10: PPH

Question 1

Define PPH

Answer 1

Primary = bleeding within 24 hours post delivery

Secondary = bleeding from 24h-6 weeks after delivery of baby

500mL post NVD and 1000 post CS

Question 2

What are the four main causes of PPH?

Answer 2

Tone
Trauma
Tissue
Thrombin

Question 3

Risk factors for PPH

Answer 3

Demographic: older age, elevated BMI
Current pregnancy: multiple pregnancy, PET, diabetes, APH, polyhydramnios
Intrapartum: instrumental delivery, prolonged labour, macrosomia
Obs hx: highly parous, previous PPH
Gynae hx: fibroids, uterine anomalies
General medical: coagulopathy, HTN
SHx: smoking, drugs, alcohol

Question 4

What plan would you put in place for a high risk woman?

Answer 4

1. Antenatally: correction of anaemia, work on all modifiable risk factors e.g. BMI
2. In labour: x2 wide bore cannulae, ensure UTD bloods, avoid instrumental delivery
3. Active mx of third stage

Question 5

Management

Answer 5

1. Assess: call for help, ABCDE, resuscitation, insert catheter, determine cause
2. Arrest: massage, stepwise ecbolics (syntocinin -> synometrine -> carboprost or misoprostol). Loss >1500mL bimanual compression and transfer to theatre
3. Replace: 2 units crystalloids then infusion, if uncontrolled massive transfusion protocol

Question 6

What is active mx of the third stage?

Answer 6

1. Ecbolic after anterior shoulder
2. Cord clamping
3. Control cord traction
4. Inspection of placenta

Question 7

What is physiological mx of the third stage?

Answer 7

• Placenta delivered w maternal effort
• No drugs
• No cord clamping or traction