Special experiences and unusual circumstances pdf

Section IX Special experiences and unusual circumstances 411 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:05 Color profile: Generic CMYK printer profile Composite Default screen 42 THE OBSTETRICIAN CONFRONTS POSTPARTUM HEMORRHAGE M. E. Setchell INTRODUCTION Postpartum hemorrhage has been recognized as a major cause of maternal death for as long as physicians have studied and written about child - birth. Until the 20th century, however, little was possible in the way of effective treatment, and, as is apparent in many of the chapters of this book, postpartum hemorrhage is still a frequent cause of death in many parts of the world. Even in the Western world, significant numbers of deaths and morbidity from postpartum hemorrhage continue to plague obstetricians, despite considerable advances in medical care in the last half-century. During the author’s career in Obstetrics which has spanned almost 40 years, one of the most striking changes has been the one whereby the individual obstetrician no longer has to deal with the problem of postpartum hemorrhage alone, but can call on a sophisticated team of helpers, involving a whole range of other spe - cialists. A mere glance at the contents of this book confirms that the modern management of a major postpartum hemorrhage can involve a team of anesthetists, hematologists, vascular surgeons, gynecologists and radiologists. Clearly, this change represents an advance which has saved and will continue to save countless lives, not only in the developed world where such teamwork is routine, but also in developing nations that are desperately looking for means to reduce maternal mortality as part of their efforts to comply with the United Nations Millennium Development Goals by the year 2015. HISTORICAL PERSPECTIVE In the middle of the 19th century, maternal mortality was around 6 per 1000 live births, and, of those deaths, about one-third were related to puerperal sepsis, and the remainder were classified as ‘accidents of childbirth’, which included ante- and postpartum hemor - rhage and deaths from obstructed labor. Table 1 shows birth and death rates in England and Wales from 1847 until 1901. It is evident that there was no real improvement in deaths from sepsis during this period, in contrast to a relative improvement in the deaths from other causes. The concept of Lying-In Hospitals was first adopted in the mid-18th century, and by 1904 there were 38 such hospitals in Great Britain. The stated intention was to provide a safer place for delivery and postnatal care, but any pur - ported benefits in better obstetric care were far outweighed by the risks of death from sepsis, which, as can be seen in Table 2, amounted to 3% in the period of 1838–1860. This appalling figure improved considerably during the latter part of the 19th century, however, following the introduction of Semmelweis’ observations and teachings on hygiene and antisepsis in 1861. Francis Ramsbotham, the first Lecturer and Obstetric Physician to The London Hospital, published ‘The Principles and Practice of Obstetric Medicine and Surgery in reference to the Process of Parturition’ in 1841, and provided some poignant case reports, revealing what the practice of Obstetrics was like at that time. The case of a rich patient in the City of London, 390 412 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:05 Color profile: Generic CMYK printer profile Composite Default screen 391 The obstetrician confronts postpartum hemorrhage Deaths Death rate to 1000 children born alive, from Year Registered births of children born alive Puerperal septic diseases and accidents of childbirth Puerperal septic diseases Accidents of childbirth Puerperal septic diseases and accidents of childbirth Puerperal septic diseases Accidents of childbirth 1847 1848 1849 1850 1851 1852 1853 1854 1855 1856 1857 1858 1859 1860 1861 1862 1863 1864 1865 1866 1867 1868 1869 1870 1871 1872 1873 1874 1875 1876 1877 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 1888 1889 1890 1891 539 965 563 059 578 159 593 422 615 865 624 012 612 391 634 405 635 043 657 453 663 071 655 481 689 881 684 048 696 406 712 684 727 417 740 275 748 069 753 870 768 349 786 858 773 381 792 787 797 428 825 907 829 778 854 956 850 607 887 968 888 200 891 906 880 359 881 643 883 642 889 014 890 722 906 750 874 970 903 866 886 331 879 868 885 944 869 937 914 157 3226 3445 3339 3252 3290 3247 3060 3009 2979 2888 2787 3131 3496 3173 2995 3077 3588 4016 3823 3682 3412 3503 3283 3875 3935 3803 4115 5927 5064 4142 3443 3300 3340 3492 4227 4524 4508 4647 4449 3877 4160 4160 3585 4255 4787 784 1365 1165 1113 1009 972 792 954 1079 1067 836 1068 1238 987 886 940 1155 1484 1333 1197 1066 