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Good evening, everybody. Thank you so much for joining us in Mind the sleep for obsessive gynie, um, Webinar this evening. So we'll Wilson thicker is an ob gyn gynie ST six. And he'll be telling us all about, um his career on answering some questions for us, so Well, I'm just gonna go straight to you. Feel free to get started. That's fantastic. Thanks very much So thanks everyone. Good evening. And firstly, thank you, everyone, for giving up your time and energy on a Monday evening to come and sit and listen to me waffle on, um, about PPH. It is always amazing when people give up their free time to listen to voluntary lectures. So we'll credit to you. Thank you very much to Sire on the team that mind the bleak for asked me to come and have a matter to you about this. And she said, My name is well, I'm ST six training in the northwest, working within arm's and gynie on a little bit more about me. So under the old system, I'm now a senior registrar ancient in my time, currently undertaking the mandatory advanced laboard 80 s m and also the benign guy in the abdominal surgery HSM proud out of To This is my youngest, Humphrey, who's currently weaning and covered in everything that gets hands on. Um, we have another daughter, Francesca, who is three, who is probably running around the house and may well crashing on this teaching at any stage fair warning for all of you. And I love teaching. I've always enjoyed teaching with benefited from very good teachers and mentors. And I think one of the most important things about medicine happen is the ability to teach and train the generation that's following behind you because it's a quality of life thing. When you become the more senior people managing label ward, you want to have a junior colleagues who you know that you can rely on an emergency on. I'm currently doing a postgraduate certificate in medical education by actual university. I am not an academic. This will not be a highbrow lecture. I am definitely a clinician. I do not enjoy writing essays. I do not enjoy research that is not me, but I do love teaching. Teaching virus screen is not my ideal. I'm much prefer teaching in person. I'm much prefer you know, scribbling on whiteboards, moving around, trying to engage people on a personal level. So do you forgive me if it comes across a bit stale? Um, and I came to office and gynie by a slightly round about root. So my foundation trading portfolio and CVS was all good towards, um, trauma orthopedics. I applied for a course surgical training job. I crashed and burned on the interview. Um, but my last rotation in foundation was knots. And I need I thought, Hey, this is quite fun. You know, this is surgical. This is medical. Um, So I did a year long political research fellowship in OBS and guy in in dropping off Pedic. And during that time, I realized I didn't actually like trauma, your feet so much like what applied for jobs. And I need trading on. But look back once. It's a fantastic specialty. And as we will talk about in the management of PPH, I always say to my junior colleagues, I would say a good 80 to 90% of ups and I need is a communication base specialty. It's one where it doesn't matter whether you are the best person in the world of forming a C section or a real damp hand with a pair of forceps. If you cannot adequately adequately communicate with the patient in front of you birth partner, the members of the multidisciplinary team, you may as well not bother because it is such a nuanced career for communication skills as it's all medicine. But in the acute setting of labor ward, that's more so. So during this session on, I'll be mindful of time, cause I want to leave some, um, opportunity for questions later on. So we're going to talk about some of the definitions of PPH. We're going to talk about why PPH is important. We're gonna talk about bit of the pathophysiology, including everyone's favorite. A little bit of bonus embryology, please. It's not gonna be much because I hate embryology, and we're going to talk about risk factors for BPH. We're going to talk about the management it will cover running through the major cetera, hemorrhage protocol. What that looks like. I've taken some examples from the unit I currently work within in terms of some of the documentation that we use on. We'll work through some case studies on then we will hopefully have plenty of time for questions afterwards. Now I finish nights this this this morning on. So I have actively manage PPH all weekend. However, if I do start to sleep in, sit, slip into a deep sleep, someone just put me on the chat. Okay, So the overarching summary P ph management, right. As a headline from the get go. If you are the first on call s H o junior, great. Whatever you want to call yourself whenever the current in vogue definition is if you are the junior on call. If there's a PPH going on, all you need to do is walk into that room and have a look. Let's make sure the patients got large bore IV access, and if they've already got one in, put another one. If, as you are progressing through your career and ups and I need a few mad enough to enjoy it and you have become the second on call the registrar's middle grade, make sure your S H O got some IV access in manage every patient as we always talk to my run A B C D. E. Approach. When you're first steps of management is by manual compression, which will cover in a short while ask for medication to be given and have a low threshold to take your patient the operating theater If you've got ongoing bleeding or what we call the major obstetric hemorrhage or M. O. H. Okay, I always just say it went out with his BPH going on. I walk into the room. I say hello to the woman I do by manual compression. I start shouting at the mid wives to give drugs, and it's just that simple. It's not that simple, but so if we're talking about definitions, all of the information that I'm gonna be giving you is mainly pulled from the Royal College of Obstetricians and on Gynecologists. Green Top guidelines on. So we've got a green top guideline, which is about prevention and management off postpartum hemorrhage. It was published in 2016 or was most recently updated in 2016. On Do they do, review and update these guidelines, but the management of people it doesn't really change, and this covers how we manage it in the UK on, But the Royal College does kind of advise internationally as well, so talking about a postpartum hemorrhage we divided into primary and secondary. Some primary post heart part of hemorrhage Is blood loss greater than 500 mils? The college say it's by the genital tract. However. You know, if you're having a cesarean section, for example, it's not going to be fired her the genital tract. But it's blood loss greater than 500 mils within the 1st 24 hours of birth. Um, it can then further be subdivided into a minor PPH, which is between 500 mils on 1000 miles or a liter or a major PPH. It is greater than 1000 mills and then major peak ages further subdivided into moderate or severe, depending on your overall blood