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CASE #2: DON’T PULL TOO HARD

It is 2am when the hospital calls. There has been a normal vaginal delivery attended by the experienced local midwife in the Hospital birthing suite – but during controlled cord traction the cord has separated from the placenta which is retained.

Your obstetric colleague is also on the way in but has asked for your assistance should a manual removal of placenta in theatre be needed.

The drive in takes six minutes. What extra information would you require and what would be your approach to this patient?

Answers invited – the prize for best answer(s) will be an invitation to a future RuralDoctorsNet podcast…

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9 Comments

  1. KIdocs.org says:

    No such thing as a retained placenta with cord still attached!

    C before A n B for this one.
    Need to have big IVs, blood ready, give all the oxytocics as early as possible

    Initial plan would be a low spinal if no epidural – so check if there is one and top up if working.

    Anticipate a big bleed once the placenta out – get in front of the game. Send labs and clotting profile now – dont wait for the bleeding!
    Get the kit ready – an experienced fundal masseuse, bakri balloon and lots of packs.

    Be aware that any anaesthetic spinal or GA will kill cardiac output in a potentially compromised / occult bleeding pt. so gently is the theme.

    If going for a GA – this is high risk for difficult tube, rapid DESAT and aspiration – so needs to be planned and slick 1st pass ETt. Use your go to techniques – nasal cannulae, cpap preox, video + bougie at the ready.

    Obs bleeding is a little different to trauma etc. hyper fibrinolytic state – so give fibrinogen (cryo) early and TXA will help

    Of course have the trusty US ready to guide manual removal. It really helps in my experience.

    Random thoughts
    Casey

  2. Penny Wilson says:

    The main priority in this patient is to determine if she is bleeding or not.

    If she is NOT bleeding, then take a deep breath and relax.
    Find out:
    – How long since the delivery of the baby?
    – Does she have an epidural?
    – And as a GP obs I also have to think about the fact that there are TWO patients – so is the baby ok or does it need resus? (Add in patient number #3 if the dad has passed out)

    A quick history
    – Any previous history of retained placenta?
    – Any previous deliveries? caesarean sections?
    – Any other obstetric complications (PIH / pre-eclampsia, thrombocytopaenia?) or medical history (coagulopathies?)

    We all get a bit impatient in the birth suite and want the placenta to deliver in the first 5 minutes but it may take longer. So, in the absence of bleeding, you have time on your side. If she’s had an active third stage (ie early cord clamping, and an IM oxytocic) then you can quite happily wait 30 minutes without panicking. Have there been signs of separation (small gush of blood and lengthening of the cord)? If so – check the vagina. Sometimes it is sitting right there in the vagina or is half way out of the cervix and you can just pull it out.

    (Note – sometimes if you have a junior midwife, they just haven’t pulled firmly enough on the cord and you can just be a bit braver and get it out yourself. That probably doesn’t apply in this case as the cord has torn or broken)

    Some other things you can do to help the placenta deliver:
    – Catheterise the bladder (big bladder prevents the uterus from contracting adequately)
    – Syntocinon infusion (30u in 500mL CSL at 240mL/hour)
    – Get the patient to sit on a commode. Gravity is very useful.

    If she IS bleeding, drive quickly! Get help, you’ll need as many hands as possible. Someone to insert IVC and take blood for X-match, start IV fluids and IV syntocinon infusion, IDC. Put an artery clamp on any vessel that’s bleeding in the perineum. You need to deliver the placenta in order to control the bleeding. Ideally you’ll be able to get her quickly to theatre with an adequate block / GA and do a manual removal with the patient draped in stirrups. I must admit – when working in a hospital where it took 40+ minutes to get a patient in theatre, I have done a sneaky manual removal in labour ward on patients with good epidural anaesthesia. It’s not comfortable, but if it’s successful it’s very quick.

    And then – anticipate the PPH. But, most of the time once the placenta is delivered, the uterus contracts and the bleeding settles. If not, manage as per usual; fundal massage, synto infusion, IDC, PR misoprostol, bimanual compression, etc.