1196 1181 1492 1464 1400 1740 3108 2504 1746 1444 1415 1464 1659 2287 2564 2616 2468 2420 2078 2450 2386 1852 1956 1973 2442 2080 2174 2139 2281 2275 2268 2055 1900 1821 1951 2063 2258 2186 2109 2237 2433 2532 2490 2485 2346 2307 2102 2383 2471 2403 2375 2819 2560 2396 1999 1885 1876 1833 1940 1960 1892 1879 2029 1799 1710 1774 1733 2299 2814 5.97 6.12 5.78 5.48 5.34 5.20 5.00 4.74 4.69 4.39 4.20 4.78 5.07 4.64 4.30 4.32 4.93 5.43 5.11 4.88 4.44 4.45 4.24 4.89 4.98 4.60 4.96 6.93 5.95 4.66 3.88 3.70 3.79 3.94 4.78 5.09 5.06 4.79 4.98 4.72 4.69 4.73 4.05 4.89 5.24 1.45 2.42 2.02 1.88 1.64 1.56 1.30 1.50 1.70 1.62 1.26 1.63 1.79 1.44 1.27 1.32 1.59 2.00 1.78 1.59 1.39 1.52 1.53 1.88 1.81 1.70 2.10 3.63 2.94 1.97 1.63 1.59 1.66 1.88 2.58 2.89 2.94 2.72 2.71 2.39 2.80 2.49 2.09 2.24 2.15 4.52 3.70 3.76 3.60 3.70 3.64 3.70 3.24 2.99 2.77 2.94 3.15 3.28 3.20 3.03 3.00 3.34 3.43 3.33 3.29 3.05 2.91 2.71 3.01 3.09 2.90 2.86 3.30 3.01 2.69 2.25 2.11 2.13 2.08 2.20 2.20 2.12 2.07 2.27 1.99 1.90 2.01 1.95 2.62 3.06 continued Ta bl e 1 Mortality in childbirth in England and Wales 1847–1901 (a period of 55 years), in General Lying-in Hospital, London 413 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:05 Color profile: Generic CMYK printer profile Composite Default screen described below, illustrates how little could really be done for intra- and postpartum hemorrhage. ‘Case C1V’ ‘I was summoned to a private patient near the Mansion House, who had been, a few minutes before, attacked with a sudden flooding in the eighth month of pregnancy, while sitting with her family at tea, in the drawing-room. Upon proceeding up stairs, tracks of blood were perceptible upon every step. In the bedroom, I found a neighbouring professional gentleman, who had been also called by the servants in their alarm at the state of their mistress; and, although this unfortunate occurrence had not happened a quarter of an hour before, it had already produced such a degree of compression as I have rarely witnessed, with its concomitant symptoms. Upon a vaginal examination a little after six, I detected the Placenta to be placed immediately over the Os Uteri; some discharge was still oozing away, but there was no tendency to pain. The urgency of the haemorrhage appeared therefore to be at present somewhat abating; and the lady for a short time seemed disposed to revive; but presently the flooding returned with its original violence. Anxiously watching its progress for a short time, and observing no diminution in the discharge, I determined on delivery; but previously I requested my professional friend to satisfy himself that the Placenta was presenting. Being answered in the affirmative, I proceeded with - out further loss of time to empty the Uterus. The Os Uteri was but little opened, yet it was relaxed, and permitted the passage of my hand with ease into the Uterus; but that organ showed at the moment no disposition to active contraction; having brought down the breech, the child was found to be alive; I therefore pro - ceeded gently in its extraction; and after the child was born, the Placenta was thrown off, and was soon withdrawn. The uterine tumour proved now to be irregularly contracted, and fell flaccid under the hand. For a short time, this lady appeared comfortable; the discharge ceased, and she expressed her warmest thanks for my prompt assistance; but by-and-by she began to complain of her breath: ‘Oh! my 392 POSTPARTUM HEMORRHAGE Time period Deliveries Deaths Average death rate from all causes 1838–1860 1861–1879 1880–1887 1888–1892 5833 3773 2585 2364 180 64 16 9 1 in 32.5 or 30.85 per 1000 1 in 57.875 or 16.96 per 1000 1 in 161.5 or 6.18 per 1000 1 in 262.67 or 3.80 per 1000 Ta bl e 2 Number of deliveries, deaths and death rates during different time periods in the General Lying-in Hospital, London Deaths Death rate to 1000 children born alive, from Year Registered births of children born alive Puerperal septic diseases and accidents of childbirth Puerperal septic diseases Accidents of childbirth Puerperal septic diseases and accidents of childbirth Puerperal septic diseases Accidents of childbirth 1892 1893 1894 1895 1896 1897 1898 1899 1900 1901 897 957 914 542 890 289 922 291 915 309 921 693 923 265 928 646 927 062 927 807 5194 5950 4775 4219 4561 4250 4074 4326 4454 4394 2356 3023 2167 1849 2053 1836 1707 1908 1941 2079 2838 2927 2608 2370 2508 2414 2367 2418 2514 2315 5.78 6.51 5.36 4.57 4.98 4.61 4.41 4.66 4.81 4.73 2.62 3.30 2.43 2.00 2.24 1.99 1.84 2.05 2.09 2.24 3.16 3.19 2.92 2.56 2.74 2.62 2.56 2.63 2.71 2.49 Table 1 Continued 414 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:06 Color profile: Generic CMYK printer profile Composite Default screen breath! my breath!’ was her urgent exclamation. My patient continued to sink, and expired soon after seven o’clock; so that in less than two hours, from an apparent state of perfect health, her valuable life was sacrificed to a sudden attack of haemorrhage, in spite of the most prompt assistance. The child was lively, and promised to do well.’ THE LONELINESS OF THE OBSTETRICIAN Fifty years ago, and for the ensuing 20 years at least, ‘Practical Obstetric Problems’ by the late Professor Ian Donald, Professor of Midwifery in the University of Glasgow, was the essential and valued textbook for all young obstetricians of that generation. Nowhere is the famous dedica - tion in the frontispiece more relevant than in relation to postpartum hemorrhage: ‘To all those who have known doubt, perplexity and fear as I have known them, To all who have made mistakes as I have, To all whose humility increases with their knowledge of this most fascinating subject, This book is dedicated.’ The sense of helplessness, loneliness and fear that Dr Ramsbotham must have felt as he watched his patient expire in spite of all his good work and intentions is something that none of us ever wish to experience in our career. As modern obstetricians, we no longer per - form our tasks in isolation; we practice in hospi - tals which, in the majority of instances, are well or relatively well equipped, are surrounded by midwives, junior or senior colleagues, and know that various other specialists are standing by in support. Nevertheless, in dealing with post - partum hemorrhage, there comes a moment when our decisions and actions (or lack thereof) are going to determine the sequence of events. Even in complex cases of more prolonged hemorrhage, when all the support of the laboratory hematologists, the blood transfusion service, the anesthetic intensivist and other sup - porting clinicians has been called in, there will come a time when the only the attending obstetrician, using his or her best and most considered judgements, has to make a decision about radical treatments such as hysterectomy, laparotomy and hemostatic suturing, ligation of vessels or embolization. The author’s first ‘lone’ experience of post - partum hemorrhage occurred whilst working as a new Registrar at the University Hospital of the West Indies in Jamaica. Having just successfully conducted a very straightforward twin delivery, including completion of the third stage of labor with a standard dose of syntometrine, my state of calm was interrupted by a sudden gush of blood of such proportion that it seemed then (and even now) as if an old-fashioned bath tap had been turned on full pelt. The sound and sight of that hemorrhage will never leave my memory; it was a moment of absolute panic and helplessness. Miraculously, something took over, and decisions and actions were taken as if they were automatic, probably because Profes - sor Ian Donald had been read, and re-read, in preparation for such an event. Bimanual com - pression, intravenous ergometrine administered by a much more experienced midwifery sister, who then made up a bottle of intravenous Syntocinon almost without being asked, and the situation was quickly under control. The young obstetrician grew significantly in maturity and experience in those few minutes, grateful that simple actions had averted what had seemed a potential disaster. During the remaining years of my training, other dramatic postpartum hemorrhages also occurred, but the range of available interven - tions was limited. Intravenous or intramuscular ergometrine, intravenous Syntocinon infusions, bimanual compression, or packing the uterus with enormous packs (one teacher described putting a pillow case into the uterus first, and then filling it with as many packs as one could get hold of) were the only effective treatments. One had occasionally seen the need for post - partum hysterectomy and internal iliac artery ligation, but, in those circumstances, there had always been the welcome presence of a more senior colleague. It is not only the trainee obstetrician who may still be faced with hard decisions. Some - times, the presence and involvement of a large team lead to confusion of leadership. Whilst protocols, guidelines and practice ‘drills’ may help to coordinate teamwork and familiarize staff in how to deal with these unusual 393 The obstetrician confronts postpartum hemorrhage 415 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:06 Color profile: Generic CMYK printer profile Composite Default screen situations, there remain numerous times when the obstetrician has to take command and make rapid or difficult decisions. In a lengthy career, one may be faced with a situation that is unique and has not been met with before. A few such cases which have