loss. But it's becoming academic that point. Once it's higher than 1000 mills, your management doesn't really change. It's just what you're gonna be doing for the poor lady when you're talking about secondary post partum hemorrhage. It blood loss greater than 500 mils after 24 hours on up to six weeks Post Natal E. On After six weeks postnatally, it's bleeding, which is not defined as a postpartum hemorrhage. The mass vast majority of this talk is a little do with a primary postpartum hemorrhage. But we will briefly cover Secretary Postpartum Man that hemorrhage, the management of which is relatively simple. So why do we care? What's the point? You know, God, everyone believes it's pregnancy. But we have the embrace report, which is a national body which collects maternity mortality and morbidity in the UK Um, it publishes a report which covers every try any, um which is, you know, a three year period. So the most recent embrace report, which was published in November 2021 focused on the years joint 17 2019. So, unfortunately, in this country, women still die as a result of pregnancy and childbirth. On in that trial, me, um, 191 women dive during pregnancy and within six weeks off birth maternal mortality ratio, which is essentially talking about the number of deaths related to live births on stillbirths after 24 completed weeks, is 8.7 900,000 maternity ease. And these are all numbers which, if you're not working up statues, that really mean all that much to you. But, you know, we're always quite interested with the embrace report and you know they separate deaths between one called direct deaths, which are causes directly related to being pregnant on indirect deaths, which are deaths, which are exacerbated by the pregnant state. So things like cardiovascular problems or neurological problems such as epilepsy. So it's not caused by the pregnancy itself but can be exacerbated by the pregnant state. But anyway, in this country, hemorrhage is the second highest cause of direct. That's it's the same it's sepsis on is only behind blood clots or V. T. A. C cause of death. And it's one of those ones where you know the the cause is of direct death kind of jockeying for position, depending on how well we're managing things. So it used to be that sepsis was a very higher rates of mortality for women. We got much better at managing sepsis on, and then it was hemorrhage for a while, and now it's PT, and we just kind of try and manage the best we possibly can. So within the 2017 2019 trillion 14 women in the UK digerati during do the hemorrhage, however, the UK is, ah, Western country. It's got access to a good health care systems. Your opinion on the NHS could defer. That's fine. But the benefit is in this country that we don't think about the medications that we are opening and using. We don't think about the cost behind it. We didn't think about the cost off. The IV access was citing on. We just go for it. We manage the women as we need, and we don't charge them. It's bloody marvelous. That's not the case elsewhere in the world and globally. Over half million dollars or half a million women a year die due to hemorrhage that numbers published from The Lancet in 2014. I'm not sure what the numbers are now on, but is mainly in countries that don't have access to you, know good health care or have don't have local health care or don't have advanced healthcare within. You know, a local areas that place that substance in Afghan seven Asia. But even in the United States, so places where there is a great disparity in poverty and wealth, um, you will get women dying from avoidable hemorrhage. That's a little bit of the background. This is the only slide That's going to involve embryology. I promise. So why do women bleed on so part off the, uh, physiological processes of a normal pregnancy In off. As you can see in this picture, on the right hand side, we're looking at at the bottom. You can see your placenta with your placental ville eye on, but I don't know if you can see my cursor. I hope you can, um, But what we can see is we can Cyrus, can you see them? Okay. Super duper. So what we've got here is the blood supply to your uterus, which from the top is the Varian artery, which it originates in the abdominal aorta. From the bottom is the uterine artery, which is a branch of the internal. I'll attack. They're nasty Moses in the kind of yeah, natural spaces the pelvic sidewall on. They give blood supply off into the uterus itself, and then they form what's called the spiral arteries of the uterus. And in the non pregnant state, he's a very tightly coiled on. Do you have quite a narrow lumen on? But one of the normal process is off. Placental implantation is that you get this invasion of trophoblastic material into the Lumen of the spiral arteries, which causes them to dilate and slow their room on dopa up. And you get a much higher flow at a lower pressure, which is why you get perfusion of the percentile bed throughout maternal cardiac cycle and all this sort of stuff. What it means is the blood flow to the uterus. That term is about 700 miles a minute. So if you want to illustrate that to a patient or in your own mind, set, just imagine. Take a bottle of wine or your favorite beverage and just pour it down the sink one of those a minute. And that's what you're trying to combat. If a woman is actively bleeding, one of the natural things that happens to try and stop women to bleeding from bleeding to death is that following placental separation, you get a flood of maternal clotting factors, which helps to reduce the risk of low blood blood clots. Post delivery. It's a very clever natural response by often you will see if you're performing a vaginal delivery or if you're doing a cesarean section, for example, if you open the abdomen and you've got some small bleeding from superficial skin vessels. If you leave those alone, by the time you finish your cesarean section, they've all clotted off on. That is just part of physiological processes. But this can be disrupted by pathologies. On one of the things that can cause abnormal pathology relates to percent or itself is that in preeclampsia you get abnormal trophoblastic invasion, which can cause alterations to the to the blood flow within the placental bad preeclampsia is a completely separate topic, which you can have a great in depth conversation on electron. We won't cover that today. Um, the other thing that can cause a blood loss is that we're really, really bad estimating it quite often in obstetrics. It's just kind of a visual eyeball. You have a look and you get Yeah, that blood loss looks to be about 600 mils, but it can be concealed. So you know you can get blood loss, which soaks into the sheets. It can run underneath the bed. It can run underneath the patient. You can kind of have some use a bias because you've done the delivery. You don't want it to be too high. You might think that there was a lot of like court deliveries. That's probably, you know, making it look a bit more than it is. Um, so quite often you can say, Oh, that looks to be about 800 mils blood loss and