Chapter 15: Postpartum Haemorrhage Flashcards
You are a trainee intern doing obstetrics on your elective in a primary birthing unit and are called to the birthing suite where the midwife is attending to a very flat baby after a precipitous delivery, and the mother, Masina, is having a postpartum haemorrhage. Blood lost is estimated at 800 mls. Masina is conscious and asking after her baby. You summon additional help whilst waiting.
You give Oxytocin 10IU intramuscularly and, and deliver the placenta by controlled cord traction and. You examine the placenta which appears complete.
Although the fundus feels firm, Masina continues to bleed.
From the following options, what should be your most immediate next action?
Inspect the perineum and lower vagina, and apply pressure if a tear is bleeding profusely
Inspect the cervix for a tear
Insert your right hand vaginally and apply bimanual compression
Insert a 20G IV line
Arrange for blood transfusion
Inspect the perineum and lower vagina, and apply pressure if a tear is bleeding profusely
You are a trainee intern in birthing suite with Ngaio, a 37 year old para 5 Māori woman who is in active labour. Because of her high parity, you are assessing her risk of having a primary postpartum haemorrhage. Which of the following elements of her obstetric history, MOST increases her risk of a primary post-partum haemorrhage (PPH)?
She has well controlled gestational diabetes in this pregnancy
She had an atonic PPH with her last birth
She has had growth restricted babies in the past
She had preeclampsia in her first pregnancy
She is Rhesus negative
She had an atonic PPH with her last birth
You are a trainee intern in delivery suite assisting a midwife at Anna’s labour and birth. Anna is a 32 year old para 1 New Zealand European woman. She was induced for post-dates at 41 weeks’ gestation. Her daughter was born 20 minutes ago and an injection of oxytocin IM was given after there had been 3 minutes of delayed cord clamping. Despite controlled cord traction, the placenta has not been delivered. The midwife checks vaginally and the placenta is above the cervical os. Anna gives a push and passes approximately 500 mls of fresh blood and clots in a gush. The placenta has not delivered. Anna continues to bleed briskly. Anna looks pale and feels sweaty. The emergency bell is pressed for assistance. A second large bore IV line is inserted, bloods sent and IV fluid resuscitation commenced. Of the following options, what should be the next immediate management?
Massage the fundus of the uterus
Administer ergometrine IV stat
Maintain traction on the cord and counter support of the uterus
Transfer to theatre for a manual removal of the placenta.
Continue cord traction till the placenta detaches, then replace the inverted uterus
Give 1000 mls of dextrose stat
Transfer to theatre for a manual removal of the placenta.
Ergometrine is IM and only after lplacenta out
You are a trainee intern in birthing suite with Nijah, a 37 year old para 5 woman from Somalia who is in active labour. In her last pregnancy two years ago, Nijah had an atonic PPH of 600mls that settled with uterine massage and an oxytocin infusion. On admission, Nijah’s blood pressure was raised at 164/112. She was given a stat dose of oral labetalol 200mg and her bp is now 140/90. You have inserted a wide bore IV line and have sent bloods for a FBC and a Group & Hold. You are in the room with Nijah and her midwife when Nijah complains of pressure in her bottom and has an urge to push. You see the head crowning and assist the midwife with the birth. What is the next most important management to reduce her risk of having a primary PPH?
Administer Carboprost (IM 250 µg) with delivery of the anterior shoulder
Administer 800 mcg of misoprostol PR when the umbilical cord has stopped pulsating.
Administer Syntometrine (5iu Syntocinon/oxytocin and 0.5mg ergometrine) IM when the umbilical cord has stopped pulsating
Allow a physiological third stage, birthing the placenta by maternal effort
Administer 10 IU of IM oxytocin when the umbilical cord has stopped pulsating
Administer 10 IU of IM oxytocin when the umbilical cord has stopped pulsating
Ergometrine contraindicated in hypertension.
Sally is a 32 year old Pākehā woman who had her second baby 2 weeks ago. It was an uncomplicated labour and birth and she had a small second degree tear that was repaired. She was discharged home on day 2 post-natal and breast feeding was going well. Sally is usually fit and well. Sally is brought into the emergency department via ambulance bleeding heavily. Her lochia had been settling but had been heavier yesterday. This morning her bleeding became heavier and when she went to the toilet she had further gushing of blood with clots. The toilet bowl was red and there were blood clots on the floor The ambulance officers had inserted a large bore IV line and given 2litres of crystalloid. On arrival in hospital Sally’s bp is 95/55 and her pulse is 110. From the following options, what is the MOST LIKELY cause of Sally’s haemorrhage?
Undiagnosed bleeding disorder such as haemophilia or Von Willebrand’s disease
Retained products and DIC
Endometritis and retained products
Retained products and a broken down perineal tear
Atony and DIC
Endometritis and a broken down perineal tear
Endometritis and retained products
2ndry PPH - usually infection +/- retained products. too long 4 perineum
You are a trainee intern on birthing suite. Meera is a 38 year old New Zealander of Indian ethnicity. She has just had her third baby. Her pregnancy was complicated by pregnancy induced hypertension that was managed with methyldopa. Meera’s past history includes asthma for which she takes regular inhalers. She requires a course of oral steroids about once a year. Meera’s baby weighed 2.8kg and is in good condition. Meera had 5U of IM oxytocin for management of her third stage. Meera is having a post-partum haemorrhage (PPH). Her perineum is intact and the placenta appears complete. You assess that the PPH is due to atony. You rub up a contraction. A large bore IV line is sited and fluid resuscitation commenced. A urinary catheter is inserted. When the fundal massage is stopped, the uterus relaxes and is boggy. Of the following options, what medications are appropriate to give Meera as management of her PPH?