faced the author are now discussed. A patient had been admitted at 34 weeks with severe abdominal pain, a tense abdomen and absent fetal heart tones. Signs of shock and the tense, tender abdomen suggested a placental abruption, and the cardiovascular and respira - tory collapse was of such severity that she was immediately transferred to the Intensive Care Unit (ITU), with a presumed diagnosis of pla - cental abruption. Despite massive blood trans - fusion, her condition deteriorated, and, despite ventilation, it was difficult to maintain her PO 2 . The ITU team felt that attempts to induce labor needed to be delayed until her condition improved. Eventually, ventilation resistance was so great that the ITU team was of the opinion that death was imminent. The obstetrician was therefore asked to consider carrying out a laparotomy and delivery of the dead baby in the hope that this might improve the situation. As the patient was deemed too ill to leave ITU, the operation was performed on an ITU bed. On entering the abdomen, a massive hemoperito- neum was encountered, and the first thought was of a ruptured uterus. However, the uterus was found to be intact, and, upon further exploration, it became obvious that the source of the intra-abdominal hemorrhage had been a ruptured liver. A general surgeon was called, who was able to secure hemostasis with several large hemostatic liver sutures, and the patient made a slow recovery. During the postoperative period, however, it became apparent that she also had HELPP syndrome. A stormy recovery ensued, but a year later the patient was pregnant again and delivered a healthy baby. Another once-in-a-lifetime experience con - cerned a late vaginal termination at 18 weeks for a major chromosomal abnormality. During the procedure, it was apparent that the uterus had been perforated and a laparotomy was therefore carried out. A small tear was found in the caecum and a general surgeon called in. He rec - ommended partial right colectomy, which was elegantly performed, and the perforation of the uterus closed without difficulty. A drain was left in the abdomen. An hour later, it was evident that there was major intra-abdominal hemorr - hage. The drainage bottle had filled and been emptied twice, and the abdomen was distended, tense and tender. Unfortunately, the general surgeon had departed for the weekend and was not contactable. When the obstetrician returned, the patient was in a desperate condi - tion, with major cardiovascular collapse. The anesthetist had inserted a subclavian line in order to obtain good venous access, and in doing so had inadvertently caused a pneumo - thorax. He was therefore inserting a chest drain. Once this had been accomplished and transfusion had restored the blood pressure, a laparotomy was carried out by the obstetrician. A small arterial bleeder was found at the ileo– colic anastomosis and was easily dealt with. The patient, who was the wife of a solicitor, made an uncomplicated recovery. The obstetrician expected that he might find a legal suit impend- ing, but instead received a case of champagne and letter of thanks from the solicitor husband. This lady also subsequently went on to have a successful pregnancy. On yet another occasion, the author was called in at 3 a.m. by a consultant colleague because a patient who had had a vaginal delivery with a very extensive vaginal and perineal lacer- ation was still bleeding heavily after more than an hour of attempted suturing of the tear, and no fewer than 18 units of blood had been trans - fused. The operating theater looked like a bat - tlefield theater, and the vaginal tissues appeared like wet blotting paper, with no identifiable anatomical layers. By then, the patient had major clotting deficiencies, and anesthetists and hematologists were busy attempting to correct that. Attempts were made at packing the vagina and applying pressure, but to no avail. A gynecological oncology colleague was contacted to discuss internal iliac artery ligation, and he advised that this should be done forthwith. The author had not participated in such a procedure for something like 20 years, and, although the gynecological oncologist said he would come in, he advised that time should not be wasted in getting on with the procedure. To the author’s relief, the requisite details of the anatomy and necessary procedure were retrieved from the 394 POSTPARTUM HEMORRHAGE 416 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:06 Color profile: Generic CMYK printer profile Composite Default screen cerebral archive almost automatically. By the time the oncologist arrived, the hemorrhage was almost completely under control, and it was then possible to complete hemostasis with a few additional vaginal