then they actually way or the swabs in the sheets and everything like that. Turn around the girl will. That blood loss is 1800 mils. You know, crumpets. That's not so great. So best practice on one of the college guidelines recommend is to either have drapes that will catchall the blood loss that you have or two away or you're swabs or have suction that you know you you count. And when you're in the operating theater, that's fine. But when you are having, say, for example, a nice calm it with three lead birth within your within your birth centers or your sexual units or home birth, you don't want to cover a woman in lots of drinks. You want to disrupt her birth experience so it can be very, very difficult todo so. I don't know how many of you are currently working in obstetrics or where you're working, but in obs and gynie. We like big cannulas on quite often if people come to us from your medical wards, where they're dealing with geriatric patients with poor IV access, and they're used to kind of get in a blue or pink cannula, if they're very much can kind of like what you're doing with these grades and green can use. But the reason is, as we've said just before, the blood flow to the uterus, a term is 700 mils a minute. If you have got a obstetric woman with a pink cannula in one, the maximum you're going to get through. There is 67 mills a minute. So if that uterus is pouring out blood and you're only able to top her up at 67 miles minute, you're not going to be able to keep up. That's why we like to be able to resuscitate a woman with that least to, you know, one if you if if nothing else, but to whiteboard IV access on Grey's, If possible, they look like drain pipes, and it's not nice for the ladies. But if you've got a woman who is needle phobic or declining IV access, this is the rationale. This is what we talked to them about in terms of why we need this big IV access. And you can probably push a slightly higher flow rate through agreeing cannula if you're using a pressure bag. Um, but yeah, if we see the the mid wives go mad, it makes me very upset if sometimes you get women brought in by ambulance crews with one tiny little pink cannula in the antecubital fossa. Yeah, a pregnant woman a term have got such massive veins on cubital fossa. You could probably put a bloody domestic drain pipe in there that big, but anyway, so please, please, please, anyone who's currently working obstetrics or thinking about career in obstetrics or a rotation coming up get comfortable with big cannulas. Okay, um, if we're going to look at a very basic on cause of PPH is we separate out bleeding into the four teas, not the forties, that you get in a cardiac arrest. So again, people coming in from medicine do not think about tension, new math or it easy or anything like that. The things that we are interested in our tone, which is tone of the uterus tissue, so that could be either retained the senator or it could be blood clots on trauma. So whether that be, I Atrovent drama. So either a cesarean section that we've done on a PCR to me that we have created do so instrumental delivery or just a a perineum that's suffered from significant trauma that may have significant varicosities on. Then finally, thrombin, which is actually quacky allopathy. He's on the vast majority of people a chisel down to this on correcting These is going to help you to manage. PPH is, and the vast majority of people ages 90% off PPH is are related to tone on poor you to right tone. So most the time is your see later on in this talk as we talked about management of PPH, the most common focus is managing the uterine tone sort in that out. If you saw that out vast majority of the time, things get better. Um, I hope that everything is making sense so far. I'm not seeing any questions in the chat at the moment on Do. If everyone's happy, I'm just going to keep on going through, and if there is anything that you want to circle back to. That's absolutely fine. Um, so can we predict BPH? And whilst you're reading this busy side of my Ms Liberty So there are some things with you within antenatal and intrapartum care that can help you to predict a P pH on the college guideline will give you the odds ratios of statistically how much higher some of these conditions will give you a risk of PPH compared to population. I'm not going to bore you with all those statistics, but certain things antenatal on so things like if you're having a percentage abruption. So if your placenta is rupturing off the wall of your uterus and your actively bleeding, that's gonna cause a risk for BPH afterwards. If you are known to have a play center that is implanted in a problematic place, so percent of previa, of course, that's gonna make you bleed on if you've got a multiple pregnancy. So if you've got twins or Twitter or triplets because you've got a gravity uterus that is stretched much further than normal after that uterus delivers. But we're chances are that it's going to relax quite significantly so again you can have a a problem with you. To Ryan tone, any woman that's had a previous postpartum hemorrhage is, of course, more likely to follow suit again. Um, other problems. Things like obesity, anemia and the college guidelines talks about Asian ethnicity. I don't know about the pathophysiology of Asian ethnicity cause you to have BPH is. But that is something that comment on within the guidelines. Um, overall, the instant in peace of PPH in the UK is about 10% So I'd say about 10% of deliveries. Um a complicated by P. Ph. On quite often a lot of your intrapartum emergencies. You would always anticipate a p. PH. So again, when you're doing your step trick training days or managing labor ward any time that you managing emergency, say, for example, shoulder dystocia or an instrumental delivery or an emergency cesarean section until the case is concluded, it until the percent is delivered and the woman is settled. You've always got to anticipate the P. PH. So again, on things like emergency C sections, inductions of labor retained placenta, prolonged labor. So if we were laboring forever, if you're admitting them within toasting on which will cover later. You know, if you got a uterus that has been asked to work and work and work for a very long time. When it finally finishes, it's work and delivers that baby. The possibility is it is just going to relax back in. Well, thank God for that and exhausted. And actually, that's when you to contract down and try and you reduce the risk again. Things like big babies. So again, if you've got a uterus that's been stretched by an enormous baby, that's more likely to to relax on things like Pyrex urine infection in labor because it's an inflammatory state can course PPH on again maternal age We always that's saying obstetrics that on maternal age of 40 or higher, carries a lot of higher risks in terms off chromosome abnormalities. Higher risk off hypertensive disorders, much higher risks related to morbidities high risk of stillbirths. So advanced maternal age is just one which is associated with higher complication rates. In obstetrics, it's