ESMOE-EOST Module 5: Obstetric haemorrhage (PPH): Scenario 1 Version 1.

Date: ……………………………. Name of health facility: ………………................................

Name(s) of evaluator(s): Signature(s):

…………………………………………………...… ……………………………………………………

…………………………………………………...… ……………………………………………………

SCORE: BEFORE AFTER

NOTES AND FOLLOW-UP

ATTENDANCE

Name Rank Ward Signature

1.

2.

3.

4.

5.

6.

7.

8.
ESMOE-EOST Module 5: Obstetric haemorrhage (PPH): Scenario 1 Version 1.2

POSTPARTUM HAEMORRHAGE
Scenario 1

MATERIALS TO BE READY AND AVAILABLE BEFORE STARTING THE SESSION:

General
• Obstetric manikin with
newborn + placenta
Learning materials
• 10 x 0.5 l plastic water
bottles
• 1 x bath towel (or any local
material used during labour
to mop/clean blood)
• Flip charts Module 5
Equipment Drugs and supplies
• Sphygmomanometer • Condoms + 16 Fr foley’s catheter
• Stethoscope • Examination and sterile gloves
• Pulse oximeter if available (regular and elbow-length)
• A supplemental oxygen • Syringes and needles
source • IV giving sets and IV pole
o If cylinders are used, • Glass test tube for bedside clotting
check that they have test
adequate oxygen • Test tubes for taking blood samples
o Flow meter and air • Normal saline / Glucose
oxygen blender • Samples of oxytocin, ergometrine,
o Tubing Syntometrine, misoprostol, and
• Vaginal speculum PGF2α
• 3 x sponge holding • String (instead of suture material)
forceps, clamps
• Catheter

CALL FOR • Responsible

HELP! TEAM LEADER for key
DISCOVERER (Most senior appropriate procedures
SBAR person)
approach
• Quick diagnosis
• Basic management LOUD INSTRUCTIONS, role allocations
of patient
and distribution of functions
to …
(Mostly 1 to 3
helpers available) HELPER 1 HELPER 2 HELPER 3

Functions:
Equipment & Medications Care for baby
Interventions Apprise family
documents & monitoring
Comfort patient

For all of the steps, please demonstrate what you would do.
Explain what you are doing as you do it and why you are doing it.
 ESMOE-EOST Module 5: Obstetric haemorrhage (PPH): Scenario 1 Version 1.2

B = Before / A = After B A
Information Key reactions/responses expected from participants
provided and
questions asked
Ms S, a 19yr P0 G1, has just had a normal vertex delivery at a level 1 hospital by a midwife. She had been referred from a clinic with prolonged
labour and had required oxytocin augmentation during labour. Following delivery of the placenta, using AMTSL the midwife notes profuse vaginal
bleeding (estimated more than 800 mls). There is a staff nurse attending to the baby who had Apgar scores of 9 and 10.
1. What will you Shout for help to urgently mobilize all available personnel
do? Perform a rapid evaluation of the general condition of the woman, including circulation (pulse, BP), airway, breathing,
oxygenation, level of consciousness (AVPU), skin colour, presence of anxiety and/or confusion, blood loss, and
temperature
Secure circulation, airway, and breathing (CAB)
Explain to Ms S what is going to be done, listens to her and respond attentively to her questions and concerns
Cover Ms S to keep her warm
Elevate Ms S’s legs
Massage the uterus to expel blood and blood clots and stimulate a contraction
Start oxygen at 6–8 L/minute
Put in a large bore IV (16 gauge or largest available) cannula or needle (two if the woman is in shock)
Obtain for laboratory investigations before infusing IV fluids (type & cross, complete blood count, coagulation studies) [Do
bedside Hb]
Start two IV infusions Ringer’s Lactate and let it run in like a stream
In one Ringer’s Lactate infuse 20 units of oxytocin in 1 L IV fluids at 60 drops per minute
Catheterise and monitor urine output
Check the placenta for completeness
Examine the birth canal for tears
Discussion Question 1
You find that the uterus is poorly contracted, well above umbilicus, there are no perineal or vaginal tears, and the placenta is complete. Oxytocin
10 iu IM was given for third stage and repeated when Ms S first arrived. BP 90/60 P 126/min. Ms S is pale and continues to bleed despite oxytocin
given for uterine atony.
Discussion Question 2
2. What will you Continue to massage the uterus to expel blood and blood clots and stimulate a contraction
do now? Continue infusion with oxytocin
Continue second IV infusion with Ringer’s Lactate
Continue to monitor blood loss, pulse, blood pressure, and uterine tone
The uterus continues to be poorly contracted in spite of oxytocin IV infusion. BP 90/60 P 118/min. Ms S is pale and continues to bleed.
3. What will you Re-examine the placenta, membranes, birth canal, and cervix
do now? Assess clotting status using the bedside clotting test
Perform bimanual compression of the uterus
Continue oxytocin infusion
Administer further uterotonic drugs:
o ergometrine 0.5 mg OR Syntometrine 1 amp IM [may repeat once]
o misoprostol 400 to 600 mcg orally if bleeding does not stop with ergometrie
o PGF2α 5 mg in 10 mL saline (inject 1 mL into the myometrium) if available
Continue second IV infusion with Ringer’s Lactate
Continue to monitor blood loss, pulse, blood pressure, and uterine tone
After 10 minutes of bimanual compression, the uterus continues to be poorly contracted in spite of oxytocin IV infusion and additional uterotonic
drugs. BP 94/62 P 112/min. Ms S continues to bleed.
4. What will you Perform aortic compression and then insert the balloon for uterine tamponade, remember to plug vagina so balloon cather
do now? does not fall out
Continue oxytocin infusion
Continue second IV infusion with Ringer’s Lactate
Continue to monitor blood loss, pulse, blood pressure, and uterine tone
15 minutes after insertion of the CT, Ms S’s vaginal bleeding is like a period. BP 102/68 P 104/min.
5. What will you Adjust rate of IV infusion
do now? Continue oxytocin infusion
Continue to monitor blood loss, pulse, blood pressure, and uterine tone
Check that urine output is 30 mL/hour or more
 ESMOE-EOST Module 5: Obstetric haemorrhage (PPH): Scenario 1 Version 1.2

B = Before / A = After B A
Information Key reactions/responses expected from participants
provided and
questions asked
Transfuse as necessary
Document all findings
Document all care provided
Continue with routine postpartum care, including breastfeeding of newborn
6 hours after insertion of the CT, Ms S’s vaginal bleeding is like a period. BP 114/72, P 88/min.
6. What will you Slowly deflate the condom by letting out 50 mL of saline every hour
do now? Re-inflate to previous level if bleeding reoccurs whilst deflating
Continue to monitor blood loss, pulse, blood pressure, urine output, and uterine tone
Discussion Question 3
CLINICAL SCORE = TOTAL NUMBER OF TICKS ABOVE
DISCUSSION QUESTIONS
1. What is in your cervical tear pack? 3 sponge holding forceps, suturing material, needle holder, sponge swabs
2. What was Ms S’s diagnosis? Ms S was in shock from postpartum bleeding due to uterine atony
3. What is in a PPH box? Uterotonics (syntocinon, ergometrine), resuscitation fluid( R/L, voluven) and drip sets, uterine balloon tamponade
materials (condom, glove, urinary catheter 16 gauge), tie string, 1l R/L and connection set), blood sampling tubes

BEFORE AFTER
CLINICAL SCORE: Assessment, diagnosis, monitoring and emergency management 41 41
CLINICAL SCORE: Total number of boxes ticked above
EXECUTION OF DRILL SCORE:
A. Activation/Communication skills
1. Appropriate equipment brought (emergency trolley)
2. Discoverer exchanges information with team leader and helpers using SBAR approach
3. Team leader assigns essential roles to helpers (care for the woman, calling a doctor, etc.)
4. Team leader addresses team members by name
5. All observations are communicated clearly and loudly
6. Communication done correctly: instruction
repeat instruction
inform team when instruction is completed
7. The delegated helper informs the patient and family of what is happening and what will be done for the woman
B. Response/Team work
8. Team responds appropriately to team leaders’ instructions
9. Team members cooperate with each other
10. The team determines the disposition of the patient (transfer, plan for further management)
C. Sign out/Documentation
11. Person allocated to do documentation
12. Care (actions) completely documented (timing of intervention and administration of drugs)
D. Sequence of activities
13. Activities performed in the correct order of priority
EXECUTION OF DRILL SCORE (A-D above) 13 13
EXECUTION OF DRILL SCORE (A-D above): Number of boxes ticked
TOTAL SCORE (CLINICAL SCORE + EXECUTION OF DRILL SCORE)
Out of a possible score of 54 54
DISCUSSION POINTS
1. Remember to replace drugs etc (on emergency trolley) 4. The environment should be quiet. Only instructions and
2. Equipment to be cleaned and sterilised appropriately feedback allowed
3. During drill there are no arguments or in-between discussions of opinions on 5. Observations are given clearly and loudly
how something should be done. Only the necessary actions are performed 6. Importance of the correct sequence of events
as swiftly and efficiently as possible 7. Documentation