7.2 - Massive Obstetric Haemorrhage - Exam Flashcards
Exam: Risk of PPH - Antenatal
- Antenatal Intrapartum
- History of PPH
- BMI >35 S
- Maternal anaemia (undiagnosed or untreated)
- Maternal iron deficiency P
- Antepartum haemorrhage (APH)
- Previous macrosomic baby ≥ 4500 g
- Polyhydramnios
- Fibroids
- Induction of labour
- Known coagulopathy
- Abnormal placentation
- Hypertensive disorders
- Placenta praevia
- Multiple pregnancy
*
Risk of PPH - IP
- Augmentation of labour
- Spurious labour - prolonged latent phase of labour
- Precipitate or incoordinate labour
- Prolonged active first stage >12 hours
- Prolonged second stage >3 hours
- Prolonged physiological third stage >1 hour
- Prolonged active third stage >30 mins
- Surgical intervention - forceps, vacuum, episiotomy, caesarean
- Induction of labour
- Pyrexia in labour
- Shoulder dystocia
- Fetal macrosomia ≥ 4500 g
- Placental abruption
- Incomplete third stage
PPH Pathway
Exam: Describe the “Rule of 30”
Why is it useful?
‘Rule of 30’
* Rise in pulse >30/minute,
* drop in systolic blood pressure by 30 mm Hg,
* increased respiratory rate >30/minute,
* a drop in haematocrit [packed cell volume] by 30%), which is suggestive of at least 30% loss of blood volume.
* helps when alot of blood is being lost quickly and in an emergency sitution - quick guide/reference
Exam: How do you calculate shock index? How is it altered for pregnancy and why?
HR Divided by SBP
Manual form of stopping PPH
bimanual massage
Bakri Balloon
Tamponde
Exam: Describe the potential causes, recognition and management of massive Post-partum
Haemorrhage.
Potental causes of PPH
Tone (70 per cent), atonic uterus, distended uterus, uterine muscle exhaustion
Trauma (19 per cent), cervical, vaginal or perineum, pelvic haematoma, uterus
Tissue (10 per cent), retained products of conception, invasive placenta
Thrombin (1 per cent), blood clotting disorders, inherited or acquired including Disseminated intravascular coagulation (DIC).
Exam: Explain the role of the midwife as a member of the multidisciplinary team in prevention,
identification and management of massive Post-partum Haemorrhage.
Midwife role
- Identify risk factors
- peri care to ensure minimal trauma
- 15 mins PV loss monitoring
- fundal rub ensure fundus is contracting and firm & central
-bimanual compression
- often associated with the woman cramping and pain
- expel clots
- insert two size 16 ivc
- check vagina and cervix for tears apply pressure, vaginal packs
- deliver placenta in a timely manner- expel clots
- inspect placenta
- Consider: Severe preeclampsia, placental abruption, sepsis, FDIU, amniotic
fluid embolism, hereditary bleeding disorders e.g. von willebrand’s
Identification:
- visual
- weighting of loss not estimating
Management
- call for help
- lie the woman flat
- administer 02
- massage uterus and or bimanual compression
- keep warm
- expel clots
- insert an IDC
- administer
- Oxytocin 10 units IM/IV, Syntometrine 1ml IM or Ergometrine 250microg IM and 250microg IV
(Hypertension -Syntometrine & Ergometrine contraindicated)
BP, HR, RR and SaO2
5 minutely Temp 15 minutely
Monitor blood loss and hourly urine output
insert IVC x 2 -
bloods- FBE, G&H, LFT U&E and clotting
strict FBC
Exam: What are the 4 T’s
- Tone
- Tissue
- Trauma
- Thromin
Exam: Which most commonly causes PPH?
- atonic uterus - fails to contract down on the spiral atertries
- distended uterus
- pelvic haemtoma
- trauma to peri, vagina or uterus
- retained product
known blood clotting disorder
placenta accreta
-
Exam: Aside from excessive blood loss how else can you identify PPH?
Drop in HR, blood pressure, o2 sats, symptomatic feeling light headed, dizzy, looking pale, drop in HB
Exam: While visible blood loss is one measure what other parameters identify a massive
haemorrhage?
vital signs
bloods
Exam: List the first 5 priorities of care following identification of a massive PPH
- call for help
- assess
- access
- cause
- drugs
- replace loss with blood fluid volume expandser rbc FFP
Exam: List the order that drugs are administered - include names/ doses/ route/ any
contraindications
Drugs
Table 2. PPH Drugs
Drug Dosage Route/s of administration
1st line - immediate management Oxytocin (Syntocinon) 10 iu IM or IV
Syntometrine* 1 ml IM (not with hypertension)
Ergometrine 500 microg
or
250 microg + 250 microg IM
IM + IV (give IV slowly)
2nd line Tranexamic acid 1 g in 100ml 0.9% NaCl IV (given over 10 mins)
CarboPROST** 250 microg/1 mL IM
After immediate management - once
bleeding is controlled, use to maintain tone
Misoprostol 400-800 microg Buccal or PR
Oxytocin infusion 40 iu in 1L CSL IV (given over 4 hours)
Exam: management of PPH for each T
Management for specific causes of PPH
**Tone **
Massage the atonic uterus to stimulate contraction and expel clots.
Administer oxytocics
Insert an indwelling catheter (IDC)
If attempts to deliver the placenta have been unsuccessful, prepare for immediate manual removal under anaesthesia in theatre
If heavy bleeding continues, apply bimanual compression until further management decisions are made
In the event of intractable bleeding, surgical intervention in theatre may be required, for example, examination under anaesthetic, insertion of a uterine balloon (Bakri), B-Lynch suture, uterine artery ligation, hysterectomy
If required, uterine balloon is inserted as per manufacturer’s instruction (see Post insertion care for more information)
If packing is used, the packs must be tied to the uterine balloon catheter and document presence and plan for removal
**Trauma **
In all cases of primary PPH, check the genital tract thoroughly to exclude bleeding from trauma, for example, lacerations, haematomas
In the presence of visible trauma, apply pressure and repair either in birth suite or under anaesthesia in theatre
Vaginal or uterine packing may be required to control bleeding
Packing the uterus is best undertaken in theatre after an examination under anaesthesia and with a senior obstetrician involved.
When packing the uterus:
tie 3–4 gauze rolls together, lightly soak gauze in sodium chloride 0.9 per cent and tightly pack the uterus and vagina to ensure an effective tamponade
document the number of packs present and a plan for their removal
If the placenta is delivered and the uterus contracted, consider other concealed causes of trauma such as ruptured uterus, broad ligament haematoma
**Tissue **
If the placenta is not delivered and bleeding continues, prepare for examination and manual removal under anaesthesia in theatre
If the placenta is delivered, check the placenta and membranes for completeness
Where tissue is retained, or bleeding continues, prepare for examination under anaesthesia in theatre
If anaesthetic or theatre staff are not available, the placenta is retained and bleeding is vigorous, manual removal without anaesthesia is only considered as a lifesaving manoeuvre
Alternatively, apply vigorous bimanual compression until further help is available
**Thrombin **
In the presence of a well contracted uterus and where trauma and retained tissue have been excluded, consider investigating for coagulopathies
Consider coagulopathy as a consequence of ongoing PPH
