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Hello, everyone and welcome to our, er, next middle education talk. We have David back with us. Er, he was off for a little while. Er, he has three events already on the platform which you can get on catch up if you want to. And this one today we're gonna talk about postpartum hemorrhage um, as always pop your questions in the chat and David will answer them at the end. Um, and also the feedback form will be in your inbox in an hour's time. We want you to fill that out and then you'll get your attendance certificate. So without any further ado I'm gonna pass you over to David. Thank you. Thanks very much, Sue and good morning everybody or at least where I am. It's morning. Um, and uh good morning and welcome. So today we're going to talk about postpartum hemorrhage and as, as usual, um, there will be some, a few questions for you at the end to test your knowledge, see how much you've been listening. And as we also, as we go along, I've got a few cases to discuss which I hope that you'll put your responses into the chat box and sue will then read them out to me so we can see them how we're, how they're, how we're progressing. Um, and also, as sue said, if you have specific questions that you want to raise, if you put them in the chat, then at the very end we'll try and deal with those as best we can. I hope that's ok. So, um, one of the things that's worth recognizing is that, uh so th this talk, er er is about postpartum hemorrhage, about bleeding after delivery. Um and there's a reference on the screen uh there which is from the British Journal of Obstetrics and Gynecology, er, from the year 2016, that's freely available to everybody. And I would suggest that you read that along with this because that contains um the most up to date uh national guidelines and international guidelines on the management of postpartum hemorrhage. And a lot of what I'm saying today will be based on that as well as from my own experience. Um And from, of course, uh up to date scientific resources, I didn't just make it all up. So, um the learning objectives have been set for today are to be able to, first of all, to be able to assess and quantify blood loss in someone and to be able to differentiate in your, in your eyes, in your head, in your mind, the difference between normal bleeding and excessive bleeding. Um And when you see somebody who's bleeding, you, you need to understand and be able to deliver quickly. The first line, the first line management techniques for dealing with postpartum hemorrhage. You, I want you to be able to understand how to coordinate with, with others involved in the woman's care, which might be uh nurses, it might be surgical teams. It will almost certainly involve anesthetic teams. Um but it will also involve people like the porters, perhaps at the front desk of your hospital who will be involved in making sure that blood samples get to the laboratory or blood for transfusion gets back up to you and letting them know that there's a real problem and that your problem takes priority over every other single thing. It's really important sometimes to let those guys know because if blood sits on their desks for half an hour while your patient is bleeding to death, that's not very good. You need to be able to uh interact with the patient and particularly with their families because they will see their loved one, lying on the bed looking terribly ill because they are and they will be asking you questions and you need to be able to deal with those in a, in a, in a honest truthful, direct manner so that they believe you and trust you and you need to be able to talk to the patient. If they can understand you, you need to be able to talk to them and tell them what you're doing and, and ensure they are with you as you go along. And then I think with something that's really important. So you've dealt with the problem, the woman has gotten better. I think it's really a problem then important. Then also that you all sit back and you look at how you manage that case and you look at what went well, what didn't and most importantly, what you could do better for the next time. So these are some really important things to try to learn from the experience. OK. So let's get on with it. So, um uh it's perhaps it's uh a bit um salutary to start off with maternal death. But if you look at this diagram, this uh this diagram represents the causes of women dying in England, Wales and Scotland uh in a three year period 10 years ago. In fact, and what's important to realize is that hemorrhage, mostly postpartum, hemorrhage, hemorrhage uh is the cause the fourth most common cause of women dying in pregnancy. And the most common cause is cardiac disease. Uh because in this country, women with cardiac disease have been living longer and having babies into their and having babies, which previously they wouldn't do. Uh And then, so that's the, that's the most common one, other indirect causes mean things like um car accidents, accidents at work, um murder killings, things like that, which are not to do with maternal health care, but then thromboembolism followed by hemorrhage are the biggest causes. So from the point of view of most of our practice in an ordinary hospital, not, not in a big center with lots of heart disease. The biggest causes of death will be from first of all, thromboembolism and secondarily then hemorrhage. So it's really important, I think for, for all of us to be aware of that and for us to be very alert to the fact that when somebody starts to bleed, we need to think this could be really serious. So some, some rules of thumb about trying to judge the severity. So here's the situation. Uh a woman, the woman walks in, uh she's not short of breath, her clothes are clean, there's no blood staining on them and she's able to answer your questions without difficulty. When you examine her, you might see some blood spotting on her underwear or her sanitary protection. And there might be a little bit of blood loss that has settled. Her BP is normal. Her pulse is normal. This woman does not have severe bleeding. This is minor bleeding. On the other hand, another woman comes in on a stretcher or in a wheelchair. The blood has come all the way through her clothes. It's on her hands and down her feet. There's a steady trickle of blood through the vulva. There are several towels soaked through and she may be showing signs of clinical shock, which means that she's hypotensive, her BP is falling and she's got a raised pulse. That's a much more severe situation. This is major hemorrhage. Uh, you don't want to panic because panic is unhelpful, but this should ring alarm bells in your head and you should inform those around you of the fact that this is a major hemorrhage. And hopefully they will understand what you mean by that when you say those words and you hopefully will have told them in advance what this means, but this is major hemorrhage. And because of it, the, the the woman needs to be cared for in a much more intensive way. So if it's minor, then