sutures. After a short period of intensive care, the young woman recovered well, as did the anatomy of the vagina and perineum. A final case involved a collapse at 36 weeks, with abdominal distension and extreme pain and tenderness. The fetal heart tones were still present, and the presumed diagnosis was pla - cental abruption. The patient was immediately taken to theater for Cesarean section. On open - ing the peritoneum, a massive hemoperitoneum gushed forth, but the uterus was perfectly soft and normal in color. A Cesarean section was carried out and a healthy baby delivered. It was assumed that the source of bleeding could be a splenic artery aneurysm accident, and a four- quarter exploration of the abdomen carried out. The upper abdomen revealed no bleeding what- soever, and eventually an arteriovenous malfor- mation at the brim of the pelvis was found to be bleeding. A vascular surgeon was called in to check that hemostasis was satisfactory. After an 8-unit blood transfusion, the patient and baby did well. CONCLUSION The plethora of interventions available to the obstetrician now includes many different drugs to promote uterine contraction and hemostasis, a complex range of hematological products, and surgical interventions, including the B-Lynch stitch, the use of intrauterine pressure balloons, and early resort to hysterectomy or radiological embolization. All are described in detail in other chapters of this book. However, decisions about which intervention to try, and after how much blood loss, remain difficult, and are influenced by the likely future reproductive wishes of the woman, as well as the facilities or lack thereof available in the particular obstetric unit. Whilst much progress has been achieved in the last few decades, there remain many parts of the world where treatment options either are not much greater than they were 50 or more years ago in more developed countries or are even less, being hampered by the logistic consider - ations detailed in still other chapters in this volume. The major challenge in the 21st century in this field is to narrow the inequalities of health-care provision in childbirth. It is hoped that this textbook, the first ever to discuss the topic of postpartum hemorrhage in a compre - hensive manner, will go a long way in helping health-care providers to achieve this goal, for it should be obvious, even to the most neophyte reader, that the problems related to postpartum hemorrhage are not confined to one country or to one region. They are indeed world-wide, and their control will be facilitated by collaborations and partnerships, as seen in this textbook in which several chapters present details of what is being done in the developing as well as the developed world. Further reading Donald I. Practical Obstetric Problems. London: Lloyd Luke Ltd, 1969 Williams W. Deaths in Childbed. London: H. K. Lewis, 1904 Ramsbotham F. The Principles & Practice of Obstetric Medicine & Surgery in Reference to the Process of Parturition. London: Churchill, 1941 395 The obstetrician confronts postpartum hemorrhage 417 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:07 Color profile: Generic CMYK printer profile Composite Default screen 43 THE MIDWIFE CONFRONTS POSTPARTUM HEMORRHAGE A. M. Ward INTRODUCTION As repeatedly stated earlier in this book, post - partum hemorrhage is a major killer of women throughout the world 1 and is the second leading cause of admission of women to high-dependency units in the Western world 2,3 . Postpartum hem - orrhage also causes significant morbidity for women in the Third and Western worlds 1,4,5 . Waterstone and colleagues 6 noted that two- thirds of severe maternal morbidity is related to severe hemorrhage. It stands to reason that any reduction in the frequency of postpartum hem- orrhage would impact the lives of women and their families throughout the world 1 . Given these circumstances, it is essential that mid- wives, as first-line staff, be able to prevent, identify early and provide appropriate manage- ment during a postpartum hemorrhage 7,8 . Midwives practising in the United Kingdom (UK) are fortunate to work in a country with a relatively low maternal mortality rate 1 . At first sight, the role of midwives in the management of a postpartum hemorrhage may seem obvious, that is, they should diagnose the bleed, call for help and instigate emergency treatment 9 . The reality of the management of a postpartum hem - orrhage is much more complex than this, how - ever, and involves an ability to work effectively within a multidisciplinary team and to possess an indepth knowledge of the social, psychologi - cal and physiological processes that surround pregnancy and childbirth. Midwives should be central to