By Collin Hofschulte
Case Study 1: Imagine yourself working on an ALS ambulance in an urban city that is dispatched to an apartment complex at 11:00 p.m. for a female having uncontrollable bleeding following a miscarriage. En route, you think back on your basic EMS training and don’t remember this topic being covered. So today, you will just have to treat the ABCs as best as possible.
You and your partner walk into a bathroom where a 30-year-old female patient is sitting on the toilet. It looks as if a gallon of blood had been poured all over the floor, across the wall, in the sink, and dripping off the bathtub. “My God,” your partner says, “It’s a blood bath in here!”
Your patient is pale and clammy, with a hypotensive blood pressure in the 70s. She is also frantic. You think to yourself, this is decompensated hemorrhagic shock. What is your treatment plan?
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Treatment approach
At the time of this call, my patient care guidelines in these instances called for standard shock treatment (e.g. supine positioning, O2, large-bore IV, warm fluids, passive warming), fundal massage and tranexamic acid (TXA). As such, my partner and I quickly moved the patient down to the ambulance where we secured an 18-gauge IV line and placed the patient on oxygen at 6 lpm. I mixed 1gram of TXA into a 100 cc normal saline bag and prepared it to administer over 10 minutes. Because our patient had been receiving care from an in-hospital OBGYN, I opted to transport the patient to this facility instead of the emergency department. Transport distance was equivalent.
With a phone in one hand and another on my patient’s abdomen attempting a fundal massage, I phoned ahead to verify that the patient could be accepted at the hospital. Although the uterus was “boggy,” the bleeding only slowed slightly. My patient complained of lower abdominal pain. Due to a hypotensive blood pressure in the 70s, I decided to forgo pain management at the time, more focusing on the fundal massage and contraction of the uterine muscle. The patient remained pale and clammy despite all of our treatments being administered successfully, but her blood pressure eventually rose 10 mmHg.
By the time we reached the hospital, a team was ready in obstetrics triage. After transferring patient care, I approached one of the physicians to ask about our performance. He replied: “There was nothing more you could do than get her to the right hospital. She is going to need blood and emergency surgery. Pieces of the placenta are still attached to the uterus, causing the bleeding. She will also need these removed in order for the problem to be corrected.”
Case Study 2: Fast forward three more years. Now imagine yourself working on a BLS fire engine where you are dispatched to a private residence for a patient experiencing uncontrollable vaginal bleeding, five weeks post-cesarean delivery. While en route to the call, you think back to the last time you treated uncontrollable vaginal bleeding. You remember that anything still attached to the inside of the uterine wall, or endometrium, might result in significant hemorrhage.
You enter the residence with your crew and find a patient laying on the bathroom floor with blood all over the floor, in the toilet and beside the bathtub. “Wow, it’s a blood bath,” you think to yourself. Sound familiar? Your rapid prime decision-making (RPDM) reminds you of the patient in Case Study 1. You feel confident in what you need to do now. Your patient presents with pale, clammy skin, weak radial pulses, a very slow respiratory rate, and decreased level of consciousness. The patient’s abdomen is soft while the uterus is normal in size, shape and tone. Shock treatment, transport and TXA are your priorities.
The patient’s husband is extremely frantic. Because the patient is only alert to verbal stimuli, you cannot get a thorough medical history from her. You pivot and try to have one of your partners calm the husband down so that this information can be ascertained. You place a large gauze pad between your patient’s legs to occlude the large amount of blood being lost through the vagina. SpO2 saturations are at 98% on room air, but because you know the patient is in shock, you initiate oxygen therapy. Due to the weak radial pulses, you take a manual blood pressure by auscultation. This reveals a blood pressure in the low 90s. You cover the patient in towels and blankets to be kept warm.
While doing all of this, you learn from the husband that the patient had an uncomplicated cesarean birth five weeks ago. Since the delivery, she has been experiencing lower back pain and spotting. Although the patient has gone into the hospital multiple times for these symptoms, they were told each time that nothing was out of the normal. The patient is otherwise healthy, with no medical conditions or bleeding disorders. You expect retained placenta is the cause, and know that the patient needs surgery.
The responding ALS ambulance had a travel time of 17 minutes but is now only a few minutes out. To expedite transport, your crew members retrieve a transport tarp from the apparatus so that you can package the patient and move her near the front door in anticipation of the ambulance. While waiting, you attempt to locate a patent IV site and make a mental note of where it is.
