A-E Examination: Post-partum Haemorrhage
Author – Dr Kalyani Shinkar Editor – Dr James Mackintosh
Last updated 20/08/24
Table of Contents
How to Use
Candidate:
- Read the brief below (1 minute).
- Take a brief history and a perform a A-E examination (10 minutes).
- Handover the patient (1 minute)
- Answer viva questions (2 minutes).
Patient/Examiner:
- Familiarise yourself with the history & examination findings
- After completing the history, viva the candidate
Candidate Brief
You are an F1 on the labour ward. Mrs Yulia Novak is a 29-year-old woman who gave birth vaginally to her first child 30 minutes ago. She is presenting with heavy vaginal bleeding. Please take a brief history and perform an A-E examination of this patient.
Background and Presenting Complaint
- Mrs Novak had an assisted vaginal birth with forceps.
- The birth took longer than expected and she had to have an episiotomy to help deliver the baby’s head.
- Since giving birth 30 minutes ago, she has been bleeding from “down below”. The blood has soaked her hospital gown and bedsheets.
- The blood appears dark red/brown. She has not passed any blood clots.
- She attended all her pregnancy scans, which were normal.
- Obstetric history is unremarkable
Past Medical History
- Nil comorbidities
Drug History and Allergies
- Nil
- NKDA
Introduce yourself, confirm the patient’s identify, and gain consent to examine the patient
- Patient confirms full name and DOB
- She gives consent for you to examine her
End of bed inspection
- She appears pale
- Her hospital gown and bedsheets are soaked with blood
Airways
- Assess the patency of the patient’s airway, ensure that the patient is able to breathe effectively, and there are no airway obstructions.
- Her airway is patent, as she is able to talk in full sentences
- There are no airway obstructions
Breathing
- Inspect for signs of respiratory compromise (e.g. cyanosis, see-saw breathing, use of accessory muscles, nasal flaring, pursed lip breathing, or increased work of breathing)
- There are no signs of respiratory compromise
- Respiratory rate
- RR = 16
- O2 sats
- O2 sats = 96% on RA
- Palpate for tracheal deviation and symmetrical chest expansion
- Trachea is central and there is symmetrical chest expansion
- Percuss
- Percussion note is resonant throughout
- Auscultate for reduced breath sounds or added sounds
- Vesicular breathing bilaterally
- No added sounds
Circulation
- Inspection (e.g. pale, sweating, clammy)
- She appears pale
- Temperature of hands
- Cold
- CRT
- 4 seconds
- Heart Rate
- 110 bpm
- Blood pressure
- 90/60mmHg
- Insert 2 large bore IV cannulae into each antecubital fossae
- Take bloods (FBC for anaemia and thrombocytopaenia; U&Es, LFTs and CRP for baseline; coagulation studies to check for coagulopathies & DIC, group and save & crossmatch 4 units of blood for blood resuscitation, and do a VBG to check lactate levels)
- Fluid resuscitation (500ml of 0.9% NaCl over <15 mins)
- JVP
- Not raised
- Apex beat
- Palpable in the left 5th ICS midclavicular line
- Heart sounds
- Normal
- Fluid status
- Dry mucous membranes.
- Perform an ECG
- Sinus tachycardia
- Catheterise the patient
- Monitor fluid input/output
- Reassess after each intervention
- Heart rate is 105bpm and blood pressure is 96/70mmHg following fluid bolus
Disability
- Level of consciousness (AVPU or GCS if a neurological cause for the patient’s presentation is suspected)
- Alert
- Pupils
- Equal and reactive to light
- Blood glucose levels
- 5.5
- Temperature
- 37.0°C
Exposure
- Fully expose the patient by removing their clothing whilst preserving their dignity
- Look for any signs of trauma, swelling, bruises, scars, rashes, or signs of a DVT
- Abdominal & bimanual examination
- On palpation, the uterus is boggy and distended.