Oxytocin infusion, IM carboprost (F2 alpha) and IV tranexamic acid
IM ergometrine, IM carboprost (F2 alpha) and PR misoprostol
Oxytocin infusion, PR misoprostol and IV tranexamic acid
IV ergometrine, PV misoprostol and IM carboprost (F2 alpha)
Oxytocin infusion, IM ergometrine and IV tranexamic acid
Oxytocin infusion, PR misoprostol and IV tranexamic acid
Carbopost contraindicated in asthma. Ergo contraindicated in HTN.
You are a trainee intern on birthing suite. Sarah is a 24-year-old New Zealand European woman who had her first baby an hour ago and you were involved in her intrapartum care. Sarah had a prolonged 18 hour labour requiring an epidural for analgesia and oxytocin augmentation for delay in progress. She had a ventouse birth of a 4.2kg baby boy with the indication for ventouse being a prolonged second stage. An episiotomy was repaired. Oxytocin 10IU IM was given for active management of the third stage of labour and following repair of the episiotomy the registrar had checked that the fundus was firm and there was no bleeding. The placenta was checked and was complete. Sarah was breast feeding her baby an hour after the birth when she felt a ‘gush’ vaginally. There is approximately 500 mls of blood and clots on the bed linen. Which of the following is the most LIKELY cause of this bleeding?
Disseminated intravascular coagulation
Uterine rupture
An unrecognised perineal tear.
Uterine atony
A retained placental cotyledon
Maternal thrombophilia
Uterine atony
You are a trainee intern in birthing suite assisting with an emergency ‘category 1’ caesarean section for Maria, a 42 year old para 5 Samoan woman. Maria is 40 weeks’ gestation and has had 5 previous vaginal births. This pregnancy she has been well antenatally but at term her LMC midwife noted that there was no increase in the fundal height and arranged a growth scan. The scan showed a drop off in fetal growth with the baby plotting on the 5th centile of the customised GROW chart. The liquor and Dopplers were normal. An induction of labour was arranged using prostaglandins. When she was admitted for induction of labour Maria’s Bishop’s Score was 4 and prostaglandins were administered. Six hours later Maria began contracting strongly. Her membranes ruptured and there was thick meconium. Maria became short of breath. There was a fetal bradycardia of 60 beats per minute. A vaginal examination revealed that Maria was 4 cm dilated and no cord was felt. The decision was made for a category 1 caesarean section under general anaesthesia. Following induction of anaesthesia the baby is rapidly delivered. It is pale and unresponsive. The patient then becomes severely hypotensive and the anaesthetist is having difficulty ventilating her. There is brisk bleeding from the uterine incision site and the obstetrician suspects DIC. Of the following options, what is the most likely diagnosis?
Placenta accreta
Amniotic fluid embolism
Uterine atony
An anaphylactic reaction to the antibiotics given at induction of anaesthetic
Uterine rupture
Amniotic fluid embolism
You are a trainee intern on birthing suite. Matilda is a 27 year old woman from Australia who weighs 70kg. She had a normal vaginal birth 30 minutes ago. Matilda has had an uncomplicated pregnancy and keeps good health. At the start of labour Matilda’s bp was 120/80 and her pulse was 70. Matilda has had an atonic post-partum haemorrhage. It was managed with an oxytocin bolus and infusion, fundal massage and an in-out catheter. Her blood loss has been carefully weighed to be 1000 mls. No other fluid replacement has been given. Her labour and birth was otherwise straightforward. Of the following options, which are MOST LIKELY to be consistent with Matilda’s vital signs?
BP 60/40, pulse 150, Rate 30
Bp 140/90, pulse 60, Rate 16
Bp 120/80, pulse 85, Rate 16
Bp 60/40, pulse 30, Rate 24
BP 90/60, pulse 110, Rate 22
BP 80/40, pulse 120, Rate 24
Bp 120/80, pulse 85, Rate 16
You are called to assist in the care of Whina, a 24-year-old G1P1 Māori woman who is having a postpartum haemorrhage. Whina had a prolonged 18 hour labour requiring an epidural for analgesia and oxytocin augmentation for delay in progress. She had a ventouse birth of a 4.2kg baby boy with the indication for ventouse being a prolonged second stage. An episiotomy was repaired. Oxytocin 10IU IM was given for active management of the third stage of labour and following repair of the episiotomy the registrar had checked that the fundus was firm and there was no bleeding. The placenta was checked and was complete. A urinary catheter was re-inserted. Whina was breast feeding her baby an hour after the birth when she felt a ‘gush’ vaginally. There is approximately 800 mls of blood and clots on the bed linen. You find the uterus to be atonic. The midwife is calling for further help. Which of the following manoeuvres would you perform to minimise further blood loss while you are waiting for further help to arrive?
Insert a vaginal pack
Undertake bimanual compression of the uterus
Insert a second IV line
Phone blood bank to request 2 units of O negative blood
Administer IV prostaglandins
Arrange examination of genital tract under anaesthesia
Undertake bimanual compression of the uterus