she needs to be looked after. Obviously, she's bleeding but not seriously. So she'll need intravenous access. A 14 gauge cannula will be adequate. She needs blood to be taken for group and, and screening for her A B and rhesus status. So you need to know what her full blood count is and you need to know what her coagulation screen is because if she's bleeding a lot, her coagulation could become disordered. And in terms of monitoring, you want to keep a close eye on her, you want to watch her pulse, her respiratory rate and her BP every 15 minutes or so. And you want to start giving her some fluid replacement. And what you should be using is not normal saline, you should not use normal saline because that is, that has no value in terms of maintaining blood uh volume. It will go out of the blood vessels almost as quickly as you put it in. You want to put in crystalloid, not, not saline, but crystalloids and uh fluids like Hartmann's uh and have it warm. So you don't, you don't make the patient any ill. Try to have it warm, running it under a tap is adequate to warm it. Um a hot tap and get on with trying to get that into her body for major bleeding. However, there was a lot more to be done and a lot more urgency involved in it. So first of all, there's those standard things of resuscitation about ABC assessing airway breathing circulation, you keep her flat, uh as much as possible, you keep her warm, using all the available measures that you might have. So blankets, warming blankets that they might that the theater might have. Um and uh and so on, you want to get blood into her as quickly as you can if she needs it and until the blood is available, you should give her uh clear fluids, generally crystalloid, not saline. Um and up to 2 L or so of that can be put in fairly quickly to get her blood volume expanded again. So there'll be some transfer of oxygen in and carbon dioxide out uh with whatever blood cells are present and you should be using either crystal light or colloids, which is those gelatin that's referred to there, you should not use the hydroxy ethyl starches because they are ineffective and have been shown to be unhelpful, whatever you can, you should be using to try to make sure that the fluid you're putting in is warm. And although normally you might use a blood filter to make sure the patient doesn't get any sort of reaction against the blood. Then in this situation, it's not sensible to use those because they slow it down and you want to get it as fast as you can. So, assess and quantify the blood loss in a postpartum patient. So how do you do that? What, what measures can you make? So, just think about that for a moment. I'm not, I'm going to answer the question, but I want you to think just for the moment about how you might try to quantify blood loss clearly, if you do um a full blood count and her hemoglobin is four, that will tell you that she's lost a lot of blood. But don't forget. But if her hemoglobin is 10, that's probably not accurate. 10 or 100 depending on which measure you're using. But, but if it's just below normal, then it's probably not accurate because she will have concentrated her blood and until it re expands, then you won't know the true state of her hemoglobin. It will probably be lower and a lot lower than what is read on the laboratory result. So, what, how else can you try to assess and quantify blood loss? So, clearly, things like BP. If it's low, I will tell you that she's probably lost some blood volume. If her pulse is high, then her heart is working harder to try to get the pulse, the blood around her body. If she's got, uh if she's breathing excessively, then she's trying harder to transfer oxygen in and out of her body, um, to keep her, uh, oxygenated. What else? So, this is a fairly gruesome picture of a woman who'd had, uh, a massive blood loss at Cesarean section. And it should be obvious to anybody looking at this picture that on the patient itself, on the bed, on the bedding, on the floor, there is a massive amount of blood, uh, and this patient has probably lost 234 L of blood. Now, if you really wanted to do to measure this, what you would do would be to collect it all up in, uh, in towels, uh, weigh them and then weigh the, uh, clean towels to try to figure out how much blood she's actually lost. And that will be a reasonably accurate measure. But, you know, in this situation, looking at it, you, you could tell that actually measuring it isn't going to be terribly sensible because she's had a huge amount of blood loss. This woman has probably lost at least half of her blood volume of four or 5 L. So, therefore, she will need at least that amount of blood. Um, and she will probably have disorders of coagulation because of the amount of blood she's lost and the amount of clotting mechanism she will have induced. So, this one is easy in a sense, it's more difficult when it's just a small amount of bleeding. But the same rules would apply about weighing the, uh, the towels that she's lying on and trying to ensure that you've got some rough idea. And don't forget that. Oh yeah. Don't forget that. Whatever you think the blog law is, you're probably wrong by a factor of a half. In other words, if you think it's a liter, it's probably 2 L. If you think it's 2 L, it's probably four. So visual estimation is not reliable and you need to try to get something more accurate, particularly if she's going to be very sick and you need to be more, more strict about her fluid replacement and so on because that's what's so often the blood loss may kill her. So she may die from that. But often it's the mismanagement of the blood replacement and the fluid replacement and um not being careful about her intravenous pressure, uh and so on, um will be the causes of her uh having really severe illness and morbidity if not even mortality. So, one of the things that's important then is that we try to as much as we can to minimize the risk of getting such terrible blood loss. So there are a few things here that I think are really important from the point of view of clinical practice. Things that I think, uh, from, from my, from my life, I've seen being really important and being uh useful things to use to minimize blood loss. So, one of the things starting from the top, I mean, you all can read um and I maybe I don't need to read them but, but it's important to point out perhaps. So II think that for all women who are delivering once the baby is delivered and once you're sure the uterus only has placenta left in it, you should give her an injection of probably syntometrine or sinos on to ensure the uterus contracts. Um and probably Oxytocin 10 units intramuscularly is probably the ideal choice. Um and giving her a lot more than that isn't going to be hugely beneficial if she's having a Cesarean section, giving that dose uh intravenously is very simple because there's intravenous access. Uh and that will be useful to cut down the amount of blood loss as well. And in women who don't have hypertension and who are at risk uh of bleeding, er, giving ergometrine