O&G SAQs · Intrapartum care — obstetric emergencies
Primary postpartum haemorrhage — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on atonic primary PPH: first-five-minute priorities, bedside exclusion of the 4 T's, the uterotonic ladder with doses and contraindications, and escalation to tamponade and theatre. Per-sub-part marking rubric included.
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Prompt
You are the on-call registrar. A 32-year-old G3P2 has a spontaneous vaginal birth of a 4.2 kg baby after a 14-hour labour augmented with oxytocin. Ten minutes after birth of the placenta, the midwife calls you: the calibrated drape holds 900 mL and bleeding continues. Observations: HR 116 bpm, BP 106/64 mmHg, RR 22, alert. (a) State your immediate priorities in the first five minutes, with the reasoning for each. (5 marks) (b) List the causes you must exclude at the bedside and how you exclude each. (4 marks) (c) Outline your pharmacological management, naming drug, dose, route and one contraindication for each agent. (4 marks) (d) Bleeding continues at 1600 mL despite your measures. Outline escalation. (2 marks)
How this SAQ is marked
Twelve SAQs, 180 marks, two 2-hour papers — roughly 15 marks and 20 minutes each. Marks come from specifics: named drug, dose, route, contraindication, threshold, time window. Write in short labelled points, not prose paragraphs. Answer the sub-part you are asked. [1]
Reveal model answer and mark schemeShowHide
(a) Immediate priorities — first five minutes (5 marks)
One mark per point, maximum five. [1]
- Call for help and declare the emergency — obstetric consultant, anaesthetist, midwifery coordinator, blood-bank alert; assign roles and a scribe.[1]
- Uterine massage plus first uterotonic immediately — rub up the fundus, oxytocin 10 IU IM or 5 IU slow IV, start an infusion (40 IU in 500 mL crystalloid at 125 mL/h).[1][2]
- Two large-bore (14–16 G) cannulae; bloods — FBC, coagulation with fibrinogen, crossmatch 4 to 6 units, U&E, calcium, lactate.[1]
- Tranexamic acid 1 g IV over 10 minutes — as early as possible, within 3 hours of birth.[3]
- Catheterise, warm, and keep a quantitative running blood-loss tally — a full bladder sustains atony; measured loss beats estimated loss.[4]
Reasoning marks are awarded for stating why (for example "shock index 116/106 is above 1.0, so significant loss is already present despite a normal blood pressure"). [1]
(b) Bedside exclusion of causes (4 marks)
One mark per T, with the method of exclusion. [1]
- Tone — palpate the fundus: boggy and high means atony; massage and note whether bleeding slows.
- Trauma — inspect perineum, vagina, fornices and cervix with good light, analgesia, lithotomy and an assistant; a well-contracted uterus with ongoing bleeding is trauma until proven otherwise.
- Tissue — re-inspect the placenta and membranes for completeness; bedside ultrasound for retained products; consider accreta if the placenta was adherent.
- Thrombin — review history (abruption, sepsis, fetal death, known bleeding disorder, anticoagulation) and send fibrinogen; oozing from puncture sites suggests coagulopathy.[1][2]
(c) Pharmacological management (4 marks)
One mark per agent with dose, route and contraindication. Marks are lost for "give uterotonics" without specifics. [2]
| Agent | Dose and route | Contraindication |
|---|---|---|
| Oxytocin | 10 IU IM or 5 IU slow IV; infusion 40 IU in 500 mL at 125 mL/h | Rapid IV bolus (causes hypotension) |
| Ergometrine | 0.5 mg IM or slow IV | Hypertension, preeclampsia, cardiac disease |
| Carboprost | 250 micrograms IM, repeat every 15 minutes, maximum 8 doses (2 mg) | Asthma |
| Misoprostol | 800 micrograms sublingual | Limited added value once oxytocin given |
Plus tranexamic acid 1 g IV (already given in part a; a second 1 g dose if bleeding continues after 30 minutes or restarts within 24 hours).[3]
(d) Escalation when bleeding continues despite the ladder (2 marks)
- Mechanical and theatre: bimanual compression while preparing; intrauterine balloon tamponade filled with warm saline up to 500 mL (approximately 85% success in pooled data); activate the massive haemorrhage protocol; transfuse to keep fibrinogen at or above 2 g/L and platelets above 50 × 10⁹/L.[5][1]
- Surgical ladder if tamponade fails: laparotomy with B-Lynch compression suture, then stepwise uterine and internal iliac artery ligation, uterine artery embolisation if stable and available, and hysterectomy before the patient is unsalvageable — delay, not the operation, is what kills.[6][1]
References6ShowHide
- [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]Gallos I, Devall A, Martin J, et al. Randomized Trial of Early Detection and Treatment of Postpartum Hemorrhage N Engl J Med, 2023.PMID 37158447
- [5]Suarez S, Conde-Agudelo A, Borovac-Pinheiro A, et al. Uterine balloon tamponade for the treatment of postpartum hemorrhage: a systematic review and meta-analysis Am J Obstet Gynecol, 2020.PMID 31917139
- [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