something to be mindful off. So in terms off how you minimize the risk of PPH for all women when we talk about screening for seven, when we talk about managing labor and I'm not going to teach to suck. Eggs are not going to tear insult your intelligence, but laborers split into the 1st, 2nd and 3rd stage. The first stage of labor is when women are actively laboring between four and 10 centimeters, the second stage of labored when they're fully dilated. The third stage of labor related relates to delivery of the placenta and then brains. So a woman can choose either what we call active management of the third stage of labor, which is where we administer drugs to help encourage percentile separation or a physiological third stage, which is where we just allow nature to separate the placenta naturally, which can also be a risk factor. So active management of the third stage reduces the risk of PPH for all women. That just makes sense because you're you're giving medication to try and reduce that leading risk that's got to be counted or weighed up against the the benefits the baby of things like the lady called cramping. So delayed court camping is where you deliver your baby. You leave them with mom, you leave the center in situ. You leave the cord unclamped and pulsating because that allows transfer percentile blood to the baby, which gives better birth weights. It increases the amount of neonatal hemoglobin so can improve. You know babies. Initial outcome following to the three slightly increases the rates of neonatal jaundice due to a juice or a ah higher hemoglobin load. But overall delayed call camping is seen as being very good for babies. However, you can't wait forever if it would be less bleeding. Overall, the management off the third stage is patient choice. Most women do up for active management of the third stage, but it all depends on his attitude, their lifestyles, their desires for intervention. You know, management off a patient choice in obstetrics is probably a conversation I could speak about for a week and a day. So, you know, stay tuned for that. Um, when we're talking about what we would use to actively manage the third stage, then the first line medications are things like oxytocin, which is, um, administer in the form of Sentosa non. So it's just the manmade version of what the body makes itself to encourage a uterine contractions or 10 units. I am for women who don't have pre existing risk factors for bleeding. The other option that we use is a drug called Symptomatic in which is oxytocin past ergometric, which reduces which in the in the data from the college guideline reduces the risk of women having minor p. PH is so it's the drug of choice for women who, you know have risk factors. Why often a lot of units in the weight the united currently working we use into matter is the drug of choice, or women have symptom. Actually, if they're acting back to management of third stage, the only time that we would use Internet caution is that if women have a background of raise BP, either antenatal E or intrapartum on since matching can send the BP sky high so we don't use it, we would result oxytocin on the guy. Lenders talk about how you can combine these different measures. T lower the overall rest so you can give you a bolus of Sinemet trinh. You can use things like tranexamic acid, which is a non hormonal method of controlling blood loss on. You can also use a continuous infusion off of oxytosis, in which is diluted in 500 miles of saline. It runs over four hours and gives you a longer term contraction of the uterus. And again, that can help to reduce the risk of the whole grain blood loss. And so what we're going to talk about now is your initial approach to managing on a tonic beauty it as we mentioned, 90% off P. PH is our atonic on S O. This is how we go about managing them day today on the label ward. So either you might be in the room because if you are your junior grade, you might be observing your your senior carrying on instrument and delivery. Or you might be a junior registrar who is carrying out instrumental deliveries on the vision. Or you might be set in the office having a lovely couple t um, reading your emails, scrolling through you instagram or tic tac or whatever young people do. You know, today's on the emergency because it goes off your behind me and the thing is, in obstetrics, a community, but this cough all the time on. But what is important then, as I said it, the very highlight. A great start, the talk communication, because until you go into the room, you don't know what that emergency is on. What you need is the staff who are there immediately, too. Communicate what's going on in a concise manner. So, yeah, emergency bother. You go running into the room and the mid wife says P pH. She's lost this much. You know. She's either just delivered senses out or she's just 11% still set you You know, we've done the PCR to me or all this stuff. So on arrival, whilst you kind of automatically focus down into the new the poor woman's external genitalia because that's probably the source. The problem. You've got to have a knish, a lady CD assessment. You know that's every every arm of medicine uses a B C D. On. So say hello to the woman. You know, introduce yourself and it's an emergency. So you got to do all this quickly, you know? But I always going to say I'm well on the obstetrician courts. Nice to meet. You were just going to try and solve this problem out on, and hopefully they leave their, you know. See, that's great look of your sons up. Um, but you know you can check if the airways painted. You will when you pull the emergency, but everyone goes in literally. Everyone in the whole unit is in there, so you will have people that you can ask. Can you do a set of ops? Can you put up high flow oxygen? Can we do a BP a lot that could be going on. What, you're carrying out your assessment. That said, if you're the junior grade, make sure there's IV access in place. And if you're the register, I make sure that someone is doing it. And if someone's bleeding when you're getting IV access, make sure you send Bloods so full blood Crown Group and save on, consider a cross match. Check the maternal obs and then the first port of call. It's by manual compression, which is what we're looking at on the left hand side. Here, in this picture of statics, is not a glamorous specialty it doesn't involve. You know it's no orthopedics where you're doing beautiful fine surgery on. Do you know needles getting close? It's not plastics. We're using tiny little suitors. It's it's quite barbaric, to be honest in some situations and by manual compression is a closed fist inside the poor woman's vagina with your hand on the abdomen and your essentially trying to fold the uterus over your fist to manually compress the, um, the uterus. And obviously, if a woman's got a really dense epidural in place, that's fantastic, because she won't feel any of that. If you had a woman that had a normal delivery with minimum analgesia, that's gonna be really painful on again. That's about communication. Ensuring that