and Oxytocin, often syntometrine as the product we might recognize er, is useful. And one of the things I think that has been interestingly uh noted in the last 5 to 10 years has been the increasing use of Tranexamic acid given intramuscularly or intravenously in addition to Oxytocin um to reduce blood loss. So I I've used oxamic acid a lot in in operative situations to reduce postoperative bleeding. And I think it's a very useful drug. There's lots of good evidence to support its use. But from a practical point of view, I think it, it is practically a, a very useful drug to be making use of. I would, I would highly recommend it if you can get hold of it. Trinex Amic acid is the same drug that we would often advocate for women who have heavy periods because it cuts down the fibrinolysis. Uh and the same, it's the same mechanism of action in terms of postpartum hemorrhage. And this is the evidence that at cesarean section, it reduces the likelihood of bleeding uh by half. Um prostaglandins uh are, are often used, but they are no better, no more effective than using a combination of Oxytocin and ergometrine. So um drugs like carboprost and various drugs like that that are used to inject the uterus with actually are no better than a combination of syntometrine uh or oxytocin, ergometrine. So the old simple drugs are just as effective as the new more fancy drugs in that regard. So what's the role of ergometrine oxytocin versus Oxytocin? So there's very little difference between them, in fact, and the, the the difference is barely in favor of the Ergometrine and Oxytocin, uh, balance. Um, I'm, I'm old fashioned and I grew up when I was, when I was a trainee. Um, uh, it's a very long time ago now but we, we always used, uh, ergometrine and Oxytocin and, and it has some unpleasant side effects. Um, it almost invariably will make women sick after they wake up from the anesthetic if they're asleep. So we would have used it a lot in situations like uh dealing with miscarriage and doing evacuations of uterus and would have always wanted to use that. Um, you can see it's working because the pulse rate goes up because it stimulates the pulse. Um, and you know that it's on board then, um, but it does have some unpleasant side effects. Oxytocin is nearly as good. There's almost no difference in their, in their value. Um And therefore you kind of think well, so, which should you be using? Um, and I think that you will often have to find yourself being um favored or, or persuaded by the anesthetist because if they are prepared to put up with the sickness that the woman might get, uh when she's asleep. And remember that if you're sick, when you're pregnant and you're asleep, then your regurgitated contents will probably go into your lungs and cause that awful condition where you've got an acid, uh, um, pneumonitis, which is very serious. Um But if they're prepared to deal with that and they've got an endotracheal tube down, then the patient will be safe if they're only using a mask and they probably will not be safe and they won't agree to it. But it's important to realize that that the old methods are probably slightly better but carry a lot of risk with them, which is why a nieces this often now will not want to use them. So that's for uh them. And remember this is a situation where the blood loss is about 500 mils. So not a huge blood loss, if we then look at a much greater blood loss situation, and we compare Oxytocin and ametrine against Oxytocin. The situation uh is actually less clear. And if you look, so I'll just flick back up to this slide. So on this slide, if you can see here, the, the the ratio that the benefit is a an e 18% increased benefit in favor of ergometrine and Oxytocin. And the numbers back here 71 to 95 suggest that because it's below one that it actually is significantly uh measured statistically, it's significantly different. On the other hand, when you look at the situation with blood loss over 1000 mils, and you look at that bottom right hand corner again, the number suggests that probably a 22% difference between Ectrin and Oxytocin and Oxytocin alone. So Oxytocin is still not quite as effective. But now the numbers cross one, which means in fact, the difference is not significant. So, particularly for blood loss over 1000 uh using ergometrine, er, is less beneficial than Oxytocin uh would be. Uh and probably the benefits of using Oxytocin alone outweigh the risks of using the ergometrine because of all the side effects of it. I hope that makes sense. And if people want to come back afterwards to question me on that, I'm very happy to do so. But the big difference here is that in an average amount of blood loss, 500 mils, 600 mils using ergometrine is probably a useful way. But when you get to be 1000 or more blood loss, then Oxytocin is probably the better one to use because of its safer profile and it's no less effective. And also there's, there's no benefit. I hope my wife's gonna answer the phone. Maybe, maybe she's not one second. Ok. Hello. Hi, this is Alex calling from the Estate Planning helpline and we're just contacting all homeowners today because of the government's new changes. I'm sorry, I'm sorry, I'm, I'm giving a lecture online. Sorry, I have to hang up, like, sorry about that. Um, so the other point is that, uh, using a small amount of Oxytocin in this situation or a large amount doesn't really make any difference. The benefit isn't going to increase significantly if you use a huge amount of Oxytocin. So there's no benefit in doing. So it's a waste of, of drug. It's a waste of money doing that. So the fluids to use. Um, so the best fluids from all this list are blood and fresh claws and plasma. Now, if you are a half an hour away from the source of blood, then you're stuck because you won't have those readily available if you work in uh many city hospitals. Um, in, I've, I've worked in, uh in Sma Lander in Herges and worked in a hospital there where they had their own blood bank, they had a laboratory on site and they were able to deliver your blood within 1520 minutes. But if you're much further away, you may not have that accessible quite so easily. And therefore you've got to plan for other ways. So the two big fluids to use are crystalloids and colloids. And if you don't know what those words mean, go and look them up and find out that you know what they're talking about and find out what you know, what they mean in practicality, what a colloid is and what a crystalloid is and they are not normal saline, normal saline is neither of those. And you should not be using it in this kind of situation. It is not a safe drug to use. Um So for, for blood, uh if you need blood immediately, then you give all rhesus negative blood cos that's the least uh likely to give rise to uh a blood transfusion reaction and then you switch to whatever the right blood typing is. Once you have that available and fresh frozen plasma will contain the um the blood clotting methods that you need. So there'll be uh the blood clotting proteins, the ones involved in the chain of blood