January Introduction

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Marc D. -


I have a couple comments on the opening case of the january 2021 episode, because I happen to practice in EM and OB as a GP in the Canadian North!

It's a great case, and one you seem to have handled beautifully! But it's a case that doesn't happen often even in big hospitals, and I find ER docs are way more scared of obstetrics than they should. You talked about blood products and tranexamic acid straight off the bat, which I get if you mostly work in the ED, but those are often not needed up front unless you have a severe hemorrhage or a shocky looking patient.

I first would like to say that most often post-partum hemorrhage is pretty straight forward. I completely agree that the trigger for PPH is ''bleeding more that you think is normal''. But pretty simple basic steps work 99% off the time :

1) Atony is key, so massage, massage, and massage again. Feel for the uterus by pressing down on the patient abdomen, above the umbilicus, and sort of sweeping down towards the pelvis. After placental delivery it should feel like a firm big grapefruit. If it feels like a soft pillow or half empty water bag, tranexamic acid won't do anything, you need to get it to contract! Remember you have large uterine vessels flowing to the placenta...which is now gone...so the large vessels are flowing straight into the uterine cavity if you don't do anything...so you want to put a tourniquet on them. The tourniquet : contracting the uterus on the vessels! So massage, massage, massage, don't stop!

2) Uterotonic medications : oxytocine, misoprostol, carboprost and ergonovin. You can add tranexamic acid, but probably the least effective of the lot. (Every ED should have a urgent delivery kit which contains at least the clamps and baby resuscitation gear, and oxytocin and misoprostol as those are kept room temp! You should even give one of them prophylacticly as soon as baby is out, without even waiting for the placenta. IM oxytocin is the easiest and best tolerated, but misoprostol would be ok too. Carboprost and ergo are useful but unfortunately kept in the fridge).

3) Usual resuscitation during that time : monitor + 2 large bores + cross-match (with or without ordering the blood straight off the bat depending on the amount of bleeding). If you want to give fluids, it should be blood, but if the blood isn't pouring out at an alarming rate and the patient is stable, you don't need to hang it right away.

4) Uterine revision. The uterus just let out a baby's head, so don't be scared, get a sterile gown and glove on and just stick in your hand!! In a bit more seriousness though, here's how you'd do it :
Give light procedural sedation if needed, but since it just takes a couple seconds to do, it's not even necessary if it's an emergency. I often just give a 100 mcg of fentanyl, with sometimes a little versed or propofol, but you really don't need to get the patient fully sedated for this.
Sometimes there might be placenta stuck in there, but most often the uterus is just full of blood clots that have accumulated because of the atony, and which then prevent the uterus from contracting properly.
So the way to empty it :
- Get your dominent hand sterile, then press with your non-dominent hand on the patient's tommy and get a feel for the uterus. You'll want to have the uterus well immobilized with your non-dominent hand to prevent it from going up into your patient's throat when you'll try to introduce your other hand in the cervix.
- Then you introduce your sterile hand into the vagina and you try to find the opening of the cervix. Even if I said it just let a baby's head through, in reality the inner os has closed a bit, but the outer os of the cervix is soft and very dilated (it feels more like flappy soft tissue then a cervix). So you try to find that closed inner os and you push your fingers into it and it should open with relative ease but still feel stiff and contracting onto your hand, which is why you need your other hand to help stabilise the uterus in order to get most of your finger into the uterine cavity.
- You won't necessarily fit your whole hand in, but you try to scoop all the clots out and try to feel the sides to make sure nothing's stuck on them. You just take your fingers and sort of scratch the inside of the uterus all around and it's pretty easy to feel if something is stuck or not. And if there are a lot of clots, you might need 2-3 passes before you're sure the uterus is empty.
After, it's probably better to give an antibiotic, but it's not urgent so just let OB choose what they want to give.

With those pretty simple steps, i'm sure the great majority of PPH are resolved. It should be way less complicated and scary then it is for most ER docs. It's just like trauma, there are some bad cases, but most are pretty simple to manage with thing we're well equiped to do in the ED. Though if not, the rest of what you said is absolutely true (vaginal and cervical lacerations, Bakri, DIC work-up, intervention radiology and OR).
So here are my suggested steps if you see more bleeding than you'd like :
- Massage
- Uterotonics
- Massage!
- Usual resuscitation
- Massage!
- Uterine revision
- Massage!
- Talk to OB if you haven't yet!
- Keep up the massage!

I hope this might help a couple people out there.

Continue the awesome CME!

Will L. -

Thanks for weighing-in on that Dr. Marc D.! 'Agree that massage is the mantra. I admit that I've likely made PPH in the ED scarier than it need be. However, like our show hosts said, it's that 5% of cases that keeps our paranoia alive.

P.s. if I could 'upvote' your comment I totally would. Thanks again.

Michael H. -

This is fantastic. Thanks for posting.

Frederick B. -

Thanks for taking the time to write this! very much appreciated!

Geoffrey K. -

What's this about a MacGyver Bakri balloon with a foley catheter and a condom?? Y'all hinted at it in the intro, but I didn't see anything in the show notes.

In my job as a flight nurse, we frequently fly into pretty resource-poor departments, sometimes to attend high-risk births. I could see this as being a really cool trick to have up my sleeve in the right circumstances, but I am trying to wrap my head around how the heck to secure a condom on the head of a foley and how to get the dang thing inflated without it coming off and reinventing itself as a uterine foreign body.

In searching, I saw an abstract of an Egyptian study from 2018. Is that what you were referring to? Any other info on this or on how to make one of these gadgets?

Anand S. -

Geoffrey - sorry for the absence of link. Will fix that but here it is: https://pubmed.ncbi.nlm.nih.gov/19432563/

Anand S. -

one more that is free to download with a great image https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2009.02113.x

Geoffrey K. -

Thanks! Also found this video (apparently borrowed from Stanford OB/Gyn) that illustrates the whole thing very nicely shortly after submitting my question: https://www.youtube.com/watch?v=S5Mu8j_VXos

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