Ignoring the guidelines 2
›› I read with interest the report on “Ignoring the guidelines” in the January 2013 case of postpartum haemorrhage (Casebook 21(1)). Whilst I agree that the ultimate decision on the most appropriate surgical management of this patient lay with the obstetrician on-call, it is important to point out that the medical management of the patient up to that point (including maternal resuscitation, and the correct implementation of the local massive obstetric haemorrhage guidelines) was the joint responsibility of the obstetrician and the obstetric anaesthetist on-call covering the labour ward.
Generally, when a massive obstetric haemorrhage occurs, in most obstetric units, the anaesthetist should take the lead with the administration of intravenous syntocinon (+/- infusion), im/iv ergometrine, im carbaprost, intravenous fluid resuscitation and administering packed red cells/blood products, since they are most familiar with these drugs and in those specific aspects of maternal resuscitation; the obstetrician (assisted by the midwifery team) should take the lead with the usage of pr misoprostol and im syntometrine, external uterine massage and bimanual compression, since they are most accustomed to using these particular drugs/techniques.
Once the decision to go to theatre has been made (jointly), whilst the anaesthetist should mainly concern themselves with continued maternal resuscitation, they still have a duty to discuss/remind the obstetrician of their available surgical options (B-Lynch suture, internal iliac/uterine/ ovarian arterial ligation, packing of the abdomen as a holding measure or to enable angiography +/- embolisation, hysterectomy, cross clamping the aorta etc, depending on the clinical scenario and cardiovascular/haematological stability), particularly if there is perceived deviation from local/national guidelines.
It is important to point out that the medical management of the patient up to that point was the joint responsibility of the obstetrician and the obstetric anaesthetist on-call
Massive obstetric haemorrhage is an extremely stressful clinical situation, particularly for the obstetrician, therefore the anaesthetist plays a crucial role in ensuring that logical sensible decisions are still being made amidst the mayhem, which includes insisting that the obstetrician calls for further assistance/senior help/consultant advice/consultant to come in, if the clinical situation warrants it.
Maternal resuscitation in massive obstetric haemorrhage is most effective when the labour ward obstetricians, anaesthetists and midwives work together as a team, so that the guidelines are followed and the appropriate decisions are made at the appropriate times, to achieve the best maternal outcome (which may still unfortunately be a hysterectomy, but at least the appropriate steps to justify that decision will have been taken along the way).
Dr Patrick Ward, specialty trainee, anaesthetics, UK
Note from Casebook:
Effective teamworking is part of the training offered on behalf of MPS by Atrainability, an organisation that specialises in the roles human factors and situational awareness play in risk and patient safety. Visit www.atrainability.co.uk for more information.