Biography

Dan Farine is a Professor of Obstetrics and Gynaecology at the University of Toronto. He is cross appointed to the departments of Medicine and Public Health and is head of the Maternal Fetal Medicine Division in the University of Toronto.

Professor Farine received his medical degree at Tel-Aviv University and completed his residency in Obstetrics and Gynaecology in Toronto in 1986. He finished his fellowship in Maternal/Fetal Medicine at Columbia University, New York in 1988 following which he was appointed as a staff perinatologist at Mount Sinai Hospital in Toronto. He became the Head of Maternal Fetal Medicine of that unit in 1990 and the Head of Obstetrics in that hospital in 1992.

Professor Farine has published more than 100 peer reviewed papers of which 9 received a research award. These included two SPO best paper awards, several best poster awards as well as awards from the Society for Gynecologic Investigation and the Society of Obstetricians and Gynaecologists of Canada. He is a co-editor of a textbook on malignancies in pregnancy and author of 12 book chapters.

Professor Farine had several different appointments in the area of medical education. The last was heading the Maternal Fetal Medicine fellowship programme at the University of Toronto. He has received 5 awards for his teaching capabilities.

Presentation

View the presentation "Active management of the third stage of labour: prevention and treatment of postpartum haemorrhage. Errors and remedies" by Professor Dan Farine

Transcript

Slide1
Thank you Gian Carlo, ladies and gentlemen. I was given the easy task to cover prevention and management of PPH in 20 minutes, and what I will try to do is to give you some ideas about the big picture of the issue, and like this dirty old man, show you a few things that are behind the scenes.

Slide 2
So as you know, our profession has quite evolved over the last 150 years. A hundred and fifty years ago it was nice to be a professor because you had one textbook and lots of grey hair and lots of authority. Nowadays, you can see the exhaustion of man by having all these textbooks, all these journals and now the internet and the electronic stuff that overwhelms you with data. So obviously there is too much data to cover in a short time.

Slide 3
That is why I am going to refer you to an excellent textbook, which is exclusively on PPH and I think that one of the authors is actually in the audience here. This will allow me to be quite eclectic for the rest of my presentation.

Slide 4
So I think one of the important things is prevention of PPH because if you prevent it you don't have to manage it, which is nice.

Slide 5
What I decided to do, just to be a bit provocative maybe, is to use the new SOGC guidelines from 2009 and take you through those because there are two different things about them. Well, first of all I have to say that I have been involved in writing and approving lots of Canadian guidelines, I have had nothing to do with these guidelines. So, it is nothing to do with me personally. I think it is a bit different than European guidelines, the approach is a bit different, but nevertheless it is very evidenced-based. So what I would like you to do to is to take you through the recommendations of these guidelines in terms of prevention of PPH.

So the first four is a pretty trivial list, the active management of the third stage, is a good thing to do because you will get less PPH. The fifth one is also pretty trivial because we have known it for the last 20 years. I am not going to spend any time discussing it. Six and seven is about a drug that is not used that often in Europe and we use it quite extensively, and I would like to maybe dwell for maybe a few more slides on this specific issue.

Slide 6
I think that misoprostol is a very important thing, especially in very specific scenarios. We will spend some time discussing that as well.

Delayed clamping is a very interesting topic, which has nothing to do with PPH so I will be delighted to be invited again to discuss this issue exclusively but we will not touch it whatsoever.

Slide 7
So, active management of the third stage includes: oxytosis of whatever kind, cord clamping, and mild traction. If you do that, you get a much better outcome than if you don't do it. You don't have to look at the numbers and the authors, the important thing is you have got less PPH and it is significant because it does not cross the line. Now, if you want all the results, I can show you the next slide.

Slide 8
I am not going to read you the next slide because it is going to be a bit boring, but it doesn't matter at whichever parameter you choose as an indicator of the prevention of PPH. If you ethically manage the third stage of labour you are going to improve the outcome in each one of those parameters and all of them together. And the four active management of the third stage of labour is highly recommended.

Slide 9
Now recommendations number six and five have to do with Carbetocin. So I would like to say a few things about Carbetocin. Carbetocin is basically a methylated oxytocin, and the major difference is that it is metabolized differently. It's got a faster action, a longer duration of action, actually a more sustained action, and the important thing, is that it actually works for a long time and has good absorption.