woman has adequate analgesia. Give that poor woman's and gas in there to bring it on. Master doing all of this. Empty the bladder. So what? Any woman that's having an active bleed. You're going to monitor the kidney function by the urine output. So normally passing indwelling catheter and make sure it stays in there attaching. You're on it. Er, if you've had a woman that's not really past much urine in labor, and she's got a really full bladder, it's got 506 100 mils in there. Sometimes you know this this at the front here, this is the urinary bladder. If that's full of urine, sometimes that can be put preventing the uterus from contracting down. So by emptying the bladder, it can facilitate uterine contractions. Um, and then, as you are doing all of that, you can actively assess the uterine tone with your upper most hand because you can feel whether or not that uterus is contracting between your two hands, um, on you. Then start shouting for you tre tonics to be given. So either you you you'll need to know what's been given already on what you've got room to give. So if you've got a woman with no BP problems, you can have all of these different drugs, and we'll talk about these in terms of the M. O H protocol. If you have a woman that's got BP problems, then you are limited to things like oxytocin on tranexamic acid on. Then we also think about fluid resuscitation. So, um, you need to think about, you know, as we said, this IV access on being able to push in fluids quickly. So it's normally you're initially two liters of crystalloids, a nice clear fluid to the saline or Hartmann's something like that. The use off colloid. So things like jealous Pan, Um, it's kind of fallen out of fashion in terms of active fluid resuscitation. But it is still mentioned in the Royal College guideline that you can use colloid to try and expand the circulating volume. But all of this is kind of used as a bridging method, because the best way to resuscitate a woman who is bleeding is by giving her some blood back on. The useful thing in obstetrics is the vast majority of your patients are fit, healthy and young, and they can tolerate blood loss. But the other thing about that is that they will tolerate, tolerate and tolerate until all of a sudden they don't. And they can drop off a quick that cliff very, very quickly, which is where you need to get ahead of that bleeding quite quickly on. So this is all things that you could do with in the room. So this is within your labor ward room. You can manage an atonic PPH, and sometimes you just get called in. Just had a a brisk bleed of 708 100 mils. You administer the second dose of oxytocin or Sinemet trian. You started on oxytocin infusion and everything settles. You put catheter into the bladder and you can walk away. That's all marvelous. What happens if the bleeding doesn't stop? So either you got the center that still in situ? That's not showing any signs of separating in a woman's bleeding. You've gone through all of these things on either. Things aren't improving, but or they're improving. But the bleeding still not settled. You then got to think about transferred to the operating theater. Now, if all of these things happening within an operating theater, so you just don't instrumental delivery or you're doing this is that section and you in the right place. But if you're in the labor board room, you got to have a threshold is to when you would take a woman to fit my personal threshold. And I think a lot of middle grade specials. If you got a woman who is about 1000 mills and the bleeding, it's ongoing, then you've got to think about transfer because transferred to data isn't always immediate and especially if they're bleeding heavily. By the time you thought about it, spoken to someone about it, turned your back, looked again. She's lost another 500 mils, so if you're thinking about it and vocalize that early on, get going. And sometimes that transfer to theater is with you is the obstetrician sat on the bed doing by manual compression. And again, you got to have a thought about the dignity in the privacy of the woman that you're looking after, so don't well, the poor things start naked on the bed with no covering. If you're taking it a theater and you're doing by manual compression before you leave that room, just make sure that someone covers her with sheet because it's not dignified being wheeled to better in that state. So then we talk about surgical methods of managing the PPH. So, um, going from left to right is kind of the surgical options from kind of less invasive to most invasive, so initially from down below. So in theater, in the thought to me visualizing the cervix, we can insert what's called into into uterine balloon tampon are so most common ones are what's called the rooster balloon or the back we balloon on. So I think that's a back we balloon at the top that's used in a lot off, um, Western European countries. In the bottom is it's called a condom catheter. So you've got a simple Foley catheter and you got a latex condoms on the top. So you you put your latex condoms over the top of your Foley catheter. You fill the condom full of water on once it sat inside the uterus on that's used in countries where you don't have access to expensive medical products, things like substance in Africa, you can use a condom catheters. Now the thing is, is that a a battery balloon costs about 250 lbs a pop. I think they're not cheap to use on. So that's why, in developing countries, a simple latex condoms follows. Catheter is far cheaper. So the way in which a battery balloon works you've got a A drainage channel on a filling channel. So you've got drainage, drainage, child town, channel it the tip, which is just similar to the police captain of the Hollow Lumen. And then you've got this water filled balloon so it comes empty. You pass it through the cervix on, and it sits inside the uterine cavity, and then you fill it up with water, and you know you normally you're gonna need a good 506 100 mils of water on what that does is it expands and pushes against the endometrium in the myometrium from the inside. And then you're giving your uterus tonic drugs from the outside. And essentially, it's squeezing the uterus between those two things and providing compression from the inside and outside. And you can then also monitor the ongoing blood loss through the Janeane Channel. So you can you connect a drainage bag to the end of that, and you can see if there's ongoing blood loss through there on. That happens exactly the same for the condom catheter s O. If that manages to get on top of the bleeding, that's fantastic. If not, then you're thinking about other surgical methods of control of bleeding. So this is what we call the be lynch uterine brace suture. I have never done one of these, and I hope never have to need to want to do one of these because the vast majority of things settle the step before with your pharmaceutical management. So if you are midway through a cesarean section, you've already got the abdomen open. Marvelous. This is what you do. If you have tried your you've