the prevention, identification and management of postpartum hemorrhage and these precepts will form the focus of this chap - ter. The degree to which midwives can achieve these goals will obviously vary with local cus - toms, resources and practices, but the goals should remain the same regardless. PREVENTION OF POSTPARTUM HEMORRHAGE Antenatal prevention Prevention of postpartum hemorrhage should begin in the antenatal period. Midwives should assess women’s risk factors at every antenatal visit and then, in partnership with the women, plan care that identifies the most appropriate lead health-care professional 10 . The antenatal risk factors, all within the midwives’ domain to determine, that most commonly are reported for postpartum hemorrhage follow 11 : ● Body mass index > 30 kg/m 2 ● Previous postpartum hemorrhage ● Antepartum hemorrhage ● Placental abruption ● Placenta previa ● Multiple pregnancy ● Macrosomic infant ● Previous uterine surgery ● Antenatal anticoagulation Other risk factors include anemia, poly - hydramnios, maternal age, uterine fibroids and a history of retained placenta 7 . Nulliparity has recently been identified as a possible risk factor for postpartum hemorrhage, rather than grand multiparity 12 . This is important, and it could well be that this group of women has not previously been identified as being at significant risk of postpartum hemorrhage. In the past, the management of such women may have been sub-standard as postpartum hemorrhage was not anticipated 12 . The above-mentioned risk 396 418 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:07 Color profile: Generic CMYK printer profile Composite Default screen factors focus totally on the physical aspects of pregnancy. To ensure the optimum safety of women and their babies and to ensure holistic care, these risk factors need to be assessed in conjunction with other risk factors for severe maternal morbidity; these include maternal age > 34 years, social exclusion and non-white ethnicity 6 . Risk assessments undertaken by midwives need to carefully consider social and psycho - logical aspects of women’s lives, as there is clear evidence that women from poor areas, socially excluded groups and ethnic minorities have poorer health outcomes than other groups of women 1,13,14 . Midwives particularly need to focus care on women who book late, are poor attendees or who do not access antenatal care at all, as these are key indicators of poorer out - comes 13 . This requires effective communication links with other groups such as Public Health Nurses, General Practitioners and Social Ser- vices to ensure these special women are identi- fied as being pregnant as early as possible and provided care in an environment appropriate for them and tailored to meet their social, cultural and psychological needs 1,13 . The National Institute for Clinical Excel- lence (NICE) has produced guidelines for ante- natal care of healthy pregnant women in the UK 10 . These are useful in honing effective use of resources, but midwives need to be mindful that the guidelines are intended to guide the care of healthy pregnant women. The NICE document 15 clearly states that women should have a plan of care that is relevant to their indi - vidual physical, social and psychological needs, and the World Health Organization (WHO) 1 further indicates that this also needs to be culturally specific to women’s backgrounds if it is to be truly effective. Although midwives clearly need to know the risk factors for postpartum hemorrhage, identi - fying risk factors is not enough if appropriate care is not then instigated 13 . Once identified, risk factors need to be acted upon. Even where women have strong views about the type of childbirth experience they desire, open, frank discussion of identified risk factors and their implication for women and their babies, with time to assimilate and consider the infor - mation provided, leads to stronger relationships between women and midwives and reduces the potential for conflict when the safest manage - ment of care conflicts with women’s wishes for their childbirth experience 15–18 . Intrapartum prevention Intrapartum prevention of postpartum hemor - rhage should begin in the antenatal period with the aim of helping women to be as healthy as possible, both physically and emotionally, and should include preparation for childbirth, focus - ing on strategies to keep the process normal 19 . Throughout the intrapartum period, midwives need to be with women supporting them, encouraging them to be mobile and offering alternative methods of pain relief that are less likely to interrupt the progress of labor 20,21 . Labor causes a great deal of insensible fluid loss and women need to be kept well hydrated