Question

Case scenario 1:

A 30-year-old woman has just delivered her third baby. The labour had been a long one but she has had a normal vaginal delivery. You are called by the midwife to attend to the patient who has collapsed in labour ward.

Outline the steps you would take in the immediate management for this woman.

Discuss the possible causes for this mother’s collapse. (For each cause describe the main clinical features and justify the steps you will take to determine the cause of her collapse)

You find that she is bleeding vaginally. Looking around the room, you estimate the blood loss to be approximately 1 litre.

Discuss four (4) possible aetiology for her vaginal bleeding. For each cause define the typical examination findings and the intervention required to manage each cause. (your answer should include all the drugs, the clinical procedures & surgical procedures - if the initial measures were unable to control the vaginal bleeding)

You managed to control her vaginal bleeding. She has received 8 units of PRBC.

Justify the additional blood products you would transfuse.

Recommend strategies to prevent post-partum haemorrhage

Discuss the long-term complications for this patient.

Case scenario 2:

You are the medical officer working in a health centre. A woman who was on her way to the divisional hospital has just delivered in your health centre. She has a retained placenta. Discuss the principles of managing a retained placenta in this setting.

Case scenario 3: You are seeing a woman in the postnatal ward, she delivered yesterday.

Discuss how you would elicit points in the history which would be important for the following:

What you will ask her about breast feeding?

What would you ask her to ascertain or determine whether she has any perineal complications?

If her temperature is raised: What history would suggest a likely cause of infection?

What history may suggest postnatal depression?

What history would suggest puerperal psychosis?

What will you ask her about her contraceptive needs?

Should you ask her about screening for cervical cancer?

What advice would you give her about resumption of coitus?

Case scenario 4:

You see a 23-year-old in post-natal ward who has been diagnosed with lactational mastitis. Her breasts are engorged, painful, red and warm to touch.

Explain the pathogenesis of lactational mastitis.

Develop a management plan for this patient’s condition.

Recommend three (3) strategies to minimize the recurrence of lactational mastitis.

Family Planning: Compare and contrast the two (2) LARC form of family planning. For the following scenarios, determine the best family planning option for the patient. Your response should be justified. You may need to elaborate on the efficacy, effects, procedure & follow-up.

A 20-year-old university student who requests contraception, says she has dysmenorrhea and heavy menstrual loss on the first day of her menses. She has a regular monthly cycle and enjoys good general health.

A 23-year-old unmarried, unemployed woman from a squatter settlement has just given birth after an unplanned pregnancy. She plans to breast feed. A 30-year-old school teacher who has two (2) children, has just stopped breast feeding and was on a low dose progestogen only preparation. She is in good health and is undecided on a tubal ligation. She thinks she has completed her family.

A 38-year-old G5P5, had a normal delivery 24 hours ago. She is stable but having some trouble breastfeeding. She would like to breastfeed for as long as she can. She is undecided about which family planning method to use.

A 28-year-old woman has a 5-year-old child. She is not keen to have a pregnancy yet. She stopped the implant due to hormonal effects. A couple come to see you, they would like to consider vasectomy for the male partner. His wife is a known cardiac case who was admitted in ICU for pulmonary oedema.

Answer 1

IMMEDIATE MANAGEMENT

Call for help: Obstetrics should be involved ASAP.

Activate your massive transfusion protocol.

Palpate the uterus to assess for atony. Perform uterine fundal massage. If no response, apply bimanual compression with one hand below the uterus and the other compressing from above through the lower abdominal wall.

Start medications to address uterine tone

• All patients get oxytocin: Either 10 units IM or 40 units in 1L NS, run open until the uterus is firm, then at 200ml/hr
• Other agents added as needed:
  • Misoprostol 800mcg rectally (can also be given orally or sublingually)
  • Methylergonovine 0.2mg IM
  • Carboprost 250mcg IM (can repeat q15min to a max of 8 doses)

Start medications to address any potential coagulopathy. Until we see the results of the WOMAN trial, I would suggest starting tranexamic acid 1 gram IV on any woman who does not respond to oxytocin. Other medications that should be considered are:

• FFP and platelets as part of massive transfusion
• DDAVP for potential von Willebrand disease
• Factor replacement for hereditary hemophilia
• Cryoprecipitate for DIC

Examine the genital tract for retained products and trauma. If there are retained products in the uterus, remove them using blunt dissection with a finger. Suture any lacerations.

If there is ongoing bleeding, you are going to need to tamponade the bleeding. There are a number of options, depending on what is available in your department:

• A foley catheter is the mostly widely available option, but is small compared to the uterine cavity – you will probably need to use more than one
• Manually pack with 12-20 yards of 4 inch gauze
• A Rusch balloon filled with approximately 500ml of saline
• A Blakemore tube (fold the distal tip backwards and inflate the esophageal portion of the tube)

If you are unsuccessful at stopping the bleeding using a tamponade method, there are three advanced techniques that can be considered, depending on your resources:

• Transfer to interventional radiology for uterine artery embolization
• Transfer the patient to the OR for hysterectomy or uterine artery ligation (probably the most readily available option)
• Temporize with aortic compression or REBOA

Heavy bleeding that doesn't slow or stop. Drop in blood pressure or signsof shock. Signs of low blood pressure and shock include blurry vision; having chills, clammy skin or a really fast heartbeat; feeling confused dizzy, sleepy or weak; and will collapse.

Uterotonics (such as oxytocin and misoprostol) cause uterine contractions and have long been used to treat uterine atony and reduce the amount of blood lost following childbirth. Use of a uterotonic drug immediately after the delivery of the newborn is one of the most important interventions to prevent PPH.

: Massive transfusion protocols(MTPs) are established to provide rapid blood replacement in a setting of severe hemorrhage. ... The importance of prompt blood replacement in the setting of uncontrolled hemorrhage is well established and intuitively practiced to resuscitate exsanguinating patients

many of the complications of severe PPH are related to massive blood loss and hypovolemic shock. Damage to all major organs is possible; respiratory (adult respiratory distress syndrome) and renal (acute tubular necrosis) damage are the most common but are rare. These conditions are best managed by specialists. Renal failure is usually self-limited, and renal function recovers fully. Temporary dialysis is seldom required. Pulmonary edema is uncommon in this previously healthy group; however, it may develop acutely or during the recovery phase because of fluid overload or myocardial dysfunction. Response to standard therapy is usually prompt.