Massive PPH after caesarean — emergency management station

Team-based emergency station: intraoperative atonic PPH after twin caesarean. Tests parallel resuscitation, intraoperative surgical ladder, transfusion targets, closed-loop communication and the decision point for hysterectomy. Includes assessor key and marking domains.

Prompt

A 35-year-old G4P3 with twins and polyhydramnios has an emergency caesarean at full dilatation. Ten minutes after delivery of the second twin the uterus will not contract, the field is filling with blood, and the anaesthetist reports a falling blood pressure. You are the registrar with the consultant 15 minutes away.

Station brief

Format. Emergency management station, approximately 12 minutes. You are the obstetric registrar in theatre. A scrub midwife and an anaesthetist are with you; the consultant is 15 minutes away and has been called. The assessor will run the clock and feed you new observations. ^[1]

Candidate instruction. Lead the management of intraoperative atonic postpartum haemorrhage. Verbalise your actions, your drug orders with doses, your escalation triggers, and your communication with the team and the consultant. ^[1]^[2]

References6Show

[1]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
[2]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
[3]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
[4]B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported Br J Obstet Gynaecol, 1997.PMID 9091019
[5]Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial Br J Anaesth, 2015.PMID 25586727
[6]Kallianidis AF, Rijntjes D, van den Akker T, et al. Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis Obstet Gynecol, 2023.PMID 36701608

Massive PPH after caesarean — emergency management station

Station brief

References6Show

[1]Royal College of Obstetricians and Gynaecologists (RCOG) Prevention and Management of Postpartum Haemorrhage: Green-top Guideline No. 52 BJOG, 2017.PMID 27981719
[2]Committee on Practice Bulletins-Obstetrics Practice Bulletin No. 183: Postpartum Hemorrhage Obstet Gynecol, 2017.PMID 28937571
[3]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
[4]B-Lynch C, Coker A, Lawal AH, et al. The B-Lynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported Br J Obstet Gynaecol, 1997.PMID 9091019
[5]Wikkelsø AJ, Edwards HM, Afshari A, et al. Pre-emptive treatment with fibrinogen concentrate for postpartum haemorrhage: randomized controlled trial Br J Anaesth, 2015.PMID 25586727
[6]Kallianidis AF, Rijntjes D, van den Akker T, et al. Incidence, Indications, Risk Factors, and Outcomes of Emergency Peripartum Hysterectomy Worldwide: A Systematic Review and Meta-analysis Obstet Gynecol, 2023.PMID 36701608