- The cervical os is closed.
- Vaginal Examination
- There is evidence of heavy vaginal bleeding.
- There are no blood clots, tissue fragments, or lacerations.
After completing the initial A-E assessment, reassess! Re-assess the patient to identify any additional clinical changes and effectiveness of any interventions you have performed.
1. What are your differential diagnoses?
- Postpartum Haemorrhage secondary to uterine atony (This is because the patient has presented with heavy vaginal bleeding after giving birth 30 minutes ago, she has signs of hypovolaemic shock, and the examination findings are indicative of uterine atony)
Other possible differentials include postpartum haemorrhage secondary to:
- Retained products of conception
- Genital tract lacerations
- Coagulation disorders
- Uterine inversion
- Placental abruption
2. Given a likely diagnosis of post partum haemorrhage, how would you manage this patient?
- Call for help immediately.
- Escalate to the obstetrics and gynaecology registrar and put out a peri-arrest call (2222).
- Lie the patient flat and keep them warm.
- Insert 2 large bore IV cannulae and give IV fluid resuscitation and blood resuscitation as required.
- Group and save & crossmatch 4 units of blood.
- Consider activating the major haemorrhage protocol if the bleeding is significant. This will give rapid access to 4 units of O negative blood.
- Arrange for urgent ultrasound scan to evaluate for uterine atony or retained products of conception.
3. Please Handover this patient to the obstetrics and gynaecology registrar using the SBAR or equivalent format.
- Hi, my name is Dr. Joe Bloggs and I’m calling from the labour ward. Can I please confirm who I am speaking to?
- I’m really worried about a patient I’ve just examined, I think she’s having a postpartum haemorrhage secondary to uterine atony.
- She is a 29-year-old woman called Yulia Novak, who is G1 P1.
- She has been experiencing heavy vaginal bleeding since giving birth 30 minutes ago. She had an assisted vaginal delivery with forceps and an episiotomy. The birth was reported to take longer than expected.
- Her obstetric history is unremarkable. She has no comorbidities or allergies.
- On inspection, her clothes and bedsheets were soaked in blood, and she appeared pale.
- Her airway was patent.
- She has signs of hypovolaemic shock. She appeared pale, her peripheries were cold to touch, and she was tachycardic and hypotensive. I have inserted 2 large bore IV cannulae and have taken bloods, including FBC, U&Es, LFTs, CRP, and coagulation studies. I have also group and crossmatched 4 units of blood.
- She was alert, apyrexial and her BM was normal.
- On bimanual examination, her uterus was boggy and grossly distended. There were no vaginal, cervical, or perineal lacerations.
- I have ordered an urgent US for her.
- Can you please come and see her? In the meantime, is there anything you would like me to do?
What is an Post Partum Haemorrhage?
Postpartum haemorrhage (PPH) refers to excessive bleeding following childbirth. It is defined as blood loss of ≥500ml after vaginal delivery or ≥1000ml after caesarean section. PPH can be classified into primary or secondary PPH. Primary PPH refers to blood loss that occurs within 24 hours of childbirth and secondary PPH refers to blood loss that occurs between 24 hours to 12 weeks after childbirth.
Causes
The causes of primary PPH can be remember as the 4Ts:
- Tone (uterine atony) – most common cause
- Tissue (retained products of conception)
- Thrombin (coagulation disorders)
- Trauma
In comparison, secondary PPH is more likely caused by retained products of conception or endometritis.
Risk Factors
There are multiple risk factors of a PPH. These include:
- Previous history of PPH
- Prolonged or rapid labour can increase the risk of PPH due to uterine fatigue or trauma
- Instrumental delivery
- Episiotomy or perineal tear
- Caesarean section
- Multiparity
- Multiple gestation
- Placental factors e.g. placenta previa, placenta accreta, and placental abruption.