Slide 10
Now, the sixth recommendation of the Canadian guidelines recommend the routine use of Carbetocin after all caesarean sections. This is derived mainly from the data by Jerome Dansereau. I was actually one of the investigators in this specific study that was done more than ten years ago - 13 years ago. What we did there, we randomized more than 600 women into getting either oxytocin or carbetocin. Obviously everybody was blinded to what the patient's got, the patients, the doctors, and we looked at what was the impact of that. So we looked at what is needed to be added - additional Oxytocin and it was about twice as much. And it was significant. Need for uterine massage, well, as you all know we all massage the uterus and it is not such a major issue, but once again it is an indicator for bleeding. The other thing that was really nice was that you didn't get the bleeding immediately, but you could deal with it later on as a solo thing as opposed to having to deal with a c-section, the baby and the PPH.

Slide 11
The effect was much longer and it also eliminated the few remote cases of fluid intoxication, which happens with oxytocin.

Slide 12
This was the other paper that was the basis for the recommendation for routine use of Carbetocin after C-section. Basically, it showed the same thing, that you have less blood loss, it is more sustained and you are less likely to need additional care and therapy.

Slide 13
Both studies also show that actually it's a very safe drug.

Slide 14
Now I am moving to the next recommendation, which is following a vaginal delivery with either one or more risk factors for PPH, you should use Carbetocin as well. This is based mainly on a study by Marc Boucher from Montreal. And what he did was he randomized the patient to either carbetocin or oxytocin, and the methodology was not that different from the c-section methodology that I described before.

Slide 15
He found that in patients at increased risk for PPH, one dose of Carbetocin was as effective as a prolonged oxytocin infusion. Once again, you needed less intervention from the attending staff both in labour and delivery and in the post partum unit.

Slide 16
What I would like to present to you now very briefly is a set of data that we are about to publish soon but has never been published before. What we did in this very small study is to use for the first time ever intra-uterine pressure catheters post partum and not intra-partum. We got 15 patients in which we inserted post partum intra-uterine pressure catheter and we measured what happens with these patients, followed by administration of either oxytocin or carbetocin. So there was one case of PPH in the oxytocin group, which means absolutely nothing. But when you compare the carbetocin and oxytocin and we had seven in each group, you could see that Carbetocin actually causes much more frequent and more sustained contraction. The uterine tone was much higher in Carbetocin and the duration of action was much, much longer, hence, reduced blood loss in those patients.

So, small series, but the study was done in a very physiological fashion and this is the way I used to do sheep and monkey studies when I was a fellow. The data is quite convincing if you look at it this way.

Slide 17
I would like to take this recommendation number seven and kind of push it a bit further just to be provocative. So what are the risk factors for PPH? Induction of labour, we know that we induce patients now about twice as often as we used to. In the United States it is now more than 30 percent. In Europe I am pretty sure it's gone up mid-20s or slightly less than that.

Oxytocin, when I looked at oxytocin when I was doing round observations as a resident in 1983 I found that in all units around the world that published the data, it did not matter if it was the US, Canada, Ireland, Germany, wherever, the frequency of using Oxytocin was 40 to 45 percent. I am talking about induction and augmentation. Nowadays the published data suggests a 70 percent rate and when we discussed it, our junior staff and residents said, "no, no it's much higher than that."

Multiples: used to be less than 1 percent. In our unit it was 1.7 percent because we are a tertiary centre. Nowadays we have three percent of multiples, so it is changing as well in the same direction.
Prolonged labour: it depends on how you define it. If you use the Freedman curve or the WHO curve it is increased very significantly. If you move to the new curve that shows that labour is progressing slower, it is still increased to the rate of about 30 percent.

Then there are things that have not changed. Polyhydramnios two to three percent, macrosomia by definition ten percent, but if you look at the old charts it is about 14 to 15 percent now. Then fast and protracted labours.

Now if you add all these numbers together you can see very easily that very few patients will not have at least one risk factor, right? Because automatically 70 percent are here. My question then is, should you really identify the patients with vaginal delivery with risk factors or should you identify the patient with vaginal delivery without risk factors, which is going to be in the range of about ten percent.

And now that I gave you this provocative idea I would like to take it a bit further.

Slide 18
The question is: which is the best way to prevent PPH in different settings? Let's look at a setting when you have no refrigeration, no real medical care by physicians, you have labour assistance and it is as low-tech as it gets. What is the best way to prevent PPH there? The best way is to use something that does not need refrigeration, to use something that does not need any sophistication, and to use something in the way that anybody can use it without any extensive medical knowledge. The prime candidate is probably misoprostol. It's cheap, it's tablets. There are very good studies that you can use it vaginally, rectally, PO. Probably the best way to use it is rectally because if you use it vaginally it may be swept away with the bleeding anyway. If you use it orally the patient is likely to be quite nauseas and she just stopped being pregnant, why do it to her again? If you use it rectally there is very good data that it actually prevents PPH and treats PPH quite effectively. I would suggest that that is the right way to go. If you want to look at papers, there was a large paper that our own group did.