clotting that's required will, will be involved in this and you will be given the right things in that regard. Plasma uh contains all of those proteins. Platelet concentrates are important because of course, uh with blood, as you're losing blood, you're also losing platelets and platelets are very important um because of the their blood aggregation qualities. Um and so giving platelets on their own is really important and you may need to do that separately to blood and fresh fal plasma because you may not be putting back enough platelets with the first two cryoprecipitate uh is a uh again a a blood product which if available will contain the blood blood coagulation products. That will are very important for the various types of factor eight and seven and five. factors that are important when you're doing blood transfusions. If you're fortunate, you'll be working within an east of this to be quite switched on to all of this because they are often more used to dealing with uh major blood loss from road traffic accidents and so on. But if not, you need to be aware that this is the kind of uh ways you should be thinking in terms of getting things in uh plain fluids until you can get blood and then blood and then type specific blood and then fresh f and plasma and then platelets if you've got them. So the cryoprecipitate is rich in clotting factors, which you may need because you'll be using them up faster than you're giving them other steps to take, which are not difficult or may be common sense as you want to be giving the, the woman as much oxygen as she can have. So you want to give her inhaled oxygen of 15 up to up to 15 L a minute and you want to give her blood in the event of major bleeding. So if our hemoglobin is greater than 80 platelets, better than uh 50 to um um so 50 pla plate count, more than 50. Um her pro time is less than 1.5 times normal and so on. You then need to figure out should you be giving her blood or not? So if her platelet count was greater than 80 I think you need to be aware of the fact that she may have lost very little blood, which that blood test might be telling you. But you need to be aware of the fact that when you do lose blood, your, your blood hemo concentrates. So the hemoglobin level will look higher than it really is because you've, you've squeezed down the blood volume. So it may be that your hemoglobin might be 80 or 85 or 90. But actually, it may be really lower than that and you may need to wait for a few hours if you've got the time. But if she continues to bleed in a sense, then actually, clinically, you're going to go and transfuse her. Aren't you talking with the patient, talking with their families? So, if you've ever been in a situation where you've seen something like this happen to a member of your family, it is so scary. Um And you're helpless, you're watching, uh you're seeing your husband or wife with all that blood coming out of them. You know, it's not good because you're sensible but you can do nothing. So it's really stressful. So you as the doctor need to be able to impart calmness and wisdom, not that you tell them lies and say everything is going to be fine if you're afraid it's not. But you say you, you will say things like we're doing the best we can. These are the problems. This is what we're trying to fix. It. May well be that some of the family who are there may be the right blood group to give the woman blood transfusions with. You could ask them, would they would they mind going and have their blood group checked in the lab? If that's sensible, that will make them feel they're contributing also. But it's really difficult to be able to, it's really important to be able to, to do that and um to try to handle that well, so that no matter what happens. So if the woman survives great. Um But if she dies then and, and she may die. But if she does die, at least her relatives, her husband, her family will think that you, the doctors took this really seriously. You did the very best you could. And despite that, she still died. And remember that even if she survives, she may have uh such a distressful time, stressful time that she may not recover from this for months. Um And it may still cause her all sorts of nightmares and problems in time to come. So I think it's really important that you interact well with the family that you be straight with them, you tell them how things are and you move along in such a way. So it's important to work with other people that you're working with around you, the nurses, the midwives, the, the any surgical teams that are relevant. Um And all of those things are important, the anesthetic team particularly will be important because they are quite skilled in all of these matters. Um And so you, you need to let them know, uh as I said at the very beginning, you need to alert people to the fact that there, there's a big problem and that you need to be aware of it. Ok. So what would be a perfect or the perfect situation? Would be if you have already practiced dealing with these things in your hospital. If you've had a chance to say supposing somebody comes in tomorrow morning, uh Saturday morning and they are, uh, bleeding very heavily. How are we going to manage this and to have, have done uh, attempts to try to prepare in advance. But if not, once a woman comes in who's having a major bleed, you need to let the midwife in charge of delivery suite know that there's a problem. You need to let the er obstetric staff, senior obstetric staff. So the most senior person you can find around the place you need to let them know that there's a woman with heavy bleeding. Um uh and you need to let the anesthetic staff know because they will be very helpful at doing stuff like getting in large cannulas into her arm. Uh and so on. She will probably need to have um uh a uh a venous axis ideally uh in her um um superior Vena cava to be able to measure her pressure there. That would be perfect if you could get that. Uh But those kind of things are really important and you can only do those by having a few people around you who know what they're doing on your own. You're probably not going to be able to do all those things. So it's really important that you bring people in and that you tell them this is what's happening. This is how it is. So, these are the people I would say, uh, um, an experienced midwife as well as the person in charge, uh, an obstetric doctor who's not just the, the junior on call, uh, but somebody more senior than that. The same for the anesthetist and the same for, uh, a blood specialist, a hematologist. If you can get hold of one that they should be the most important person. And as I said earlier, it's really important that the porter staff, the guys at the front desk who bring blood samples up and down and blood to the lab or whatever that they understand that this stuff has to have priority because it's so important situations where you need to be aware of increased risk of postpartum hemorrhage. Uh So in our textbooks, we will read about these four things. Tone thrombin, trauma and