This scenario is major PPH.The Principles of management are as under ,the clinician should be quick,alert,logical action taken simultaneously,following the hospital protocol:The immediate management is to secure the airway,breathing and circulation,this will require intubation if conciouness is altered,oxygyn by mask(4-5 liters per minuite,2 large bore cannulas are inserted and 20cc blood should be drawn for investigation s,run clear fluids if blood is not available.
Urgent call for help the sceniour midwife(as well as the midwife incharge),call middle grade obstetrician(alert the consultant),call the anesthetist middlegrade (alert the consultant anesthetist),call the hematologist (consultant),call the blood bank(place the order as ongoing PPH,O NEGATIVE blood if cross matched sample will require some time to be supplied),call poters for sending the investigations,allot 1member of the team to record the findings,the interventions done,i.v.fluids,drugs given,to monitor pulse ,blood pressure,respiratory rate.It is important to communicate with the patient and her partner and keep them informed .
INVESTIGATION AND MONITORING.
Send blood for grouping and crossmatching(at least 4 units may be required)FBC,renal function,(blood urea,serum creatinine),liver function as base line,s.electrolytes,Cougulation profile,but FFP,Cryoprecipitate ,platelets could be transfused before the investigation reports are available.Transfer to HDU/ICU to minitor continuously BP,Pulse,respiratory rate,urine output(there fore catheterize the patient with Foleys),insert CVP Line.
Keep the women warm,give warm fluids,do not use filters as it slows down the infusion rate,give appropriate doses of anti d (if RH NEGATIVE).Immediately rub up a contraction,give uterotonics oxytocin 5 -10 i.u as bolus(as per protocol),or as a infution along with the i.v fluid,carboprostol 125 ug repeat if necessary ,syntometrine i.v,coud be repeated ,arrest the bleeding ,look for tears,cervical,vaginal tears,see if placenta and membranes are complete,look for uterine fundus (as inversion may be the cause),use the balloon tamponade if atony still persists.Anticougulants will be required in massive blood loss,therefore haematologist s opinion is required in this regard.Verbal consent for further surgical management as appropriate will be necessary.Document every action.
B)The balloon tamponade is the 1st option among the surgical interventions,it is also acts as a test to note if hysterectomy may be resorted to,as sooner the decisions are made the better the prognosis for the patient.Brace sutures provide haemostasis in majority of the patients,otherwise step wise devascularization is resorted to,internal iliac artery ligation,or uterine artery ligation will be required.Uterine artery embolization is done if expertise is available.A subtotal hysterectomy is justified to save the life of the life of the mother .Accurate documentation,filling in the incedent report form,and communication with the women and the relatives,after the incidence,to convey future effects are important measures in clinical practice.
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