For the developing world when you do have some care, when you have an iv, when you have a setting of a hospital or at least a clinic, probably oxytocin is the right way to go. Because you use it in a very large number of labours anyway; 40 percent or 70 percent. It's really cheap and you might as well extend the use to post partum. The other provocative thing I would like to suggest is that if Carbetocin is good for patients with risk factors, and most of my patients do have risk factors, why not just use it as your first line anyway? When I presented it in my own group, once we discussed the results of our small series with the 15 patients, people said, "but you know it's much more expensive than oxytocin." And what I showed them is in our own unit it is the price of two scalp electrodes that we never think about when we have to replace them two or three times. In the setting of somebody who is bleeding quite a lot, all of a sudden you say, "well, spending $40 is not that expensive."

Slide 19
Now let's move on to management. As Tim said before, actually it was always aetiology number one, and it has become more of an aetiology because nowadays we tend to get Oxytocin for about two and half years, right? We have patients with triplets that somehow labour for a while and so forth. We will always have to look for them.

Uterine inversion, there is no change in frequency but accreta has. Because we do more sections nowadays we have many more accretas. In my first ten years a staff in a busy unit we had seven accretas. In the last SNFM we submitted a paper with 58 accretas within three years. The paper was about elective management of accretas during the c-section. So, we had an accreta, it was diagnosed using ultrasound and MRI. We booked a surgery after discussing with the patient what we were going to do, and we put a bunch of different things in terms of managing it.

This is the price that we are paying for elevated or increased caesarean section rates. As you all know, these are the cases when you need 32 units of blood, 68 units of blood, and so forth.

Slide 20
These are the rules that we drill into the residents and you have heard some of these before. First of all like good boy scouts or girl scouts, be prepared. It can hit you when you least expect it. Practice prevention is a great thing to do and we have the MoreOB as was said before, but it doesn't matter which one you use. Assessing the loss really means that you need to know how much blood that is lost. Assessing the maternal status means that you cannot look only at the perineum, you have to look at the face and your monitors as well. It is better to be aggressive and be ahead of the game because very few of our patients cannot take over-management. So a patient with Eisenmenger cannot get too much fluid or too much blood a patient with cardiomyopathy. We had only, well we had a lot actually in my centre, ten a year of cardiomyopathy or Eisenmenger, but still it is a very small portion, over 7,000 patients. Diagnose the cause, but it is almost invariably atony, then treat the cause.

Slide 21
Managing PPH.

Slide 22
Be ahead in the game. Call for help, and it is very helpful to have as many people as you can and as many people with grey hair that can push strings and make a difference in different places. This is like a chess game. And you have to think if you want to win the game you have to think about four or five moves ahead. And it is not a bad idea to know your overtures as well. The first few moves in the game you do automatically because you have been there before. Then you have to realize when you're going to be stuck, which is usually the operating room, invasive radiology that quite often refuse to be vertical during the night and try to convince you that it should stay horizontal and not come to help you. Factor VII I am not going to go into because it is a very specific and selective issue. Usually it can be done in more places but getting haematology once again - they refuse to switch their REM mode into being awake for quite a while.

Slide 23
Furthermore I think that Tim said it before--you need to know what is really the issue in your own labour floor. Knowing you can does not really help you. For instance, in our place do we take the patient to the main OR when you have some more facilities, or do we operate on her on the labour floor when we have technically less facilities but in reality we can do as much as downstairs. Are you getting invasive radiology knowing that it will take them two hours just to go to the washroom and get over the prostate before they decide to come down to the hospital? Or do you just say forget them and we'll just do it surgically? Can you get an ICU bed and how long will it take you, and so forth.

Slide 24
There is no way I can cover this in the few minutes that I have so I am going to be very eclectic on this slide. In terms of your treatment, you have lots of those. There are lots of things you can do. I am going to try to concentrate on the low-tech one. So let's start with the left hand. This is something that is quite available on the labour floor, right? If you are only right-handed you should probably not practice obstetrics because you are likely to drop the kid anyway. So what can you do with your left hand?

Slide 25
It is interesting because I spoke to people from different countries and they have different ideas. You can certainly massage the uterus during the c-section or doing the vaginal delivery. You can exert pressure and the different techniques of exerting pressure and if you are just right to get your help to get your anaesthetist, to get the blood, probably the smartest way to do it is just to grab the lower ____ with your hand and squeeze. This gives you time, a few minutes to get your team going.

