Where you are:
You are an FY2 working in the Obstetrics and Gynaecology.
Who the patient is:
Mrs. Jefferson aged 35, multigravida, had her 5th Delivery an hour ago. She is bleeding. Nurse called you.
Other Information:
There is a nurse in the cubicle.
Special Note:
None.
What you must do:
Assess the patient and do the initial management.
Depending on patient’s condition :
Patient :
- Conscious and Can answer Qs with full sentences = take short history.
— What Happened ? Bleeding (Since when? How much?) Heart Racing? Dizziness? Medications ( Blood thinners )? Medical Conditions ( Bleeding Disorders ) ? Allergies? smoker’s cough?
- Can’t finish one sentence or confused = postpone Hx and start your assessment.
Monitor Either
- Ideally I should attach the monitor
- I can See my patient is attached to the monitor.
Monitor :
O2 = Normal or Slightly Decreased. BP = 80/60. H.R. = 120 b/min.
Patient : -
- Talks, Airway is Patent.
- Not talking or struggling Check Airway.
Interfere ( ABCDE )
A- Airway.
1- O2 Low = O2 Low = give 100% O2 high flow rate 15L/min via face mask.
2- O2 Normal = Move to B.
B- Breathing.
1- Examine chest ( Auscultation ).
2- Take Chest X-ray + ECG + ABG.
C. Circulation.
1- Check : Capillary Refill + Pulse + BP + Insert 2 Cannula.
2- Take Blood (Relavent Invx ( Blood Group Cross matching + routine blood
invx. Iron studies. Clotting profile. KFT. LFT).
3- BP Low =.I.V. Fluids 1L.
D. Disability.
1- Check : Blood Sugar + Temperature.
2- Re-assess BP :
A – Improved = Continue your assessment.
B – Still Low = O- blood 6 units start pt on 2 units 2ml/min and re-assess.
E. Exposure.
1- Check Abdomen : ( CS wound for Bleeding. Swelling. Skin color changes ).
2- Check Private Area : Bleeding from Front Passage + Insert Catheter ( urine
output).
3- Re-assess BP: A-Still Low = Give Oxytocin 5-10 Units I.M/I.V. + Uterine Massage.
Start Discussion :
Introduce yourself + Patient. Explain Situation + Positive findings + what was done.
Admit. Involve Senior. Further Invx ( US). Safety Netting.
You might be asked about Causes and what to do next:
- Bimanual compression then
- Balloon tamponade
- Haemostatic brace suturing
- Bilateral ligation of uterine arteries
- Hysterectomy if needed
For the clerking for PPH, you have to rule out the 4 T’s which are:
- Thrombin - do you have any bleeding disorders or on any blood thinners?
- Tissue - has the after birth/placenta been delivered? Was it complete?
- Tone - were you told you were having a big baby? How long did your labour last?
- Trauma- what mode of delivery? Was any instruments used or did you sustain any tears?
- And always ask if this isn’t her first baby, if it has happened before.
- You will get maximum marks in data gathering.
- GMC is shifting from the usual PPH presentation.
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Where are you:
You are an FY2 in Obstetrics and Gynaecology department.
Who the patient is:
Ashley Hopkins is a 35 year old lady who is gravida 5 and has just delivered a new baby. This is her 5th delivery. One hour after delivery she has been noticed to be bleeding per vaginally.
A nurse requested you to come and see her.
Other information you have about the patient:
None
What you must do:
Please assess the patient and handover to the crash team
Patient’s information:
- There is a nurse inside and a talking manikin.
- Opening sentence: “Doctor, the patient is bleeding, what do we do?”.
- When the doctor asks” tell me about the patient” ,the nurse says” I just know that she had her 5th delivery one hour ago and no any other information.
- She started bleeding one hour ago.
- In the last 10 mins she started experiencing dizziness.
- The patient (manikin) is only mumbling.
- She had third degree tear but it has been sutured.
Set Up
- Monitor with the following observations:
| Parameters |
Initial |
After Deterioration |
After IV fluid/oxygen |
| BP |
110/80 |
77/50 |
110/70 |
| Pulse |
107 |
120 |
100 |
| Oxygen Saturations |
96 |
88 |
98 |
| Temperature |
37 |
37 |
37 |
- IV cannula of different colours
- Oxygen mask
- IV fluids bag
- NACL 0.9%
- Hartman solution
- 5% glucose
- Nebulizer mask
- A bucket under the bed with blood.