Finally, the ambulance arrives. You and your crew immediately carry the patient to the ambulance stretcher where a verbal transfer of care is given to the ambulance crew at this time. You tell the crew what IV site is most viable, and you also inform them that patient is a perfect candidate for TXA administration. These reminders allowed the attending paramedic to focus on initiating therapies rather than repeating a patient assessment in order to validate the conclusion.
In all, the ambulance has a scene-to-hospital time of no longer than 10 minutes. The patient is delivered to a hospital capable of providing blood transfusions and OBGYN surgical care. When you arrive at the destination hospital, the patient is significantly more responsive. She is now screaming out in excruciating pain. Paramedics hadn’t quite administered anything for pain management as transport time was so short.
On follow up, your suspicion was confirmed, the cause for the massive bleeding was retained placenta.
Post-partum hemorrhage occurrence
World-wide, post-partum hemorrhage is one of the leading causes of maternal mortality. Retained placenta is the continued attachment of the placenta to the uterine wall, which contributes to bleeding. Retained placenta can be caused by placenta adherens (when there is failed contraction of the myometrium behind the placenta), trapped placenta (a detached placenta trapped behind a closed cervix) and partial accreta (when there is a small area of accreta preventing detachment).
While statistics vary, the rate of retained placenta is around 1-3% in vaginal deliveries and 1-6% of all pregnancies, including miscarriages. While often considered a rare occurrence, I have now seen this emergency in the prehospital environment at least three times.
Post-partum hemorrhage symptoms
Patients or family members may be prompted to call 911 when the patient is experiencing a level of bleeding that is more than normal. However, you should know that the patient could already be in a state of persistently low blood volume and oxygen carrying capacity. As was the case in the preceding cases, the severity hypoperfusion were advanced even before first responders arrived.
Post-partum hemorrhage treatment
It is imperative that EMS providers recognize the need for expedited transport and administration of blood products, on top of their standard shock care for patients experiencing post-partum hemorrhage. Surely, we all know that normal saline and high flow oxygen does not replace red blood cells. These patients ultimately need surgical intervention and blood transfusion protocol as soon as possible.
Providers should consider the benefits of TXA administration. Did you know that TXA was initially invented for postpartum hemorrhage care? TXA works by reducing the breakdown of fibrinous blood clots already formed in the body. In some studies, TXA has been found to reduce the need of blood transfusions by at least 33%. TXA is relatively inexpensive and can be administered quickly and easily. If your organization does not have this capability, please advocate for it. It can mean the difference of life and death for severely hemorrhaging patients.
Post-partum hemorrhage takeaways
By exposing the ambiguity of these infrequent situations, I hope that you might feel more confident in delivering prehospital care to patients experiencing massive hemorrhage from retained placenta. Regardless of certification level, every provider can benefit these patients by coordinating their clinical impression and expediting patient-centered care.
- Retained placenta can result in bleeding due to continued adhesion to the highly vascular uterine wall.
- Patients with vaginal bleeding should be treated like trauma patients; they require prompt surgical intervention and sometimes blood transfusion.
- Focus on minimizing scene time and expediting the continuum of care in a professional manner. Do not delay transport in lieu of providing on-scene treatment.
- When indicated, blood transfusions and tranexamic acid (TXA) should be provided as early as possible.
- EMT-level providers experiencing longer transport times should consider requesting an intercept from paramedic or critical care providers capable of providing a blood transfusion and/or TXA.
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ABOUT THE AUTHOR
Collin Hofschulte is a career firefighter, fire instructor and medical coordinator for the City of Duluth, Minnesota. He provides EMS training and education to over 140 staff members. He is also a regional sales manager for HEN Nozzles. He serves as a principal for the NFPA Technical Committee on Emergency Service Organization Risk Management as well as the Technical Committee on Incident Management Personnel Professional Qualifications. He has formal education from Riverland Community College, Mayo Clinic School of Health Sciences and Columbia Southern University, and currently holds a Paramedic licensure, Associate of Arts Liberal Science degree, Bachelor of Science degree in Fire Administration and Master of Science degree in Fire Executive Leadership with a concentration in Human Resource Management.