done a vaginal delivery and you've tried joining to try and balloon. It's not working. Then you think about your race, You So you have to create a laparotomy. So you have to do a transversus Ishan like you would for a C section. Get down to the uterus. You have to open the lower segment. You pass your stitch in and then bring it out over the top, looping around the back. That's it. Through posteriorly, as you can see here and then back over the top down and out. And then you tired to cross. So you kind of create a lovely pair of braces for your uterus and and squash it down, Um, and then over here is what's called you tryin artery ligation. So we've got Butrans arteries coming in from the said the branch of internal I lack. You find where it is running up the side of the uterus on. Do you pass a suture around it on either side to tie them off and to reduce the But for now, these are dissolvable stitches, so they will dissolve in times. It's just about reducing your blood loss temporarily again. I'm not. I'm not even have to get to here. I hope Never have to get to hear These are advanced surgical methods that you would not be embarking on anything other than on experience consultant on then the final surgical management of a postpartum hemorrhage. If you've tried all of these and then you tried all of these again and the woman is continuing to bleed, then the only other option to consider is a peripartum. Distract me. So removal of the entire uterus, which obviously means that you have, would no longer be able to have Children Naturally. Um, it's a very difficult procedure because your term uterus has got huge caliber blood vessels. The anatomy is all distorted, is normally something that needs to be a decision by two consultants who are in agreement that this is the right course of action to take. And when you are taking women to theater for surgical management of the people that you do always need to mention the possibility of a hysterectomy because sometimes you start these procedures on spinal anesthetic. But if you're embarking on to a hysterectomy, then you are gonna be anything ties in that woman on the general anesthetic, and you want to make sure that she's gonna be aware that she might wake up without a uterus on again. I have only seen one peripartum hysterectomy. Um, and that was due to a woman who was known to have a bleeding risk because she had a percent of a creature, which was, you know, is where a placenta invades ALS the way through the wall of the uterus and ended up in her bladder on. That was just one of those ones where there was no way that you could safely managed to get that percent out without her bleeding to death, other than removing the uterus at the same time on. So this slide is just a sample off the PPH documentation she sheet that we use in the trust I currently working. So the duration a massive obstetric hemorrhage describe is one of the most useful people in the world on. Do you need to have someone who is going to be able to accurately document who's there? What's going on? What time of your major interventions, what time you given your bloods? What time do you think about going to the theater. You know, it's a really helpful aid, Manoir, because sometimes describe can say, like you given. Second, since Metron have you started giving him a bait, which is carboprost, you know, Have you given at the right time, you know, because 15 minutes is elapsed Now, cover later on in a summary slide. The kind of the drugs that we give our they act on what? The doses on the intervals and all that sort of stuff. So every unit that you work and should have a P ph management pathway on a P ph management scribing sheet on begin. This is a flow chart from our local guideline, which is adapted from the college guideline, which is talking about major hemorrhage so lost great in 1000 on. And how we follow that and is engine is just a summary. It'll the things that we have talked in our I'm just now. So all of your medical therapies, your A B C D. Assessment on your threshold for taking a woman through to theater. I'm just mindful of time, and I'm waffling on forever. So talking about fluids and blood products, this table here on the left is taken from the college guideline in terms of of what we give him when, um, on the right hand side so that there therapeutic goals BPH management. You're constantly monitoring your your your your lab work and sometimes point of care testing that he McCue. So Amy's try to have a hemoglobin above 80 platelets. Great 50. Your clotting factors are you. I hope that you got underneath distance going to manage all of those because you're busy trying to sort out the bottom end. Um, so, normally, if you're having a major major hemorrhage, you're giving blood and fresh frozen plasma in a 1 to 1 ratio on. But you're thinking about things like platelets and crying for his precipitating. If you got a low platelets or or or high fiber religion, you think the guideline does talk about is the thought about cell salvage. So if you work in a big enough hospital where you got ready access to sell salvage and they Kenbrell a cow an emergency, that's fantastic. If you've got a savings sample elective procedure where you got a patient who's either ah, high bleeding risk or known to refuse blood products to say for example, jobs witnesses pre booking self salvage for that can be really, really helpful. Um, a brief thing to talk about his human factors related to obstetric emergencies with obstetrics and management of labor ward. It is a multidisciplinary team. It's used the obstetricians. It's the mid wives, your shift leaders. It's your health care assistance who might be running off to get Bloods. It's your anything test. That's your theater team. There's so many people that is involved in magical emergency, and communication is something that often is the root cause for a lot of problems, and we'll talk through some case study shortly on. But we can talk about some of my personal experiences with human factors on. It's not just about communication with staff. It's communicating with the patient starts about the birth partners because quite often the patient in front of you is kind of just dealing with it, and they might be kind of zoned out. They might be kind of disassociating from it the partner, whether that be the romantic partner, the, um, um father, sister in law. Anyone who's in that room can be traumatized by by these events and actually communicating and debriefing with them is also really important. Um, as we mentioned, a scribe is really important is someone also need to maintain that kind of one step back. That helicopter view it tends to be the more senior people, and that's one of the reasons why I quite like quite like but 11. My preference is to perform by manual compression, because that's one job that you can do while thinking about all the other steps. If you've got you know, if you if you enter a room in someone's already doing by manual compression, then one of things that you can do is just take a step back, hum, monitor the situation and actively manage