An interesting technique that I found is practiced in Eastern Europe and in Israel, is uterine twisting. I never thought about the uterus being like a cork of champagne but if you actually twist the uterus you are going to reduce the blood flow. If you go to one and a half twists like they do in some places in Israel, you stop the bleeding. Obviously you cannot stay with the patient for the next two years with your hand twisting the uterus, but as a means to get things going for a while, it not a bad idea.

Furthermore, what you can also do is use aortic pressure. By using aortic pressure you achieve two different things: one of them you buy time, and number two if you try to deal with it operatively you can actually see what you are doing and not have this wave of blood that is trying to sweep you away from where you are. So the left hand is a great instrument.

Slide 26
Drugs: what will happen with drugs is that you start giving it more and more and more. You switch to all the drugs, including the drugs that do nothing to your uterus but may help only the left toe. Basically over there misoprostol is a very effective thing - it's available. Oxytocin is a tricky thing because if you over give it you may get hypotension, which is not exactly what you want, and you don't even know what is causing the hypotension, your primary condition or your therapy. Carbetocin probably does less of the hypotension so it is something to consider.

Slide 27
Ergometrine: if the patient is hypertensive you should not do it, if she is hypotensive it is not a bad way to go about it and you can give it about five times.

Hemabate: I don't know which ones of you have hemobate available in their centre? Can you raise your hands? Very few. It's actually a great drug. In Canada it is not approved but all the hospitals ask for special permission and we actually have it everywhere. It is basically a methylated TNF2-alpha, and you can give it, either I/M, or preferably into the uterus, and you can select where you are going to give it, to the lower segment or to the upper segment, and it does marvels. You can give up to eight dosages.

Slide 28
Tamponading, the truth is that there is no data which one of those is better. I have played only with these two, they are pretty much the same. We now have only the Bakri one and I don't know why. It works very, very nicely but that's not my favourite technique.

Slide 29
I will get to it in a few seconds as to what is my favourite technique. Surgery: the list is actually much longer than that. Local stitching with a very big needle is a very helpful thing to do, especially if you have an accreta that is not kind of percreta style. Very often with just wide stitch in figure of eights you can control bleeding that will take you ages to deal with B-Lynch stitches and so forth. You can go for the uterine artery and actually if you lift up the uterus you reduce the bleeding and it is easier to get you to another without going close to the ureter. And if you end up doing the hysterectomy, which is not a bad idea in a multipara who actually does not want to have any more kids, remember that the best way to go is with a sub-total.

Slide 30
This is almost my last slide and I am not sure the people in the back can see the bottom of this slide. But the bottom of this slide shows a pioneer in obgyn from the States, Simon Bolivar, are you allowed to say Bolivar in Spain nowadays, DeLee, who was the chairman in Chicago. Basically he was one of the many that promoted uterine packing. And before 1950 uterine packing was the first mode of therapy of PPH. As of 1950 it vanished. So in William's 10th edition it was gone, never to reappear again. In reality in the last 40 years there have only been 36 case reports of using packing.

If you look at this paper and I usually try to quote papers from the last few years, and this paper from 1943 is really a senior citizen, right, and a 67-year-old paper. I still like it, why? First of all they had nothing. They had no blood at the time, they had no oxytosis, they really had nothing. They could do only packing, and they did it well. So in a series of 400 cases, 398 cases were successful to packing. The two that were not successful were repacked and this was successful. Now why then did we stop using packing if it is so great? The reason we stopped packing is because you may mask the bleeding by obliterating the flow of the blood, so the patient is bleeding behind your packing and actually dying while you don't really know that she is bleeding. Right? Well, wrong. The reason for that is we have ultrasound nowadays. So you can pack the uterus, if you are a smoker you can go outside to have two of those, if you a non-smoker like me you go for a coffee and a half. You scan before you leave and make sure there is no bleeding there. You come back. If there is no bleeding after 15 minutes she will not bleed. Usually you remove it the next day and the patients are doing extremely well.

So I find that this is a much cheaper method than the Bakri balloon. The other thing is that half the time the nurses take too long to get me the apparatus. The only thing you need to do is lubricate the packing otherwise when you remove it they will bleed locally from just removal of something that is stuck. I usually use ____ but it doesn't really matter.

Slide 31
I will be very happy to accommodate any questions and discuss anything that I have not covered and I have not covered lots of things.

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