
- Uterine packing or Rusch balloon
- Compression of aorta
- Surgical or interventional radiological options: internal iliac or uterine artery ligation, hysterectomy, arterial embolisation
A review of the different balloon tamponade devices available describes the urological Rusch balloon, the dedicated Bakri balloon, a condom sutured to a Foley catheter, multiple Foley catheters, and the Sengstaken-Blakemore tube (SBT). In order for the SBT balloon to reach the uterine fundus, either the tip of the catheter can be cut and the gastric balloon inflated, or the SBT can be folded and the oesophageal balloon inflated. Normal saline is used to inflate the balloon until tamponade is achieved. If the cervix is dilated, vaginal packing may be necessary to prevent migration of the balloon out of the uterus..
The Royal College of Obstetricians and Gynaecologists published 2009 guidelines on PPH. The full text is available here. After commencing resuscitation, summoning help, considering the ‘four T’s’, and examining the patient they recommend:
- Bimanual uterine compression (rubbing up the fundus) to stimulate contractions.
- Ensure bladder is empty (Foley catheter, leave in place).
- Syntocinon 5 units by slow intravenous injection (may have repeat dose).
- Ergometrine 0.5 mg by slow intravenous or intramuscular injection (contraindicated in women with hypertension).
- Syntocinon infusion (40 units in 500 ml Hartmann’s solution at 125 ml/hour) unless fluid restriction is necessary.
- Carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of 8 doses (contraindicated in women with asthma).
- Direct intramyometrial injection of carboprost 0.5 mg (contraindicated in women with asthma), with responsibility of the administering clinician as it is not recommended for intramyometrial use.
- Misoprostol 1000 micrograms rectally.
Balloon tamponade may then be attempted in cases of uterine atony pending surgical haemostasis if necessary.
As with all life-threatening emergencies, the resuscitation doctor should have a plan, and know his or her options regarding personnel, facilities and equipment. We recommend a closer look at the articles and guidelines referenced above in formulating your own plan as to how you might save a young mother’s life.