everyone else. If you're the junior grade in the Room IV access, that's all you need to do on. The other thing is escalate, escalate early and escalate high. So if you are the junior, you call your middle grades that you register. If you're the registrar, call your boss if you have. If you've got bleeding, especially if you think you out theater, whether it's daytime or nighttime, it doesn't matter it up. The phone call for help because you're gonna want it sooner than you think. And when you come to the end of your case, it's always about the D's, So you've got to think about what you do after everything finishes, so documents. So you got to write your management of events. And that's why the scribes so key, because you got to be able to show that you've managed everything in a stepwise manner at the right time. Debriefing. So that patient that's birth partners, that staph that's a verbal and potentially written discussion as to what you don't. Why the implications The Long term Outcomes Day Taixing, or whatever kind of risk management reporting software that you have any blood loss over the over 1500 mils is on obstetric instant that need to be reported investigators the other ones of doughnuts and drinks or entire optional. But you need to have some self care after any form of emergency on. So these are things that you need to look after yourself with on a brief talk on secondary PPH. So these the PPH is after 24 hours on up to six weeks. Afterwards, the initial management remains the same. So with a B C D, and these tend to be women that coming in from home, saying, Well, I had a normal vaginal delivery three weeks ago. I'm now bleeding, um, in pain. I don't feel very well, so quite often we need to do things that have done. The examination, respectful of examination, will assess the genital tract microbiology with high vaginal swell attention and despite course, walk. Quite often, we treat with empirical antibiotics to treat for, in fact, the lining of the womb. Quote. End of trying tests. Um, Andi. We also consider using a pelvic ultrasound to try and look for retained products of conception to say, for example, a small piece of uterus uterus, a small piece off presented that might remain in situ or some blood clots, Or what have you sometimes with postpartum ultrasound scan? It's quite a difficult one, because if you scan a woman within the first few days of delivery, you're always going to see something inside that uterus. You're always going to see some blood clots. It's how much you're going to act on that, because if you take a woman back to the operating theater postnatally for a surgical evacuation, which is where you pass a suction tube through the cervix into the uterus. There is a risk of of perforating the uterus. The risk of perforating a non pregnant uterus is about one in 1000 and that goes up six fold to six in 1000 in the immediate post natal period. And you sure the absolute numbers of six in 1000 aren't that high? But when you say it's a six fold increase, that's actually something that you don't really want to undertake to readily on. That risk can be higher if a woman is breastfeeding, so that's a bit of a battle through on going to do a few case studies now on DTA Talk about some of the potential presenting features off some of these PPH is These are all patients that I have actually managed within the last month. So these are common, common, common obstetric presentation. So we've got Ms is a 36 year old lady. Let their sexual Maybe she's a para 33 normal deliveries. She got raised. Bm i. She's got twins on board. She's being induced a 37 weeks. She's needed a lot off induction age is to start her neighbor. She's then been augmented with Sentosa. No, she's gone up a jury and set you. She's needed to have assisted delivery. So both of her twins, the first one I needed to have an A P Z arteries help make room to get them out. You delivered the placenta, and now you've got risk bleeding. And just take a moment to have a consideration of what you might be thinking about in terms of your underlying cause. You hope by now this one's got IV access. You'd hope that some stage in this labor even before she had come in the hospital. I hope she's got IV access on board. Um, this woman's poor uterus is like a deflated hot air balloon. She's having an atonic PPH. She has had a uterus. It's been stretched for weeks and weeks and weeks. It's already had three pregnancies and deliveries, so it's tired. You know, it's labored for hours on Sentosa non on, and she's also having assisted delivery. So the second state has been accelerated and that you just just doesn't know what it it. So you're gonna manage her with an A B C D approach. You're gonna give her those uterotonic. You assess that up? Easy, Artemis. You've done it correctly. You've done at the right angle. It's not bleeding too much, but it can be a source of trauma. So you need to make sure that you close that you're actively managing her blood loss. You're asking the staff to weigh it at the end of the at the end of the closure, you're happy that you're keeping on top of it. You are not concerned with the vital signs. So the outcome is that she has an 800 mile blood loss. The bleeding settles, and you just say, Well, we need to a full blood count six hours postnatally to make sure that she doesn't require any transfusion. And she may need some iron. This is be a 19 year old. Prime it. She's being induced a 38 weeks for pelvic girdle pain. Matt request pelvic pain. She gets augmented with some toast in on just never. General, Uh, she has rapid progressive, fully dilated. And she has a kiwi delivery, just fetal to stay distress on maternal exhaustion. You carry on a PCR to me on, but she's got a very vascular paraneal with very bleedy vessels. It looks like little fountain jet off coming out of that paradigm. And she's bleeding actively, very, very quickly. Um, so the cause that PPH is trauma, you make sure you try and tone is adequate, but you're pretty sure that's going to be the case. You try and get that trauma close as soon as possible. He makes your school IV access. You give her fluids, you take bloods, you consider. And you would give tranexamic acid because tranexamic acid is gonna help to reduce that blood loss. Because not tone issue on you. Consider transfer to this lady. You think all the blood loss was only about 800 mils? That's a fine. You walk out of the rooms to your documentation. The midwife comes and she said, Well, I've waited all of that. It's about 1700 mils there your crumbs So she's lost a lot. She needs to have a head pendency obs socially Half hour early on, she's that indwelling catheter with the Iran Better cross match of two units on back. Chew a lien. Fortunately, her postnasal hemoglobin is only 107 which is not significant drop, then she's systemically well, um, Final case study. Mrs. See a 39 year old patient power to to previous normal liver issues and induction in labor after her, her membranes ruptured, she stays at one centimeter for quite some time on, despite all mending her labor, you then get an emergency, but