tissue. So, um these are pointers towards uh things that will tell you whether a woman is more likely to have a postpartum hemorrhage. So for instance, the tone refers to the tone of the uterus. So if somebody's had a very long labor, maybe uh 1824 hours or longer, then it's likely that when she gets to deliver her uterus is going to be exhausted. And the ability for it to start to contract again to expel the placenta will be quite limited. So she, in that case, will have a floppy uterus which will not recover quickly. And so she's much more likely to have a postpartum hemorrhage if she's had um, a bleeding disorder or taking anticoagulants because she's had uh a pulmonary embolus or a DVT in the past, then she's more likely to be, uh at risk of, of a postpartum hemorrhage because her blood clotting will be abnormal if you had, if you had the time and the perfect situation you would stop those, uh, drugs 48 hours or so before she goes into labor and switch her over to uh things like heparin. But most of the time that's not possible. And so therefore, you have to be aware that this woman is more likely to be heavy bleeding. Trauma is uh fairly sensible as a cause but often not predictable. So if somebody has a Cesarean section, then they're more likely to bleed. But if they have a perineal tear, if they have a tear in their cervix, um and all those places happen during delivery, you need to be able to identify those causes of bleeding and to be able to uh then deal with them quickly and so recognize them, deal with them and stop the bleeding and don't waste time doing other things if you can see those are clearly the case and finally tissue. So the, the problem generally in that situation of tissue is of tissue left behind in the uterus, generally, um maybe a piece of placenta that's still sitting there, that's not allowing the uterus to contract. That's a possibility. Um But, but otherwise it'll be things like, um uh a piece of placenta, almost certainly. But uh on the bottom of the screen, you can see a written placenta accreta. That's a condition which um when I was a trainee, we almost never saw because few women had Cesarean sections. And as the rate of Cesarean section has been climbing over the years, the likelihood of the placenta in a subsequent pregnancy implanting into the scar of a previous cesarean section begins to increase. Um And so placenta accreta, which means in English stock, placenta or, or grown in placenta um begins to increase. And so the possibility that that's the case uh needs to be recognized and very often the the management of a placenta accreta is sadly only to take out the uterus because unless you've been aware of it as a possibility um and have planned a Cesarean section to get in and remove it surgically. By the time it gets to the point of recognizing that she's had an enormous bleed, it's often too late. There's been so much blood loss and so on, the only way to rescue the situation is to remove the the blood vessel, the whole uterus completely. Um There are other ways of dealing with it, but often in an emergency situation, those in an emergency situation, those are not terribly helpful. Um You can, for instance, uh uh embolize the uterine arteries and that will probably close off the blood. But to do that, you need to have a very skilled radiologist who can cannulate up the uh up the, the femoral artery into the iliac arteries and then into the uterine artery and to identify it and then uh embolize it and all of that while she's bleeding significantly. So those are not easy ways to do uh that, that management. So here's a case history. So, um so if you can look for people's responses to these. So this woman, this woman has a, a twin delivery, uh she delivers the placenta following an injection of 10 units of Oxytocin. The midwife says the placenta was intact it straight after delivery. She had some slight bleeding trickling, but now she's bleeding much more heavily. Uh has stoked, has soaked several pads and incontinent sheets. So the question that I would ask you, uh is, so you're on the labor ward. Uh And you, this woman is there in front of you. What would you do? Now, what will be your next line of management? You all know I'm not medical. So pop your answers in the chat and I'll read them out. Sue can cheat by giving her own answers. Um A to e assessment to me, she says, yeah, yeah, I mean, clearly. So you want to assess her to make sure she's got airway breathing and circulation. Yes, fair enough. But a bit more action. Uh fundal massage. So, fundal massage. So, you may remember that I said in some of my earlier slidess and actually massaging the uterus is not effective. Oh, ok. Well, this, no, no. Well, that's all right. It's not your fault too. No, no. The next we're all taught to do fungal massage and it makes us feel good because we can feel the uterus contracting under our hands. But actually, it's not really effective compared to other things we could do. Ok. Salmon says palpate her abdomen for a soft uterus and then do a bimanual uterine massage. Um mm. Ok. Yeah, I uh I'll accept that as being a step further forward. Yeah, he's definitely getting you to think today. Of course, any other options. Uh I will quickly call for help and use the emotive bundle bundle CMO tiv E it's in capitals. Ok. Maybe, maybe AAA set of uh a acronyms that we don't understand. Ok. But you know, calling for help, calling for help was always the right answer. Give her more of Oxytocin, give her more Oxytocin. Thank you. A ok. And besides Oxytocin, oh, ergometrine, ergometrine, well done. Sue. You're very good. Um So yeah, exactly. Give her ergometrine because unless it's a huge amount of bleeding, it's likely to be effective as well as the Oxytocin. Good. Now, that's an important step forward. What else? So ABC means airways, breathing and circulation. So what can you do for the circulation? Give her blood Mm. Maybe a blood transfusion. Yeah, maybe give her blood. I, well, the first instance, give her what IV fluid, I viv fluids. And does anybody want to say what kind of IV fluids she should have or not have? I've got emotive down again. I don't know what that means. No. Mean, crystalloids, crystalloids. Ok, great. We'll move on to the next one. Good, good answers. Well done. So you did a really good job there. Thanks. OK. And the next one is after a short labor and a second stage of 35 minutes, a woman delivers a baby of 4 kg. Two hours ago, she's now started to breed to bleed, sorry, moderately and continuously. She's not breastfeeding. Consider the possible causes for her bleeding. So this is not about management. This is about why could you be bleeding, given those set of circumstances? Ok. I've got a toy at O NY. Yes. Good. Now, is that likely with a short labor and a short second stage? Ok. To me, she's really giving us lots of answers. Uh Retained placental tissue, macrosomia, macrosomia, what will the macrosomia do? So the macrosomia is not the cause of her bleeding. The macrosomia so means a big baby. Ok. Um And 4 kg is pretty big. Um So macrosomia is not