    This is a really topical question given the recent press about the benefits of delayed cord clamping to the fetus: http://www.guardian.co.uk/society/2013/apr/25/cutting-cord-babies-risk-nhs (and see the original BMJ article from 2011 http://www.bmj.com/content/343/bmj.d7157). I wonder if we will be seeing a move towards physiological management of the third stage which will increase the risk of PPH and retained placenta…

  3. Francois Pretorius says:

    I have been in the unfortunate position of having to deal with this a number of times and can add a few comments:

    1. I agree with Casey that a placenta is only retained when the cord is detached.
    2. This is an emergency as a women can bleed out very quickly.
    3. Call a “code” and get help.
    4. If the patient is actively bleeding and she has had an epidural/spinal, get in there and take the placenta out.
    5. If she is not bleeding, take her to theater, as you may need to revert to manual removal quickly.
    6. I am not very keen on spinal anesthesia in a actively bleeding patient as the chances for hypotension is far more, plus fiddling around to try and get the needle in may waste valuable time.
    7. Expect the uterus to be atonic after a manual removal and dealt with it accordingly. I use 40U of Synto in 1L and run it over 4hrs, plus 1gm of Misoprostol (5tabs; 1 orally, chewed and 4 PR)
    8. Cross match blood and do co-ags; don’t forget HELLP syndrome in patients with PET.

    As with Casey, just some random thoughts.
    Cheers
    Francois

  4. rfdsdoc says:

    thanks folks
    I cannot add much more to the excellent comments and feedback so far.
    I would comment on the potential for umbilical vein injection as cited in this WHO review recently

    http://apps.who.int/rhl/pregnancy_childbirth/childbirth/postpartum_haemorrhage/cd001337_diazv_com/en/index.html

    Its a simple intervention with no demonstrable harm and in resource poor settings may be of some benefit.

    As for manual removal..I agree..spinal anaesthetic needs great caution. Procedural sedation in the right hands is quicker and safer in my opinion.
    You can do a LSCS under IV ketamine alone..so manual removal is not out of the question under K.
    The key is adequate volume resuscitation prior to the attempt!

  5. Penny Wilson says:

    Hmmm… I might have to respectfully disagree with the point about the placenta being retained only if the cord is detached. If you’re pulling hard enough to snap or tear the cord you may well be “pulling too hard”. I have unfortuntely been on the receiving end of an inverted uterus (thankfully in caesarean so easily fixed) but it is NOT a situation you want to have in the labour ward as it can lead to profound hypotension and torrential bleeding. If you are pulling firmly on the cord and there are no signs of separation, and you can feel the uterus pushing against the hand that is guarding it, I would advise you not to pull the cord hard enough to snap it, as you may well accidently invert the uterus in the meantime.

  6. mark raines says:

    I work remote. Only O neg in the blood fridge, distant from any lab that cross match blood for me. But I do have access to an OT and generally work with a bunch of skilled fellow health practitioners. You can’t be a numpty muppet in the bush!

    I admit to having pulled an umbilical cord hard enough to pull it off but never enough inverted a uterus (except in a sheep, but that is a different story). I have found you will usually feel a tearing at first and you should stop then and there and be patient.

    Remember to put a clamp on the torn end still attached to Mum.

    Did the cord tear because someone had too many weeties for breakfast or just inpatient?

    Is the placenta now just trapped or still attached to the uterus?

    If the placenta is still attached will it still separate, can you afford to wait an hour, or is it pathologically adherent is it placenta accreta?

    If the fundus still soft and wide then it is likely to be still attached. Can you scan the uterus. Apparently the myometrium is thinned where the placenta is still attached.

    Has she had a curette or previous section. Will it be safe to attempt manual removal of a placenta accreta in a remote hospital?

    Remember the cord can be very thin and fragile and placentas more likely to be retained with preterm deliveries. Thankfully most Mums follow the rules and don’t birth under 37 weeks where I work currenlty!
    I agree that if there is no bleeding there is no need to rush. There is time to get everything ready to go to OT and do it under controlled situations anticipating having to manage PPH. Make sure you have enough help and everyone knows what they have to do.

    Look them in the eye, call them by name.

