Scenario in a Nutshell
Massive postpartum haemorrhage (PPH) following caesarean section, unresponsive to uterotonics, requiring hysterectomy.
Stage 1: Initial assessment of patient suffering with postpartum haemorrhage 6 hours after caesarean section.
Stage 2: MDT management of haemorrhage, commence algorithm for uterine atony and activate massive haemorrhage pathway.
Stage 3: Anaesthesia, surgical management of atony and correction of coagulopathy.
Target Learner Groups
All members of the multidisciplinary obstetric team: anaesthetists, midwives, obstetricians, operating department practitioners/anaesthetic nurses, theatre team.
| Specific learning opportunities |
| Knowledge of risk factors for PPH |
| Knowledge of treatment algorithm for massive haemorrhage |
| Knowledge of interpretation of point of care testing |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2/ST3+ | √ | |
| Obstetric ST3+ | √ | |
| Postnatal ward midwife – responds first to the buzzer | √ | |
| Postnatal midwife shift lead/other responding midwives | √ | |
| Operating Department Practitioner (ODP)/anaesthetic nurse/theatre team – scrub nurse/runner | √ | |
| Suggested facilitators | ||
| Faculty to play role of anxious husband (if enough faculty to allow for this) | √ |
Details for Facilitators
Patient Demographics
Name: Adenola Age: 35 Gestation: 6 hours post elective LSCS Booking weight: 92 kg Parity: P2 |
Scenario Summary for Facilitators
35-year-old West African patient had an elective caesarean section performed 6 h ago. Indication for caesarean section – previous myomectomy for uterine fibroids 4 years ago and one previous emergency caesarean section for fetal distress.
The elective caesarean section had been uneventfully performed under spinal anaesthesia. Blood loss was 400 ml and postoperative uterine tone had been good. She was transferred to the postnatal ward.
The scenario starts 6 h post elective caesarean section.
Patient has been trickling blood PV for 45 min and the bleeding has now become heavy. She appears to have lost 1.5 litres of blood and is feeling faint.
Following resuscitation, activation of massive haemorrhage pathway and commencement of uterotonics, she remains unstable and has ongoing uterine atony. She is transferred to theatre for GA, EUA but requires hysterectomy. Point of care testing shows marked coagulopathy.
Set-up Overview for Facilitators
| Clinical setting | Postnatal ward, on a postnatal bed |
| Patient position | Sitting up in bed at 45° |
| Initial monitoring in place | None |
| Other equipment |
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| Useful manikin features |
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Medical Equipment
For core equipment checklist see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Arterial line | Rapid fluid infuser | Bakri balloon |
| Haemacue | O-negative blood | Other simulated blood products |
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Information Given to the Learners
| Patient rings her buzzer to call for help. Facilitators inform postnatal midwife of information that she would have received from handover. |
| Time: 17:30 |
| Facilitator explains to the first responding midwife: |
| The buzzer is going off in this bed space. From handover you know that this patient is 6 h post elective LSCS. Indication (if they ask) is previous myomectomy and previous emergency caesarean section. Her caesarean section today was uneventfully performed under a spinal anaesthetic. EBL 400 ml. |
| Her attending midwife is on her break and you are responding to the buzzer as you pass by the bed space. |
Scenario Schedule
Figure 27.1 TEG.
Suggested Topics for Debrief Discussion
How easy do you think it would be managing a postpartum haemorrhage on your postnatal wards?
Would you have access to all the equipment that you would need?
Would a checklist make this emergency easier to manage?