to ensure adequate circulating volumes at delivery to enable them to cope with any excessive blood loss 22 . Women should also be provided with a quiet, private environment where they feel safe and protected to reduce the need for interven- tion during the process of labor 21,23 . All this is even more vital in areas where there is no direct access to intravenous fluids in the event of a postpartum hemorrhage. Midwives need an indepth understanding of intrapartum risk factors and need to constantly reassess the woman for risk throughout labor 24 . Intrapartum risk factors for postpartum hemor - rhage include: ● Prolonged labor > 12 h ● Prolonged third stage > 30 min ● Retained placenta ● Febrile illness ● Instrumental delivery ● Cesarean section, especially emergencies in late first or second stage of labor ● Amniotic fluid embolism ● Placental abruption The first four conditions are most likely to cause an atonic uterus, whereas operative deliveries are the main cause of uterine, cervical or vaginal 397 The midwife confronts postpartum hemorrhage 419 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:07 Color profile: Generic CMYK printer profile Composite Default screen trauma; embolisms and abruptions are common causes of coagulopathy, although this is the least common reason for postpartum hemorrhage 11 . The debate on whether to manage the third stage of labor actively could fill an entire text itself when considering practice in the UK and other developed countries. In the Third World, however, this is a different matter and routine active management of the third stage of labor could save many women’s lives as well as saving many more from the abject misery of severe morbidity brought about by a postpartum hem - orrhage 1,5,6,12 . This treatment needs to be carried out in conjunction with having in place trained birth attendants that understand women’s specific cultural issues and are aware of when pregnancy and labor are not progress - ing normally 1 . The type of management used for the third stage of labor may be of no real consequence in a well-nourished, healthy population, but it is vitally important that midwives can clearly identify those women at increased risk of a postpartum hemorrhage, as well as understand- ing and carrying out expectant and active management of the third stage of labor 25 . Table 1 describes the main components of each management option for the third stage of labor. DIAGNOSIS OF POSTPARTUM HEMORRHAGE AND POSTPARTUM PREVENTION Definitions in themselves may not be useful, as they often involve measurement of blood loss retrospectively. As blood loss may not be entirely revealed, its estimation is notoriously inaccurate and difficult 26 . Healthy, young women can compensate for routine post-delivery blood loss very effectively, and this toleration is increased even further if there has been a healthy increase in blood vol - ume during pregnancy 22 . Normally, plasma vol - ume increases by 1250 ml and the red cell mass also increases, resulting in women being able to tolerate a drop in their pre-delivery blood vol - ume of up to 25% and remain hemodynamically stable 22 . In practice, this means that midwives need to be encouraged to ignore machines and use their clinical skills of observation. They need to be alert to signs of earlier stages of shock – pallor, sweating and muscle weakness characterized by severe and rapid fatigue 22 . When women become restless and confused, shock is advancing rapidly and immediate, aggressive treatment is needed if not already instigated 22 (see also Chapter 8). There are only two definitions for post- partum hemorrhage, primary (occurring within the first 24 h after birth) or secondary (occur- ring after 24 h and before 6 weeks postpartum). In contrast, experienced health-care practi- tioners will recognize that, in practice, there are three different presentations of postpartum hemorrhage: (1) Rapid loss of blood at or just shortly after delivery; (2) Constant heavy lochia that persists for a significant length of time after delivery; 398 POSTPARTUM HEMORRHAGE Active management Expectant management Oxytocic drug given at delivery of anterior shoulder No oxytocic drug given Cord clamped and cut immediately Cord not clamped until pulsation ceased, then only clamped at baby’s umbilicus When uterus central and well contracted, controlled cord traction applied No cord traction Signs of separation awaited: ● Rise in fundus ● Lengthening of cord ● Trickle of blood at introitus Midwife delivers placenta and membranes Maternal effort delivers placenta and membranes Ta bl e 1 Options for the management of the third stage of labor 420 Z:\Sapiens Publishing\A5211 - Postpartum Hemorrhage\Make-up\Postpartum Hemorrhage - Voucher Proofs #T.vp 30 August 2006 14:25:07 Color profile: Generic CMYK printer profile Composite Default screen [...]