the cause of her bleeding, but macrosomia might cause what? Ok. I've got some different answers, trauma to tissue trauma, thrombin, and cervical tear. Uh ok. So now we're on the right track. So you're right. So the likelihood is a short labor and a very short second stage. Really? Uh So there's, there's a risk of things like a cervical tear. Yep, or a large perineal tear that might not be hugely obvious, but, you know, a, a big baby like that with big shoulders, uh, like some big Ulster man playing rugby for Ulster. Um, it's likely that, that she might have some traumatic bleeding from that. So II think that's what, that's what I would want you to be thinking about in that situation now. So can we go on to the questions which you've got? Last question? What's the relevance of the she is not breastfeeding? What's the relevance of that? So if she was breastfeeding, um the drug that gets released when you stimulate the nipples is Oxytocin which causes her uterus to contract. Ok? Ok. If she was breastfeeding, you could put the baby to the breast and maybe it would contract. OK. So then if it was to do with the previous question, it would start uh reducing the blood. Uh Yeah. Yeah, perfect. OK. Sorry everyone. Hello. So you want to pull your questions up? Yeah. Yes, please. OK, perfect. Your first one. Yup. OK. Right. It's up. So what you should be having is a woman with her fourth baby. Normal vaginal delivery. No allergies normally fit and well, she's, she has a pph lost 600 mils due to uterine atony or A, I don't know one of those words, yours is contracted and you're asked to preside, prescribe a suitable drug to prevent further bleeding. So I'm going to allow people to put their choice, their answer choices in the chat. And so you can call them out. There are five options. Yeah. And we've got five responses too. I everyone can answer as soon as possible so that David can explain. Ok. we've got, we've got a clear winner at 50% is the middle one. The Syntocinon infusion. Ok. So you have both the top two and the last one as options. Ok. So I would agree completely with that Syntocin infusion. Um So giving her, uh miSOPROStol or mee, remember I said that prostaglandin options are no better and probably more expensive than Oxytocin products. Remember I said that earlier. So they're there to somewhat distract you syntometrine uh would be possibly. So the one and three would be my favorites uh in terms of doing this, but actually to prevent further bleeding over the next 24 hours, really a drip with syntocinone in it is the most ideal way to make sure she has no further bleeding. Uh Sinomin will only act for three or four hours at most. Um And a bolus of Syntocinone will again only act for about two hours. So giving her Syntocin an infusion over the next 24 hours would be the ideal thing and you could of course, be tailing it off and stopping it if there was no bleeding at all. Ok, great, good. Uh, thank you asks David, um, 1 g of tranexamic acid question mark. So, um, that, that would, so that wasn't an option that I gave, but that would not be a stupid thing to do. That would be quite a sensible thing to do. Yeah, I would agree. It wasn't, it wasn't in my options, but actually giving her a gram of tram acid would be a good idea. Well done. Whoever said that, uh, that was Rinky. Well done. Ok. Next question it's up. Now this question is all about causes. They're all big babies. Mm. You don't see many babies that size in Bristol. Old scrawny. Ok. We've got a few answers. Uh, oh, we've got two that are exactly the same. Uh, the baby's weight and her labor was 16 hours. Those are the two top ones with the 46% each. Oh, no, the labor was 16 hours has now gone up to 50% and the baby's weight 43. So, II would, I would think, uh, if you look at all this, what? This is our first pregnancy. Um uh So she, she's 39. Um, that's probably not the cause of her bleeding. Um, the baby was 4.2 kg. That's a big baby. And again, she might have had trauma to her cervix or, or to the, to the vagina which the midwife didn't see. But I think the most likely cause for bleeding here is going to be the fact that she's had a big baby who gave her a 16 hour labor. And that long labor is probably the, the most likely factor that's going to give rise to her youth was being tired and Atonic. So I would be inclined to go for that one in this situation. And I think that that's probably this case and therefore the management of this, I think would be to give her some uh some sento on to keep the uterus well contracted notice. Also the baby had a bottle feed, not a breastfeed. Um And so there's no oxytocin being released from the brain to tighten up the uterus uh sort of more naturally. Is that OK? Perfect. Shall we go on to the last one? So maybe this question is a bit unfair because I didn't deal with this at all during the lecture, we dealt with primary postpartum hemorrhage during the lecture. Um But hopefully you'll come across this kind of situation in clinical practice and will therefore understand what the likely causes are of bleeding in this kind of situation. And if not, we'll discuss it. Now, what is Vaughan Willebrand's disease? Will brands, what is that? So, Von Willebrand's is a uh an unusual condition. Uh It's, it's a blood clotting disorder and it's most often seen in clinical practice in young girls who start their periods and their periods are incredibly heavy because they can't clot their blood. So, for the first, other times you might see it is if you go to the dentist and you have a dental extraction and they, they pull their teeth out and they can't stop the bleeding. Um So it's due to a failure of Factor 13 or something in the blood clotting cascade. Um and um uh it's, it's very rarely seen and, but one of the ways it's either in dental extraction or in young girls in their early teens who start to have periods and whose periods are uncontrollably heavy. Ok. All right. Thank you. So perhaps it should be clear from that, that this is probably not due to Von Willebrand's disease. Yeah. Sorry if I just gave away, I just excluded one for you. So anybody willing to put their name to their. So we have got 52% say Endomet Meis, uh 26% say retained products of conception. Yeah. And 15% say rupture of vaginal hematoma. Ok. So the 50% who said endometritis are the correct? 