    Got a white board somewhere? Whiteboard markers on doors and picture glass or windows works just as well.

    Get organised

    • Consent (including laparotomy and hysterectomy – worse case scenario) but more importantly
    explanation for the woman and partner
    • IV access
    • IDC
    • OT and anaesthetic, caesarean/hysterectomy tools
    • Warm fluids
    • Oxytocics ready including F2 alpha, misoprostol, (if you have given ergometrine for bleeding you may
    need GTN to get your hand into to the uterus)
    • Bakri balllon,big sutures for a B Lynch or one its variations
    • Midwife and family to look after baby (I hope there is only one and there isn”t an undiagnosed twin!!)

    How long would I wait if nothing was happening depends on the situation, time of night and availability of staff and the patient’s anxiety. I think an hour would be reasonable.

    Apart from gravity, I tried the umbilical vein injection, but sometimes is hard to do if the only bit of umbilical vein you can see is in the midwive’s hand. The times I did it didn’t stop me going to theatre. Maybe there is a window of opportunity? There is some work that suggests cannulating the umbilical vein with a 10 Fr feeding tube and injecting 50 units of oxytocin in 30ml of saline may help (the volume is important). So may F2 alpha (20mg) or even crushed up misoprostol tablets (800mcg) !

    I have been told a cold pack of peas to the belly may help!

    Things get a little different if whilst chatting with the anaesthetist on the phone, apologising for calling him in a 2 in the morning you turn back to the patient and see a fountain of blood soak the bed sheets and floor beyond. Then I think you have to go with sedation in the birth suit and get the placenta out. I would give midazolam 5mg and fentanyl 100mcg (1 amp rule) I have been a little anxious about giving ketamine after seeing the fear in the eyes of a young guy who thought ghosts were eating his heart out after being ketamine to put his shoulder back in – I know that not evidence based.

    I have had to do this a couple of times and I believe I have saved a life and blood volume. As an intern I recall getting very anxious in OT in busy teaching hospital waiting for paperwork was being completed whilst life giving red stuff was soaking the sheets. The registrar arrived to save the day but she needed a couple of units to be safe to walk around holding her baby.

    My thoughts.

  7. KIdocs.org says:

    Excellent advice from you all – fantastic stuff. This is turning into a useful resource.

    Good thoughts too on getting organised – human factors – use of checklists etc…

    OK – who;s got a Bakri balloon and/or has practiced B-lynch sutures?

  8. James Doube says:

    On a tangent… A future option when conservative measures fail to stop PPH from an atonic uterus may be the intrauterine use of a haemostatic dressing. Recently a few cases have been published where chitosan gauze (Celox) has appeared to prevent hysterectomy (eg American Journal of O&G, Jan 2012 e13, or a poster called something like “The use of a haemostatic combat gauze is effective in severe cases of postpartum haemorrhage” from ACOG).
    These agents are not commonly used in Australian hospitals (I am not sure any have TGA approval) but are routine in more austere prehospital environments and a severe PPH last year got me thinking about other possible uses. Whilst some are exothermic (such as QuikClot), and therefore intrauterine use would seem inadvisable, chitosan is not. It is remarkably effective at stopping bleeding, and can be removed easily, so may provide another option to stem the tide which is independent of muscles and clotting cascades (and minimise further dilution of the mothers good blood with substances far less able to clot or transport oxygen…. Should PPH be seen in a somewhat similar way to penetrating trauma…?).

  9. KIdocs.org says:

    Yes, I have wondered about having this stuff in my prehosp pack or indeed available in theatre/ED for the (rare) occasions when retrieval service cannot access us.

    Anyone using this stuff – Jamie, presume AAD carry it?

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KIdocs.org

KIdocs.org

Rural Doctor on Kangaroo Island, South Australia with interests in emergency medicine, anaesthetics & trauma. Supporter of #FOAMed; EMST Director. Sites - KIdocs.org & RuralDoctors.Net Opinions expressed on this site must not be used to make decisions about individual health related matters or clinical care as medical details vary from one case to another. Reader is responsible for checking information inc drug doses etc.

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