It was somebody’s wedding day. We jocularly refer to his type as the ‘knock down man.’ They are the ones who put you to sleep or block your nerves before the surgeon comes with his knife. They are called Anaesthetists. It was the wedding day of one of us. He had jocularly predicted that on his day, we would be tied down in the operating theatre with emergencies that would make it difficult for us to attend the ceremony. Talking about the power of the tongue, it came to pass.
It so happened that we were actually called out by 3am on that day for a possible surgical intervention in a case of obstructed labour. For some logistics challenges related the chaotic traffic situation in Lagos, we couldn’t start until 6am. The Caesarian Section (CS) went on uneventfully using the previous scar line for the incision. When I asked the patient what the scar was for, she told me that it was from the surgery she did when she had ectopic pregnancy. It turned out that perchance she didn’t know what she was talking about. While closing up the wound words came from the labour ward that there was a second case. There was a need to hurriedly clean up the theatre in readiness for the second section.
Just when we were about to start the second case, we were called to the recovery room where we met the patient in a pool of blood! She was actively resuscitated with crystalloids, fluids, and blood and drugs to make the uterus contract with vaginal pack. We proceeded with the second case and were through in no time. Just then, a second alarm was raised with respect to the first patient. The bleeding was now torrential. At this point, no one was thinking about the wedding anymore. Everyone was called out for whatever help and assistance they could render. The Chief Medical Director of the hospital threw the door of the blood bank open and we had all the blood we needed. When all the conservative measures we took failed to arrest the bleeding, it was time to open up the patient. What we found was not different from our initial clinical impression. The uterus was FLABBY. After weighing the various options available, an emergency hysterectomy was performed. The uterus was removed leaving the cervix and the ovaries behind. Curiously, no evidence of surgical intervention was noticed on the fallopian tubes.
For recaps, post partum haemorrhage (PPH) is the loss of blood following childbirth. A loss of 500mls at the time of birth or 1, 000mls and more within the first 24 hours following delivery can be considered as PPH. In cases of massive blood loss within a short period, signs of shock may be evident. These include increased heart rate or tachycardia, fainting attacks and increased breath rate, known as tachypnoea. As the blood pressure drops following blood loss, the patient becomes restless and may lapse into unconsciousness. It must be noted that post-partum haemorrhage can occur anytime during peuperium, which is approximately six weeks after confinement. This is the period during which the body gradually returns to its pre-natal physiological state with involution of the uterus.
In our environment the commonest cause of PPH is poor contraction of the uterus known as uterine atony. Experienced care givers may anticipate these following poor uterine contractions during labour or what is often referred to as incordinate uterine contraction. In this environment, those with multiple births and big babies are commonly at risk of PPH. Advanced maternal age in the range of 35-40 years are also at risk. Other causes of PPH include uterine tear or rupture and
blood clotting challenges. Some delayed PPH in our environment could be due to retained placenta tissue that was not removed during delivery and trauma to the cervix and the low genital tract. The so-called ‘generous episiotomy’ that could be a complication of instrumental delivery. Again those delivered through Caesarian Section and those who had induction of labour with medications and maintained on it during the process are all prone to PPH.
Post-partum haemorrhage is a caregiver’s nightmare anytime. Depending on its severity, quick and aggressive intervention should be the name of the game. As a precautionary measure extra intravenous lines must be set up and kept running to prevent a vascular collapse. Intravenous fluids with plasma expanders must be handy and blood transfusion must be instituted as soon as possible. Blood clots in the uterine cavity and vaginal vault must be evacuated; if need be by manually compressing the uterus. Anti shock measures when applicable should be put in place.
Medications like MISOPROSTOL, ERGOTAMINE and OXYTOCIN should be given until the uterus contracts and hardens up. Depending on the circumstances of the delivery, a low genital tract examination could be done using a SPECULUM. Lately, TRANEXAMIC ACID has been found to be useful in most bleeding situations and has actually been credited with decreasing the risk of mortality in mothers. We feel that in the very near future this drug should be one of the routine drugs in delivery theatres. Ultimately, there may be an indication for surgical, intervention. The options available to the surgeon would depend on the morbidity of the patient and the safest procedure to carry out especially where there is no strong anaesthetic back up. These may involve tying the arterial supply to the uterus or the removal of the uterus known as hysterectomy.
PPH can be prevented by being proactive. This involves administering medications that aid uterine contraction once the baby comes out. Secondly, the concept of active management of the third stage of labour is becoming common place these days. This simply is the aiding of the extraction of the placenta by applying gentle traction on the umbilical cord while the uterus is pushed up. The old fashion way of applying fundal pressure and massage could be used in desperate situations. The main drawback is the pain and discomfort it causes the mother. It must always be born in mind that PPH is usually triggered off during the third stage of labour.
To obtain a good result in the management of PPH, resuscitation, which should be prompt, is the hallmark to avoid some untoward sequel of acute blood loss. In our environment, the most dreaded is the ischaemic necrosis or rather death of cells due to blood loss of the anterior pituitary gland. The first sign is failure of lactation before the manifestation of other endocrine failures. PPH, most of the time, comes unexpectedly and could be nightmarish to the rookies; and its management, baptism of fire.