Maternal bleeding 18.05.2023 v3 (1).pdf

Maternal bleeding Causes of pregnancy bleeding Management of pregnancy bleeding Post-partum haemorrhage Estimation of blood loss Learning from incidents Session objective Understand maternal physiology and how observations differ in pregnant/postpartum patients Describe so...

Maternal bleeding Causes of pregnancy bleeding Management of pregnancy bleeding Post-partum haemorrhage Estimation of blood loss Learning from incidents Session objective Understand maternal physiology and how observations differ in pregnant/postpartum patients Describe some causes of bleeding in pregnancy Management of late pregnancy bleeding and ante-partum haemorrhage Recognising and managing post-partum haemorrhage London Ambulance Service NHS Trust 2 Maternal physiology Physiological changes that occur from early pregnancy mean that maternity patients have up to 50% additional circulating blood volume. What does this mean? PREGNANT AND POST-PARTUM WOMEN MAY APPEAR WELL EVEN WITH SIGNIFICANT BLOOD LOSS London Ambulance Service NHS Trust 3 Remember Haemorrhage may be: - Revealed (evident blood loss) - Concealed (occurs within the abdomen/uterus) London Ambulance Service NHS Trust 4  Early ante-partum Post-partum bleeding Late ante-partum bleeding (20 weeks) (From birth- 4 weeks weeks) post-partum) Miscarriage Late miscarriage Tone (atonic uterus) Ruptured ectopic Low-lying placenta Tear (trauma to the pregnancy Placental abruption vulva from birth) Uterine rupture Tissue (retained Ruptured vasa products) praevia Thrombin (Clotting disorders) London Ambulance Service NHS Trust 5  Medical co- Miscarriage morbidities Smoking Loss of pregnancy before 24 completed weeks Hx previous loss gestation Obesity More common within the first 12 weeks (1st trimester) 15% of confirmed Substance use Maternal age pregnancies result in (over 35) miscarriage London Ambulance Service NHS Trust 6 Miscarriage signs and symptoms Bleeding Light or heavy, often with clots and/or jelly-like tissue Pain Central, crampy, suprapubic, or dull backache Can be as intense as labour pains Hypotension and bradycardia Can indicate cervical shock due to retained tissue in the cervix London Ambulance Service NHS Trust 7 Care during suspected miscarriage Babies and pregnancy tissue must be conveyed in to hospital. In all cases, inform the woman and discuss her preferences about the management of the remains. Where the baby is discernibly formed, wrap in a towel from the maternity pack. Treat family and baby with utmost respect and sensitivity. Be honest- if you do not know they answer, do not give false hope. London Ambulance Service NHS Trust 8 Ectopic pregnancy The egg implants somewhere other than the uterine wall Occurs in 1-2% of pregnancies Most common between 6-8 weeks gestation but can present as late as 20 weeks Can result in maternal death London Ambulance Service NHS Trust 9 Signs and symptoms Pregnancy of unknown location (PUL): women with a positive pregnancy test may be sent home for expectant Vaginal bleeding management if a baby is not located on scan. Vomiting and nausea Lower abdominal pain The patient may not have taken Sharp cramps/one sided a pregnancy test yet. Women of childbearing age with any of pain these symptoms should be Pain in neck, rectum or considered at risk of ectopic pregnancy, especially if they shoulder have missed a period. Feeling faint/collapse London Ambulance Service NHS Trust 10 Placental abruption When the placenta either partially or fully detaches from the uterine wall Smoking doubles risk. Also more likely to occur with high blood pressure, substance use, trauma and infection Symptoms include vaginal bleeding (may be no blood seen externally), constant abdominal pain and hard rigid abdomen London Ambulance Service NHS Trust 11 Placenta praevia When the placenta embeds near to or over the opening of the womb (cervix). Can cause ‘silent’ bleeds- vaginal bleeding that is not associated with pain. London Ambulance Service NHS Trust 12 Bleeding in pregnancy v. APH Bleeding during pregnancy (any gestation) amounting to 50ml or more is an Ante- partum Haemorrhage (APH) Any fresh bleeding after 20 weeks, regardless of amount- RED FLAG London Ambulance Service NHS Trust 13 Management for bleeding >20 weeks and APH It may not be possible to determine cause of bleeding in pregnancy (normally diagnosed on scan/auscultation of fetal heart/internal examination in hospital) Pre-alert to nearest obstetric unit (unstable? ED) Cannulation if paramedic already on scene London Ambulance Service NHS Trust 14  1 red flag or 2 amber flags = TIME Where to go: Convey to maternity (obstetric CRITICAL unit): If 20 or more weeks Go to the nearest hospital with gestation AND woman stable obstetrics on site Convey to ED with obstetrics Early blue call pre alert via PD09 on site: If less than 20 weeks gestation OR woman unstable (for example, ongoing life DO NOT CALL A MIDWIFE threatening haemorrhage, recent seizure, reduced GCS) London Ambulance Service NHS Trust Case review 40 y/o G2 P1 30+4/40 COVID +ve Confirmed Vasa Praevia 18.23 Patient notices vaginal bleeding 18.25 999 call connected 18.27 First on scene 18.37 Blue call (pre-alert) to nearest obstetric unit 18.41 Arrival at obstetric unit Maternity team ready on arrival, transferred straight to theatre London Ambulance Service NHS Trust 17 Outcome  Emergency caesarean section of a live male infant  Baby resuscitated and transferred to NICU  Blood transfusion given  Since discharged home with parents Shared with patient’s permission London Ambulance Service NHS Trust 18 PPH recognition and diagnosis How do we diagnose a post-partum haemorrhage? - Blood loss of 500mls or more visualised - Heavy bleeding post birth not stopping Inco sheet saturated - Signs of clinical deterioration post-birth with 500mls (regardless of blood loss visualised) London Ambulance Service NHS Trust 19 London Ambulance Service NHS Trust 20 PPH management Fundal massage (under direction) Drugs (call for help early) IV access Tranexamic acid Use gauze to apply pressure to any tears O2 and fluids as per observations Rapid extrication and conveyance London Ambulance Service NHS Trust 21 How to perform fundal massage London Ambulance Service NHS Trust 22 Learning from incidents Women compensate well- until they don’t Estimate and document volume of blood loss Do not delay on scene- this patient requires an obstetric theatre Bring in any pads or clothing contaminated with blood Allocate separate teams to mother and newborn (if applicable) Obstetric unit is the only appropriate destination of conveyance London Ambulance Service NHS Trust 23 Summary The Maternal Assessment Card should always be used from conception to 4 weeks post-partum, due to physiological changes that alter the parameters of observations 1 red flag or 2 amber flags requires a pre-alert to the nearest obstetric unit Haemorrhage may be evident or concealed Datix all pregnancy and post-partum bleeding London Ambulance Service NHS Trust 24