- Talking manikin is drowsy, just mumbling.
- There is a nurse in the station wearing a uniform.
O/E: Groin area soaked with blood.
When the doctor mentions that they would like to check for laceration, the examiner says:” it has been sutured.”
Emotions and attitudes:
- The nurse is anxious and keeps asking:” what do we do now?
- After treatment, the talking manikin would start to talk.
Questions:
- What do we do now?
- what’s next?
- Which mask of oxygen do we use and how many litters per minute?
- Which cannula do we put and how many cannulas?
- When the doctor mentions Oxytocin, How do we administer that?
- How much Oxytocin do we give?
- Which fluid should we give? How much fluid? At what rate should I give the fluid?
Examiner’s prompt:
- When the patient become stable, the examiner says: “I am the registrar in Obstetrics and Gynaecology department, please handover your patient.
- OR Please say” I am from the crash team please handover the patient to me”
Data Gathering
GRIPS: Introduces him/herself to the nurse.
Takes history form the nurse about the patient.
- Any hx of Pre-eclampsia , Hypertension or Diabetes?
- How many babies did she deliver?
- When did she deliver?
- How many hours did the labour last?
- How much is the weight of the baby?
- Any medical problems?
- Is this her first pregnancy?
- Any instruments used for delivery?
- How many babies did she deliver today?
- Any problems like placenta abruption or Previa?
- Ask to have a look in the notes of the patient.
- Any bleeding disorders?
- Is there any chance she could have retained product of placenta?
Responds to nurse’s questions and comments.
- What are we going to do, doctor?
- So what do you think is happening?
- What colour of the cannula?
- What blood test should we do?
- How much oxygen should I give?
- How do we administer Oxytocin?
Assesses the patient:
- Vitals, looks at the monitor
- PV Inspection
- Abdominal Examination
Management:
- Oxygen 15 L/min
- Keep the patient flat
- Insert Grey cannula
- Blood tests (FBC, U&E, LFTs, Glucose, Group and save, clotting screen, cross match 4 units)
- 2 liters of Hartman solution and colloid.
- Transfuse blood
- 5 units of oxytocin IV infusion.
Handover to the registrar:
- An SBAR approach is a good system to ensure you give them all the details in systematic way. Think about what the person you are speaking to will want to know, and have the notes, drug chart and nursing charts available so that you can answer any of their questions.
Introduction
- Explain your name, role and department.
- Explain what you want from them (e.g. see a ward patient, give advice over the phone, take over a patient’s care, perform an investigation or see a patient in clinic)
“Hello, it’s XYZ here, the FY2 in Obstetrics &Gynaecology department. I have got a patient who I need your help with.”
Situation (core details)
- Patient details (name, age)
- Patient location
- Major problem at the moment
“This is called Ashley Hopkins, a 35-year-old woman who has just delivered her 5th baby one hour ago and has been bleeding per vaginally since delivery.”
Background (admission and history)
- Admission details (if inpatient): date, admission reason, treatments
- Past medical history
- ± any other relevant aspects of the history e.g. premorbid state
“This is her 5th delivery. She has been noticed to be bleeding per vaginally one hour after delivery. She is normally fit and well.”
Assessment
- Vital signs
- Examination findings
- Investigations received/pending
- Management so far
- Airway: is patent
- Breathing: Her oxygen saturation initially was 94%, went up to 98% after giving oxygen 15 L/min.
- RR: Normal
- Circulation: Her blood pressure initially was 80/60, increased to 120/80 after giving 2 litters of IV fluids. HR was initially 125 then it is 100 now. I have also sent bloods, although the results are not yet back.
- Disability: On examination, she is mumbling only. There is PV bleed and blood dripping down.
- Temperature: Normal
Recommendation
- Diagnosis/differentials
- Management plan
“I feel that she has primary postpartum hemorrhage possibly due to retained placenta or prolonged labour.”
“ she has a risk of postpartum hemorrhage due to grand multiparity.”
“ I think the patient may need Oxytocin, repeat TV USS, possible evacuation of retained placenta products.”