10) Obstetrical Hemorrhage; Bleeding During Labor, Placental Stage and Post-Placental Period

Question 1

Why is Obstetrical Hemorrhage IMPORTANT!?

Answer 1

• Can lead to MORE than 1L BLOOD LOSS
• Resulting in maternal death!

Question 2

What are the Types of Obstetrical Hemorrhage?

Answer 2

1) Antepartum (BEFORE Labor, in 3rd trimester) = Placenta Abruption + Previa

2) Intrapartum (DURING Labor + Delivery) = Uterine Rupture and Placenta Accreta (Placenta attaches too deeply to Uterus Wall)

3) Post-Partum (PPH) = Occurs within 24 (Primary) or from 24h to 12 weeks (Secondary)

Question 3

What are the Risk Factors for Obstetrical Hemorrhage?

Answer 3

• Abnormal Placenta - Placenta Abruption, Previa, Accreta
• Trauma during Delivery - Forceps, Vacuum, C-Section, Hysterectomy, Uterine Rupture
• REDUCED Blood Volume - Under 18, Preeclampsia, Sepsis
• OVERSTRETCHED Uterus - Polyhydraminos, Induction of Labor, Chorioamnionitis, Prolonged Delivery
• Amniotic Embolism

Question 4

Explain Post-Partum Hemorrhage (PPH)

Answer 4

• Normal Blood Loss = 300 - 500ml

EARLY PPH

• MORE THAN 500ml within 24h Vaginal Delivery
• MORE THAN 1L during C-Section

LATE PPH - occurs 24h - 6 Weeks

Question 5

What are the Causes of Post-Partum Hemorrhage (PPH)?

{MEMORISE!}

Answer 5

NB! Any deviation from normal stage 3!

• Placenta completely *separates from uterus
• Myometrium contracts
• Vessels constrict
• Coagulation pathways activate

Question 6

What are the 4T’s of PRIMARY Post-Partum Hemorrhage?

Answer 6

1) Tone = Uterine ATONY (Uterus FAILS to contract after delivering placenta)

2) Tissue = Retention of Placental Tissue (TO PREVENT Uterus Contaction)

3) Trauma = Vagina, Cervical, Perineal TEARING (Birth Canal Trauma) as a result of Forceps, C-Section, Uterine Rupture

4) Thrombin = Preeclampsia (HELLP Syndrome), Hypertension, Placental Abruption)

Question 7

What are the Degrees of PERINEAL TEARS?

Answer 7

1) Superficial

2) LACERATION to PERINEAL MUSCLE

3) DAMAGE to ANAL SPHINCTER - Cause Fecal incontinence

4) LACERATION to RECTAL MUCOSA - ANTERIOR WALL of Anal Canal

Question 8

What is the Management for PPH / OH?

Answer 8

• Empty the Uterus - deliver fetus, remove placenta
• Massage Uterus - to stimulate contractions
• Bimanual Compression
• Surgical Repair, Balloon Tamponade, Hysterectomy
• Administer Uterotonic Agents - *Oxytocin

Question 9

Explain Bleeding during Placental Stage

Answer 9

1) Abnormal SEPARATION of Placenta

• Retained, Partially Separated, Unseparated, or Retained Placental Parts

2) Abnormal PLACENTATION - Normally it’s attached to Decidua Basalis

• Accreta - Chorionic Villi attach to —Myometrium instead
• Increta - Chorionic Villi *invade into Myometrium
• Percreta - Chorionic Villi *penetrate into Myometrium + Serosa

3) INVERTED Uterus - When the FUNDUS collapses into Endometrial Cavity

• Partial - NOT PAST the Cervix
• Complete - PASSES Cervix BUT, remains in VAGINAL INTROITUS
• Uterine Prolapse - FULL DESCENDING of Fundus

NB! Managed by MANUAL REPOSITIONING