50% well done. So this sort of situation. So look at the, look at the clues. So it's two weeks since she had a baby, she's unwell, she has a temperature, she feels unwell, she hasn't eaten or drunk in 24 hours uh because she probably doesn't feel well enough and she started to bleed 12 hours ago. And it has been continuing. So Von Willebrand's clearly is not the cause. So which, which of those causes on the list that you've left with four, which of them is most likely to be associated with a high temperature of 40 °C and feeling unwell. And I hope it kind of sticks out like a sore thumb. That endometritis is the one that's the most obvious answer. So for those of you who said rupture of a vaginal hematoma, um, that's a possibility. But, but what would have happened between today and yesterday to cause it to rupture unless she had intercourse which at 15 days after a normal vaginal delivery is probably unlikely. And, and secondly, have you ever heard of somebody having a vaginal hematoma after delivery that then ruptures and causes bleeding, which continues to bleed? Because remember if it's a hematoma, if it's a hematoma, it's a blood clot and if it ruptured, then the clot would evacuate. But would you expect to continue bleeding? And then the other answer was about retained pro of conception. So that's, uh, that's very unlikely at 15 days because by and large before then, uh, it will have shown itself as probably a bleeding in the 1st 24 hours because the uterus won't contract down properly. Um Although often when you, when you do an evacuation of uterus as which might be part of the management, you may find bits of placenta left inside, but mostly the cause is going to be due to infection uh of the wall of the uterus rather than due to any products of conception left behind. So um uh we may want to have some questions about that if people disagree with me and I'm very happy to do that. Should I end? Stop? Um Perfect. Yeah. And then just click back down on the present now and it'll stop sharing. That's it. OK. Great. Click on it again, that plan now bit and stop presenting. There we go. OK, perfect. So do we have any questions everyone? So for those of you who said um answers all of the endometritis, does anybody want to question my logic? And, and I mean that seriously, um sometimes people will feel afraid to question the teacher because they think, oh, I can't, I can't do that because he's so wonderfully important and I'm not. Um but I think, you know, if you think if you really think it was the answer was um retaining products and we should talk about it. So, uh OK. So some Taha you put up the case of the lady who was not producing milk after PPH. So, um now let me that was uh on one of the case histories. So, um so you're asking whether this is due to Sheehan syndrome? So Sheehan Syndrome er, is an unusual uh is, so Sheehan Syndrome is a quite an unusual condition. Let me just shut my door cos somebody's just opened and there's a cold wind coming in. Uh, not leaving. We do keep it real all medical education. Pardon me? We do keep it real on middle education, don't we do? Oh, yeah, I've had my dogs running around like mad things too. Uh, so Sheehan Syndrome, uh, happens when you have massive postpartum hemorrhage. Um, and if you lost, you know, say an average woman who might have 4 L of blood, if she lost three or 3.5 L of blood, she might get Sheehan syndrome after that, but that will not present immediately. So, and Sheehan syndrome represents infarction of the pituitary following on a major hemorrhage much more commonly seen nowadays in situations like a severe road traffic accident in men or women. Um And the only reason it happened in women was because they have an increased blood flow to their pituitary during pregnancy. And then if you shut the pressure off, then you get uh drop in BP and infarction or at least uh uh hypoxia of the pituitary and then maybe infarction on top of that. So the she wasn't producing milk after the PPH. And that was in, in the history story, that was just part of the context of it. She wasn't producing milk cos she didn't want to breastfeed the baby and because she wasn't breastfeeding the baby, there was no Oxytocin, sorry, there was no oxytocin being produced to cause further uterine contraction. Does that make sense? Ok. Um ok. Thank thank you for the clarity. I'm just gonna run back up some of these here uh to see what other people have been saying. We now know what emotive stands for. Oh yeah. He called for help you massage, which doesn't work. Oxytocin, Tranexamic acid IV fluids. Oh yeah. Ok, good. I like that. Um point of care. Testing for hemoglobin and lactate. Yeah. Ok. Very good. Uh torn tissue trauma. Trin. Ok. Yup. IV. Fluids. Hartman. I like that. Yes. Yup. So for those of you who have used emotive, be aware of the dangers of using acronyms that other people don't understand. Um So people generally understand ABC airways breathing um and circulation. So Tenisha, you wrote a to E assessment. What, what do the D and E stand for apart from death and exit? That's it. Sorry. Sue, I kinda hope he does know what he stands for uh disability and E exposure? Ok. Uh So doc, what are the possible guns indicated? And what stress of the blood test? I guess that's a, you know, disability and everything else. Thank you, Wendy. Yup. Ok. So when the prostate dentin is indicated, I guess that um in, in the labor war that I used to work in um Carboprost would have been used last resort almost uh because you used prostaglandins when you had nothing else to give. Um And therefore that's a pretty bad sign, isn't it? That you're using something when you're so desperate that you will use this. So generally speaking, um, II think, I think that, you know, in terms of, uh trying to manage severe blood loss, whether it's due to um doing something stupid, like cutting the uterine artery or whatever, um um which, which can happen and I've seen happen. But the, the standard approaches in pregnancy of giving, um, ergometrine and oxytocin uh are, uh are the most effective you can do. And don't forget that in, in late pregnancy, the uterus is very sensitive to Oxytocin. Um And therefore, I think that prostaglandins have a role, but they tend to be the role of we have nothing else to do. Let's try this, which is rather desperate. I once had a woman who um I did a Cesarean section on because she had bleeding at 34 weeks and she um we did it, uh we did it not in the maternity hospital, we did it in the general hospital. So we would have good access to um the in the intensive care services afterwards. And she went to the ICU after the delivery, the baby survived thankfully. But the mother uh went to ICU and she continued to bleed uh all night long afterwards and we couldn't stop it with all the traditional methods. Um And we reopened her and we shoved three or four huge cotton packs down behind the uterus where she was bleeding from and eventually, um the thing that saved her life was that one of the radiologists took her to the X ray theater and cannulated her femoral artery and went up the femoral artery and into the uterine artery through the internal iliac and squirted in some uh clotting mechanisms to kill off the uterine artery and to um block the arteries both sides and to stop bleeding. That that's not going to happen everywhere. That was in a super specialist hospital. But it, you know, that stopped her bleeding when everything else didn't and couldn't, I'm just gonna share ring who's actually put up the um emotive um er thing. So I'm just gonna share it um just so that everyone can see it. Can you see it? Yeah, so um just in case you wanted to say anything more about it and thank you, win you for finding that I was trying to find it too. So it's interesting that they talk about using Saline. Um II think