because the midwife think she's having a seizure because she was suddenly very, very rigid. Uh, you do your A B c the assessment, and you actually realize that she's gone from one centimeter to fully fully dilated in about 10 minutes, and that would probably make me go a bit rigid in a bit. Upset on the baby has also not really enjoyed that sudden process of coming rocketing through the perilous, and it's having a fetal bradycardia, so the heart rate's dropped. It's not recovering, so you need to expedite that every soon as possible. So you do a rapid forceps delivery in the room. Brilliant. I've done a really good job of Save that baby, and you can think about closing the A PCR to me and make yourself covered. However, the placenta's in situ and she's leading. She's lost about 800 mils meeting. Okay, We need to think about going to data. So when you get to that 1000 Miles lost you, then take her to the operating theater and you have a chat with your anesthetic colleague about General anesthetic versus Spinal. We opt for a spinal shots further, 500 mils of blood loss. So we activate the major obstetric hemorrhage. Preschool. Get up, center out as soon as possible. However, we give her you tonics. It closed up easy on me, and yet she's just pouring blood. Poor important. It's like a tap that's been turned on and will not stop. There's also no evidence that any of this blood is clotting together. On it is just water. It's like dilute squash. You try putting a battery balloon in that still not doing it. You're ah, hemoglobin. In the middle of theatre, she got platelets, the platelets of 17 and a hemoglobin of 55. She has an underlying clotting disorder on, and the only way they're going to make her feel better on to arrest this P. PH is to give her a clotting. Factors back on DeVry thing else is just about actually resuscitated the patient while you're waiting for blood products from the from the lab on. So she has a seven liter blood loss. She requires multiple blood products. She is considered for escalation to intensive care. However, she's settled enough that she could be on high dependency on the battery Balloon is captain of 24 hours, and the patient made a full recovery. So we're coming to the end. I'm really sorry that we're not getting much time for questions, but I am happy to stay a little bit longer. If everyone else's would say BPH is a common of sexual emergency was about 10% of pregnancies could be complicated by P. PH. There are multiple risk factors, but it can occur in the absence off any risk factors whatsoever. As we discussed, worldwide hemorrhage can on often is fatal, and it can still be fatal in this country. If not manage appropriately, we have to manage it with MDT approach For junior colleagues, make sure that you've got IV access. That's the only thing I want you to do and everything else you could just be helpful and manage an AB CD approach. Remember and treat your forties. Maintain your scans of communication. Consider your human factors escalate, escalate, escalate. I always remember to document, debrief and date X in terms of the drugs that we use in a P. PH. On the left is the medications that you use on the doses and the mode of action. I won't go on at length about all of these different things. Um, I understand these lights gonna be uploaded to a platform where you can review that later date. Um, apologize to your midwife because you're going to give a lot of medications that encourage smooth muscle contraction because all of the uterus tonics encourage smooth muscle contraction because that's all the uterus is. Unfortunately, the other thing that is a smooth muscle in that region is the bowel. And it's very, very common for a lot of these you tonics to cause quite profuse diarrhea. So the poor woman and new apologize to her to the poor woman is going to have quite a turbulent time with her bowels during this postoperative period on, especially if she has had a spinal epidural. It's not particularly mobile. It's going unfortunately, well, quite a lot of changing of pants, and she eats but is a necessary evil. And that's me with two minutes to spare. I hope that's been helpful for everyone. Um, I hope that, um, that it's been informative. And I welcome any questions. Thank you so much. Well, that was really fascinating. I really enjoyed the talk. I was glued through the whole thing. We just have a couple of people who are asking about, um so they've got So I think someone is in an ambulance service and other persons in the community. And they've said that they have me is a prostate all someplace or rectal as a first attack. Prehospital. Yes, a drastic if that's also used in hospital. So, yeah, as going back, that's, like needs a prostate. Or we do use in hospital as a kind of third line drug. And the only reason being that in in the ambulance service on in developing countries the reason I mean the prostate is useful is that it doesn't need to be stored in a fridge. So that's why it could be used by Kroos. Call it our colleagues in the ambulance service. Whereas things like sent ocean on ergometric sent a metric compress. They have be stored in a fridge, so there's a sort of practicalities around it that could be difficult s so that's why they're first line. The reason why they're not first line in in in in the secondary setting is that the mode of action from the prostate only reaches peak activity anywhere between 30 and 180 minutes. So it's a bit of a delay in it kicking in, so it tends to be for us in hospital. We give it at the end of a case once you're happy that everything is settling. But Maura's a kind of this will help over the next few hours to keep minimizing the blood loss. Thank you. Um, another question is, I think Wrinkle is answered it. But is the battery balloon used only for a tonic causes of bleeds or kind of used to be used for other reasons as well? So we mentioned the clotting issue. Yeah, it is mainly used for a tonic P pH is. It can be used as a step to kind of help to reduce the blood loss in in a clotting disorder. However, the only way you're going to arrest bleeding secondary your clotting disorder is replacing the clotting factors on. So, yes, it is mainly used for a tonic. PPH is a traumatic PPH. If you've got a really bad vaginal trauma, putting a back people lose is not really gonna help. And you can't put anything that you could do to help with. Vaginal trauma is following closure is put a ribbon Gore's pack into the vagina and that sometimes something that we use is that you're packed the vagina with with ribbon. Gore's as much ribbon goals you can put in there to put local pressure against the against the walls, the vagina. Unfortunately, with that again, it's really uncomfortable on. So you want to try and get that removed a soon as possible? Yeah. Um, I think that's it for questions. Thank you. Honestly, thank you so much. I think it was really fascinating book. Thank you. Know you're very welcome. And thank you for attending. Okay. I'm going to switch off the live feed now. Thank you so much. We love meat, You know, problem. Thank you.