- Maternal factors e.g. increased maternal age, hypertension, diabetes, obesity, pre-eclampsia, or coagulopathies, such as von Willebrand disease or thrombocytopaenia.
Diagnosis
The diagnosis of PPH requires a combination of clinical assessment, laboratory tests, and imaging studies.
Clinical Assessment:
- The patient’s history may reveal risk factors for PPH.
- The signs and symptoms of PPH vary depending on the severity of the bleeding.
- A hallmark feature of PPH is heavy vaginal bleeding, which may be accompanied by blood clots.
- Patients may present with signs of hypovolaemic shock due to blood loss, including pallor of the skin and mucous membranes, cool skin, tachycardia, hypotension, fatigue, dizziness, or loss of consciousness.
- In significant bleeding, DIC may occur, which can clinically manifest with haemorrhagic signs such as subcutaneous haemorrhage e.g. petechiae or bruising.
- Examining pads, linens, or containers used to collect blood during and after delivery can help to estimate the amount of blood loss.
Abdominal examination
- Abdominal pain and tenderness may be the result of uterine contractions attempting to reduce bleeding or suggest an underlying problem such as retained products of conception.
- The uterus should feel firm and well-contracted. A boggy, distended, or grossly palpable uterus is indicative of uterine atony.
- Palpation revealing an overdistended bladder may indicate a barrier to effective uterine contraction.
Bimanual Examination
- Bimanual palpation of the uterus may reveal findings consistent with uterine atony
- Assess if the cervical os is open or closed
Vaginal examination
- Inspect the vagina, cervix, and perineum for lacerations or other signs of trauma.
- Assess the extent of vaginal bleeding and look for any blood clots or tissue fragments.
Laboratory Tests:
- FBC to assess the patient’s haemoglobin and haematocrit levels, which can indicate the presence of anaemia and severity of blood loss. FBC is also important to assess for thrombocytopaenia as a possible cause of PPH.
- Coagulation studies to evaluate for coagulation disorders. In cases of severe bleeding, coagulation studies such as aPTT, PT and fibrinogen can be measured to assess for DIC.
Imaging:
- Ultrasound may be used to evaluate the uterus for uterine atony, retained products of conception, or other causes of bleeding.
Management
The management of PPH involves a systematic approach aimed at controlled bleeding and addressing the underlying cause. Treatment options to stop the bleeding can be categorised into mechanical, medical, and surgical.
Immediate Actions:
- Initial management involves calling for help, considering activating the major haemorrhage protocol in cases of significant bleeding, and focusing on stabilising the patient’s airway, breathing, and circulation. This involves establish large-bore IV access for fluid resuscitation.
Mechanical Options:
- Bimanual uterine massage can be performed to stimulate uterine contractions in cases of uterine atony.
- Catheterisation may be carried out to stimulate uterine contractions, as a distended bladder can prevent uterine contractions.
Medical Options:
- Uterotonic medications, such as oxytocin, ergotamine, carboprost, or misoprostol, may be administered to stimulate uterine contractions
- Tranexamic acid may be administered to stop the bleeding in cases of ongoing haemorrhage
- Blood products e.g. packed red blood cells, fresh frozen plasma, and platelets may be given to correct anaemia, thrombocytopaenia, or coagulopathy if present.
Surgical Options:
- Intrauterine balloon tamponade: This involves inserting an inflatable balloon catheter into the uterine cavity to apply pressure and stop the bleeding.
- B-lynch sutures, which involves applying sutures around the uterus to mechanically compress it to control bleeding.
- Uterine artery embolization, which involves occluding the uterine arteries, thereby reducing blood flow to the uterus and promote haemostasis.
- Hysterectomy: This is considered as a last resort if conservative methods fail to control bleeding.
- Continuous Monitoring: The patient’s vital signs will need to be monitored closely to reassess for changes in clinical status and to detect signs of deterioration.
- https://www.ncbi.nlm.nih.gov/books/NBK499988/
- https://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage