Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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4 Haemorrhage
relation to the resuscitation of these women. A scoring system of the type described in Chapter 19, Critical
Care, may help in the more timely recognition of such cases in future.
Consultants have a duty to maintain their skills and recognise their limitations. Previous Reports have
recommended that a consultant undertaking a caesarean hysterectomy should have support available
from a colleague. Perhaps the lack of recognition of continuing intra-abdominal bleeding is due to a lack
of experience by “obstetric only” consultants in dealing with surgical emergencies. The current tendency
to divide obstetrics from gynaecology has led to a situation where some obstetric consultants have little
surgical gynaecological experience and thus may not always be able to cope with procedures such as
emergency hysterectomy in sick and bleeding women. It is good practice in such situations to call straight
away for the aid of colleagues with greater gynaecological surgical experience. In the “lessons I have
learned” section of the individual Enquiry report forms, several consultants have regretted not calling in
additional, more skilled, consultant help sooner. In general terms it is a good idea to call for a consultant
colleague to help, whether or not that consultant is on call. It is also essential to involve skilled consultant
anaesthetists in these decisions.
It is interesting to recall that this Chapter of the last Report noted “in several cases the consultant
anaesthetist had to persuade the obstetrician that physical signs such as oliguria, tachycardia or
hypotension were attributable to haemorrhage and further surgery was required”.
Management of uterine atony
As every undergraduate midwifery and medical student should know, in many cases postpartum
haemorrhage is caused by atony of the uterus. In treating atony it seems that the drug ergometrine, as
fi rst advocated by Chassar Moir in the 1930s5 , is frequently forgotten, despite the fact that in a European
survey of policies undertaken in 2003 as part of the EUPHRATES project, 42 % of maternity units in the
UK said that it was their drug of fi rst choice for the immediate management of obstetric haemorrhage6 .
It is a very effective oxytocic agent and should be used except in cases of hypertension. The two drugs,
syntocinon and ergometrine, should be the drugs of fi rst choice to prevent and treat atony of the uterus7 .
Given its relative frequency, maternity staff should have a high index of suspicion of the possibility of
postpartum haemorrhage. In clinical situations such as prolonged labour or second stage caesarean
section, the likelihood of an atonic uterus should be anticipated. Syntocinon and ergometrine should be
used, given slowly intravenously, or as one ampoule of syntometrine intramuscularly. Additionally it is good
practice to start a syntocinon infusion immediately after delivery of the baby, with 40 units of syntocinon in
500 mls of saline to run intravenously over the next two to four hours.
The identifi cation and management of placenta percreta
Placenta praevia with a morbidly adherent placenta caused three maternal deaths where profuse bleeding
was impossible to control. Cases such as those where a woman has an anterior placenta praevia and
a previous caesarean section scar require all the energies and planning of consultant obstetricians,
gynaecological surgeons, anaesthetists, interventional radiologists, blood transfusion specialists and on
occasion, vascular surgeons and urologists.
All women who have had a previous caesarean section must have their placental site determined. If
there is any doubt, magnetic resonance imaging (MRI) can be used along with ultrasound scanning in
determining if the placenta is accreta or percreta 8 . Should either be the case it may be preferable in some
cases to leave the placenta in the uterus after delivery of the baby by classical caesarean section. There
are reports citing successful outcomes where the placenta is left in situ 9 . It might be diffi cult to do this in an