Case of the Month #45 Major Obstetric Haemorrhage - Part 1

Published 02/11/2023


Category: Obstetrics 

A 39-year-old grand multipara (Gravida 7 Para 5) presented to the Labour Ward actively labouring at term. Apart from a long history of smoking, she was otherwise fit and well with a BMI of 28.  

Her obstetric history included one forceps assisted delivery, followed by a miscarriage and then four vaginal deliveries.  

She laboured quickly and delivered a healthy baby girl within an hour and a half of arrival. A 16G cannula had been sited and blood taken for Full Blood Count (FBC) and Group and Screen (G&S).  

The woman received 10 international units (IU) of oxytocin IM for an active third stage of labour. The placenta was delivered with difficulty with controlled cord traction, inspected carefully and noted to be intact. Post-delivery estimated blood loss (EBL) was 500 ml. 

Despite a prophylactic oxytocin infusion, the patient continued to have moderate vaginal bleeding. Mechanical and pharmacological management initiated by the senior obstetric and anaesthetic team failed to control bleeding. The decision was taken to undertake examination of the genital tract and uterus under general anaesthesia in theatre. 

On arrival in theatre the patient’s observations were as follows: 

  • Oxygen saturations 100% with Fi02 1.0 during pre-oxygenation. Respiratory rate 22 breaths per minute. 

  • Blood pressure 95/52, heart rate 135 beats per minute. 

  • Glasgow Coma Scale (GCS) E3 V5 M6 (14). 

Following induction of general anaesthesia, the EBL was approaching 1500 ml and therefore the Major Obstetric Haemorrhage protocol was activated.