Scenario in a Nutshell
PPH and retained placenta in delivery room. Uterine inversion. Failed manual replacement. Transfer to theatre. Successful hydrostatic replacement of uterus. Atonic PPH follows manual removal of placenta.
Stage 1: Uterine inversion diagnosed and manual replacement attempted with simultaneous resuscitation.
Stage 2: Hydrostatic repositioning of the uterus in theatre under GA.
Stage 3. Manual removal of placenta, postpartum atonic haemorrhage.
Target Learner Groups
All members of the multidisciplinary obstetric team: midwives, obstetricians, anaesthetists, operating department practitioners/anaesthetic nurses, theatre scrub team.
| Suggested learning opportunities |
|---|
| Recognition of symptoms and signs of uterine inversion |
| Effective team management of uterine inversion with concurrent attempts at uterine replacement and resuscitation |
| Demonstrate methods of uterine replacement – manual and hydrostatic |
| Knowledge of drugs and doses – tocolytic and uterotonic agents |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic ST3+ | √ | |
| Obstetric ST3+ | √ | |
| Midwife Coordinator | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse | √ | |
| Scrub nurse | √ | |
| Suggested facilitators | ||
| Faculty to play role of midwife | √ | |
| Faculty to play role of obstetric ST1 | √ | |
Details for Facilitators
Patient Demographics
Name: Charlotte Age: 28 Gestation: 39+4 Booking weight: 75 kg Parity: P3 |
Scenario Summary for Facilitators
A 28-year-old multiparous woman has just had a spontaneous vaginal delivery. She is now para 3 and has had two vaginal deliveries previously, for one of which she required a manual removal of the placenta.
She was booked for antenatal care locally and had an uneventful pregnancy.
She is using entonox for analgesia. She had a PV bleed following delivery and the midwife had difficulty in delivering the placenta.
She called for medical help and the Obstetric ST1 attempted to remove the placenta with difficulty. No vaginal trauma was noted. The placenta was unable to be delivered. After this, the bleeding increased and a postpartum haemorrhage (PPH) was diagnosed.
On examination, the uterus is not palpable abdominally and there is a large visible mass at the introitus. This patient has an acute uterine inversion.
There is haemodynamic instability, with marked bradycardia. Attempt at manual replacement in the room fails.
The patient is transferred to theatre, requires a general anaesthetic, manual/hydrostatic and pharmacological treatment of uterine inversion and PPH with simultaneous resuscitation.
Set-up Overview for Facilitators
| Clinical setting | In delivery unit, on a delivery bed |
| Patient position | Lithotomy |
| Initial monitoring in place | Pulse oximeter, NIBP |
| Other equipment | 16G cannula dorsum of hand. Midwife is attaching 1 litre of Hartmann’s to the cannula. 40 IU syntocinon: 10 IU in 500 ml normal saline running at 125 ml/h |
| Useful manikin functions | Birthing manikin with uterine inversion model or pelvic part task trainer with soft uterine inversion model |
Medical Equipment
For core equipment checklist, see Chapter 9 including advanced airway equipment.
| Additional equipment specific to scenario | ||
|---|---|---|
| Local emergency checklists for uterine inversion/postpartum haemorrhage (if available) | Kiwi/silicone ventouse cup ± black anaesthetic face mask | Warmed saline (several litres) and giving set |
| Rapid IV infusor/fluid warmer | Intrauterine hydrostatic balloon device (e.g. Bakri®) | Tocolytics: eg: terbutaline, glyceryl trinitrate (GTN), magnesium sulphate (MgSO4) |
| Cardiovascular drugs: atropine, ephedrine, phenylephrine, metaraminol | Uterotonic agents: syntometrine, syntocinon, ergometrine (Haemabate), carboprost, misoprostol | Induction agents (thiopentone and propofol), neuromuscular blockers (depolarising and non-depolarising) |
| Arterial line | Entonox mask/mouth piece | Tranexamic acid |
| Prophylactic antibiotics | ||
Information Given to the Learners
| Information given to ST3 obstetric trainee and midwife coordinator who have just been called to attend the room |
| This handover is given by a facilitator playing the role of the obstetric ST1. |
| The SBAR handover is as follows: |
| Situation: This is a woman who is having a PPH and I can’t get the placenta out. |
| Background: Charlotte is a 28-year-old, previously fit and well multiparous woman who was 39+4 weeks pregnant. She had a spontaneous NVD 20 minutes ago and is now para 3. She has had 2 previous NVD, needing a manual removal of placenta last time. |
| She is otherwise fit and well with no known allergies. |
| There was a brisk loss following delivery and I got called in to assist as the midwife was having trouble delivering the placenta. She had syntometrine for 3rd stage. Now there is a big mass at the introitus and I can’t palpate the uterus abdominally. I’m worried she might have a uterine inversion. |
| Action: I have tried to remove the placenta over the last 5 minutes but I can’t. The bleeding is getting heavier. We have started a syntocinon infusion and some Hartmann’s. She has lost about 600 ml so far I think. |
| Recommendation: Can you help me get this placenta out? |
