AFJOG

GUIDELINES • 1-2 litre colloids (Voluven®, Gelofusion®) • Keep patient warm on flat surface with legs elevated. • If a cell saver is available, set up and start collection • Continuous blood pressure, pulse, respiratory rate measurements. Monitor temperature every 15 minutes • Assign one nurse/sister to record events/fluid administration and vital signs. • Insert Foley’s urinary catheter and monitor in and output closely. • Give pooled platelets if platelet count < 50 • Give cryoprecipitate if fibrinogen < 1g/l ESTABLISH AND TREAT THE CAUSE OF PPH (4 T’S) Tone: If atonic uterus: • Rub uterus to stimulate contractions • Empty bladder • Repeat Carbetocin (PABAL®) 100μg IVI bolus OR 10 IU Syntocinon infusion/slow IV bolus injection. If none of above available, give 1000ɥg Misoprostol (Cytotec®) rectally • ALL DRUGS MUST BE AVAILABLE IN THE FRIDGES OF THEATRE AND LABOUR WARD AT ALL TIMES (carbetocin does not need to be in the fridge) Trauma: • Examine vagina, perineum and cervix for tears and suture where appropriate • For uterine inversion: replace the fundus of the uterus as soon as possible • Discontinue oxytocic drugs • Keep placenta in situ if still undelivered • Immediately attempt to manually reduce the fundus by placing a hand in the vagina and pushing the inverted fundus (with palm and fingers) along the long axis of the vagina in the direction of the umbilicus (and often passing the level of the umbilicus to generate traction from the uterine ligaments) • If a constriction ring has already formed around the inverted fundus (which may become edematous), attempt to replace the part closest to the ring first, gradually easing the rest through the ring • If this fails, administer an acute tocolytic to cause uterine relaxation and attempt again or prepare for theatre with inhalation agents to cause relaxation • Alternatively, use hydrostatic method (O’Sullivan): Make sure uterine rupture is excluded, prepare warm normal saline with biggest giving set available, and insert in the vagina. Let sterile fluid (2-5 litres may be needed) run rapidly into vagina from a height of 100 – 150 cm while closing off the introitus manually or with a silastic ventouse cup. • If this fails or if the patient is unstable, prepare for theatre and laparotomy • After reduction, start oxytocin infusion as atony or recurrent inversion occur frequently after reduction • Administer antibiotics Tissue: • Attempt manual removal of placenta or book theatre for removal of placenta ± evacuation of uterus • If still bleeding, insert uterine balloon catheter (Bakri®, Ellavi®) (or glove/catheter if unavailable) for intra-uterine tamponade If still bleeding, arrange theatre. Intra-operative: (drape patient in the modified lithotomy/Lloyd-Davis position) • Consider Examination Under Anaesthesia – repair any genital tract trauma; explore uterus for retained products of conception and evacuate if appropriate • Laparotomy – try B-lynch suture (compression suture) • Bilateral ligation of uterine and ovarian arteries • Bilateral ligation of internal iliac arteries (last resort and requires surgeon with the necessary skill) • Hysterectomy (ideally involve second consultant obstetrician) Transfer patient to ICU post-operatively or as soon as patient stable enough to transport. Continue to monitor for recurrent PPH. Debrief the patient and family. REFERENCES ¥ AUTHORSHIP These guidelines were drafted by a clinical team from Mediclinic and were reviewed by a panel of experts from SASOG and the BetterObs clinical team in 2019 and revised by the Scientific Committee of BetterObs in 2023. All attempts were made to ensure that the guidance provided is clinically safe, locally relevant and in line with current global and South African best practise. Succinctness was considered more important than comprehensiveness. All guidelines must be used in conjunction with clinical evaluation and judgement; care must be individualised when appropriate. The writing team, reviewers and SASOG do not accept accountability for any untoward clinical, financial or other outcome related to the use of these documents. Comments are welcome and will be used at the time of next review. Released on date: 20240610 African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 34