Obstetric Haemorrhage

 

A 35 yo woman G3P2 requires a Caesarean section for failure to progress. Her epidural is topped up with 10 mls 0.5% bupivacaine with fentanyl 50 mcg and the baby is delivered,  but the surgeon is unable to deliver the placenta intact. Blood loss is 1L over a 10 minute period.

The patient is comfortable though slightly anxious about the bleeding.

The anaesthetist places a second large bore IV cannula and orders 4 units of blood which will take 30 minutes to arrive. He gives syntocinon 20 units IV followed by ergometrine 0.25 mg IV times.

The surgeon is still unable to deliver the placenta and says he thinks this is a case of placenta accreta. He injects prostin F2 alpha into the myometrium. At this time the BP is 80/ 50 and HR is 110. Bleeding is continuing.

The anaesthetist calls for assistance. This will arrive in 20 minutes.

 

OT staff are establishing two fluid warmers and pressure bags on the IV lines.

About 15 minutes after delivery blood loss is 1.5 litres and 2 litres of Hartmanns solution have been given. This is followed by 1L of gelofusin.

The BP is now 60/ and the HR 120. The patient is distressed and hyperventilating.

General anaesthesia is induced with thiopentone 100mg and suxamethonium 100mg.

 

Repeated doses of metaraminol 0.5mg are given to maintain the BP at around 70.

Two units of O Neg bood are given.

Blood is sent for FBE and clotting studies.

Measured blood loss is 2.5 litres by this stage.

A further 6 units of blood and 4 units of FFP are ordered.

The surgeon commences emergency hysterectomy.

 

Comment 1

Probably could get more crystalloid into this patient. 2L not a lot to have given by the time you put O Neg up.

Question

What are the risks and benefits of converting to a GA in the middle of this scenario?