that um I think that if you are giving Oxytocin, you're probably far better off using it in a pump rather than infusing it in a bag of Saline. So normally we give Saline when we're giving Oxytocin in the labor ward and you're inducing labor or you're speeding up labor, you give it in a bag of fluid of Saline like that. But, but given the fact that we don't want to give her Saline, I think I would be using it in a pump, um, in a concentrated manner, um, which will be much safer because the problem with Saline is that it goes uh ok, to, I'll come back to that. Um, the problem with Saline is that it doesn't stay in the blood vessels, it goes out uh into the extravascular space. Um And so you get fluid accommodation which will uh cause problems in terms of edema, but it will cause problems uh in the lungs because it's going to cause them to be fuller and less good at uh transferring gasses and so on. So, trying to keep all the, all the fluid in the intravascular space is the most important thing. I think I wouldn't disagree with most of all of us. Now, Tanisha, you said if we had PPH due to D IC, how do we treat this? So you treat this. Uh If you can, if you can get on top of it, you treat it like you would treat any other D IC, which is to start to reverse the problems of the coagulopathy. Um Therefore, you would begin to give her fresh Os and plasma, you begin to give her platelets and the cryopreservative which contain uh all of the the fibrin factors that you need in the cascade downwards. Jemima John, you asked about kind of hysterectomy done if the bleeding and stop after a long time. Well, actually, if you're going to do a hysterectomy, it's probably better to do it after a short time than after a long time because the woman will recover more quickly. And the answer is yes. Uh, of course, you can, um, if you have exhausted everything. Um, but that's not a, that's not a decision that you, uh, or, or me, you know. So I'm, I'm a retired doctor now. Uh, you can tell that by my gray hair and beard. But even if I was doing a Cesarean section at four o'clock in the morning in the hospital and I had, uh, or a vaginal delivery and I was dealing with a pph that was uncontrollable. Um uh And I was thinking about, should we do a hysterectomy? I wouldn't do, I wouldn't do that myself. I would, I would ring a colleague even though they were at home in bed and not expecting to be called. I would ring somebody else and say, can you come in here and tell me what, what I'm missing out on because it may well be that I've forgotten something. Um, and I think I would be reluctant to do that on my own. I would almost always call somebody else and generally speaking, there will be some, you know, there will be somebody else available, you phone them all, you have them all on your phone, you bring them all and say, hey, get up or whatever. But II think so you could do a hysterectomy. I would never take that decision on my own uh even as a consultant, I would always want to do that with somebody else. Uh And so, but yes, you can do it, of course. But it's a big deal. And as Tishia says, uh considering her age of 34 it'd be a rough decision to do a total hysterectomy. Um I think that would be, I think that's sensible. And then she says that you are, she, I presume with Tetha, I'm not sure if you try an artery embolization is the protocol before a hysterectomy. If we follow the algorithm, the algorithm being the emotive one probably not, but you know, um mm protocols are made to be broken. Um And when you, I guess uh I often had this challenge when I, when I run out uh people say to me, but that's not on the protocol and you think, yeah, I know. But um what, what statement do you love? I love that statement. We seen the challenging one. The procedures are meant to be challenged. Rules are meant to be broken. Well, the thing is, you know, uh well, OK, you, you'll all remember me by that protocols are meant to be broken. The thing is that, you know, if you've done everything that the protocol says and you're still stuck, then you know, we are not e every one of you listening in here today uh are qualified in medicine, you are all intelligent. You are all able and competent at your jobs and there will come a time in your life when you will be in a situation where you will think. I have no idea what to do here and you will think I'm stuck and you'll, and, and your junior doctor will say to you, the protocol says you should do that. So, but we, we did that five minutes ago or 10 minutes ago or half an hour ago. We, we, we're passed that that time is gone or whatever. And so um protocols are, are guidelines to help you. They are not rigid pathways to follow. And so um you could all come back. I I'll give you my address if you want to sue me. There you go. Sorry. And maybe I shouldn't be saying these things to you because you're, you're all young and uh influenz and maybe sue won't let me lecture anymore because I'm too dangerous. Maybe we'll just skip this bit out. We'll just delete this part on catch up. Ok. Yeah, that's a good idea. I don't want to be recorded. The same protocols are made to be broken. Ok. Thank you for leading me down that pathway of temptation. Can we now pull ourselves back from that and have any other questions, please? Before we finish what said on middle education stays in middle education. How's that? Oh, that sounds like a good one to me. Brilliant. Does anyone else have any other questions? We've gone well over time and I'm so sorry. Um If there's no other questions, thank you so much. Uh David actually has one more one, don't you, David with us? Next Friday, next Friday. Same time. Um What are we doing? Talking about? We are talking about, I'll find you first. We are talking about hypertension, preeclampsia, and hypertension in pregnancy. Let me just get a link and then I can pop it in the chat if anybody is interested. This is the look, I look forward to getting your feedback apart from whatever. Let's not even say the name again. Please do come back, won't you? Um There, there is a feedback form as well in your inbox by now. So please do fill that out. Um David would love to hear from you. Um But anyway, we're gonna say goodbye. Have a lovely weekend, everyone. We have another meal education event tomorrow morning. So if you'd like to attend tomorrow, midday at UK time, if you want to uh attend that, that'd be great. If not, like we said, Da is here next Friday and you can catch his three previous events on medal as well. So if you want to do something over the Christmas period, um catch up on David, then you can and maybe we'll get him back in the new Year as well. All right. So we'll think Muhammad is asking her the feedback for it should be in your, it should be in your, it should be in your, um, inbox. Um, they all arrive in the inbox. Let me just double check that though. Yes, some people have filled them out already. So it is in your inbox. Yep. There you go to, she's there taa I'm gonna get you to help out on medical education. Ok. Right. Well, we're gonna say goodbye now. Ok.