... Obstetric Anaesthetists Association (OAA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI)21, stating that ‘an increasing shortage of blood and blood products and growing anxiety about the use of donor blood are leading to an increasing interest in the use of cell salvage in obstetrics Staff will have to be suitably trained, and equipment obtained and maintained .’ In November 2005,... maternal and perinatal outcomes and specifically hemorrhage and perinatal mortality2–14 Bateman and colleagues3 reported that patients who delivered out of hospital in the USA were more likely to be African-American, multigravid and to have had no or poor prenatal care Similarly, other ethnic minorities (Asians living a long way from the hospital in Europe) are also at risk for out-of-hospital deliveries and. .. Dedicated time is given for this training, which has been shown to improve outcomes and efficiencies and can be achieved with effective timetabling and allocation36 Anecdotally, the training improves communication and team work, but needs to be audited against unit guidelines considering maternal outcomes and focusing on morbidity and mortality rates, as well as adherence to the guidelines themselves DEBRIEFING... not responding to treatment and therefore require the expertise of senior obstetricians and anesthetists and admission to an intensive care setting COMMUNICATING EFFECTIVELY In any emergency health care, professionals are relieved when help arrives, but the larger the team the more complex communication and the more difficult it can be to manage the situation effectively and utilize the team efficiently31,32... situation, and help must be urgently requested prior to commencing any treatment27 Midwives need to constantly ensure that women have patent airways and are breathing adequately; here, expensive technology is not required If women do not respond when spoken to, then they potentially cannot manage their own airway and an individual with the appropriate skills and training needs to do this Until the airway and. .. that they are valued and the role they play in the effective running of the team, all of which can help increase job satisfaction and reduce the number of professionals leaving midwifery and obstetrics37 CONCLUSION Midwives are central to the effective prevention, recognition and treatment of postpartum hemorrhage They need to be aware of the risk factors for postpartum hemorrhage and take appropriate... are identified They should also be skilled in basic life support and have an understanding of the pathophysiology of hypovolemic shock This knowledge must be used in conjunction with an understanding of women’s social, cultural and psychological well-being Training as multidisciplinary teams can be effective in improving outcomes for women and their families The Yorkshire model may be beneficial in units... 2005 28 Carfoot S, Williamson P, Dickson R A randomised controlled trial in the north of England examining the effects of skin-to-skin contact on breast feeding Midwifery 2005;21: 71–9 29 Kline CR, Martin DP, Deyo RA Health Consequences of Pregnancy and Childbirth as Perceived by Women and Clinicians Obstet Gynecol 1998;92:842–8 30 NMC Guidelines for Records and Record Keeping London: NMC, 2005 31 Brownlee... Generic CMYK printer profile Composite Default screen 44 SEPSIS AND POSTPARTUM HEMORRHAGE B Das and S Clark INTRODUCTION Sepsis and postpartum hemorrhage are linked by common predisposing factors, especially considering that secondary postpartum hemorrhage can follow infection of retained placenta or endometrium Depending on the extent and severity of the condition, postpartum uterine infection is designated... from 10 000 to 25 000; lochia was offensive and a transcervical swab grew E coli and anaerobes She was therefore administered an intravenous clindamycin and once-daily intravenous gentamicin regimen for uterine sepsis Gentamicin levels were regularly monitored and the patient was discharged after 8 days intravenous therapy, having being ambulant, afebrile and pain-free for 48 h The baby remained well . Section IX Special experiences and unusual circumstances 411 Z:Sapiens PublishingA5211 - Postpartum HemorrhageMake-upPostpartum. factors and their implication for women and their babies, with time to assimilate and consider the infor - mation provided, leads to stronger relationships between women and midwives and reduces. Semmelweis’ observations and teachings on hygiene and antisepsis in 1861. Francis Ramsbotham, the first Lecturer and Obstetric Physician to The London Hospital, published ‘The Principles and Practice of Obstetric