Open the floodgates OSCE by Michael

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

A registrar has just joined your department and has approached you for some teaching regarding management of post-partum haemorrhage. They have not worked in an ED that includes a regular obstetric casemix previously.

Instructions for the candidate

You are the education consultant. You work in a hospital with obstetric services. You are to outline an approach to management of PPH to the new registrar.

Domains being examined

  • Medical Expertise
  • Communication
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a moderately experienced registrar, but have never worked in a hospital with obstetric services before. You have never treated PPH and have heard it can be terrifying. You know that PPH can be prevented with routine use of oxytocin during the 3rd stage of labour. You don't know of any other specific causes, but can think of trauma such as vaginal lacerations or uterine inversion.

For the examiner

None

Domains Assessment Objectives

Medical Expertise
Appropriate approach to PPH

Communication
Clear stepwise approach to PPH expressed succinctly and accurately
Allows questions and answers appropriately

Scholarship and Teaching
Sounds teaching technique, learning plan and follow up

Other Assessment Notes

1. Call for help!
- obstetrics and organise theatre

2. Resuscitation
- High flow O2
- Cardiorespiratory monitoring
- 2x big IV access
- bloods: CBE, EUC, LFT, extended coags, Group & cross-match blood
- Crystalloid resuscitation
- Talk to patient about what is going on!

3. Address specific causes: 4 Ts (#5 = Theatre!)

*TONE
- fundal rub
- oxytocin
-- ensure 10IU prophylaxis given
-- give repeat dose (IV)
-- infusion 10IU/hour x 4/24
- ergometrine 50 mcg x 2 doses
- misoprostol 1g PR
- prostaglandin F2a
- insert IDC
- manual compression
- uterine packing (Bakri balloon, foley)

*TRAUMA
- perineum
- vagina
- cervix
- uterine inversion

*TISSUE
- check delivered placenta for completeness
- remove retained products at cervical os
- need theatre to remove retained placenta

*THROMBIN
- activate MTP
- clotting factor replacement
- tranexamic acid
- avoid hypothermia, acidosis
- abdominal aortic compression (?role for REBOA)

*THEATRE
- haemorrhage control
- lynch suture
- arterial ligation
- hysterectomy
- embolisation

Bonus points for:
- definitions of PPH
- talking to patient and family
- calling for obstetrics and arranging theatre from beginning


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