Complications of the third stage and perineal trauma Flashcards
PPH
blood loss of 500mL or more during or after childbirth
severe over 1000mLs; or amount that causes haemodynamic compromise
primary 24 hrs
secondary btwn 24 hrs and 6 weeks
4 T’s
tone
trauma
tissue
thrombin
tone
- 70%
- Atonic uterus
- Precipitate labour
- Prolonged labour
- Polyhydramnios
- Multiple pregnancy
- Full bladder
trauma
- Lacerations
- Episi
- Uterine rupture
- Uterine inversion
- Extensions/lacerations at c-section
tissue
- 10-20%
- Retained products
- Retained placenta or succenturiate lobe
thrombin
- Coagulation disorders acquired in pregnancy
- Idiopathic thrombocytopenic purpura
- Von willebrands disease
- Thrombocytopenia with pre-eclampsia
- Disseminated intravascular coagulation
- Pre-eclampsia
- Dead fetus in utero
- Severe infection
- Abruption
acute management PPH
- Rub up a contraction
- Give an oxytocic
- Empty bladder
- Syntocinon infusion
prophylaxis
- Avoid anaemia, dehydrations, prolonged labour
- Empty bladder 2nd hourly
- Oxytocic for 3rd stage
syntoconin
IM 10 units
40 units IV in 1 litre of hartmanns at 250mls/hr
use electrolyte solution
syntoconin side effects
painful contractions
nausea, vomiting (water intoxication)
transient vasodilatation & hypotension if undiluted IV doses high doses or prolonged administration in electrolyte-free fluids can cause water intoxication
syntometrine
IM Syntometrine 1 mL following expulsion of placenta, or when bleeding occurs:
Repeat dose of 1 mL after no less than two hours if necessary, The total dose given in 24 hours should not exceed 3 mL
don’t use if blood pressure issues
syntometrine side effects
Nausea, vomiting uterine hypertonicity & abdominal pain headache, dizziness skin rashes hypertension bradycardia cardiac arrhythmia chest pain anaphylactoid reactions
ergometrine
Ergometrine 250 micrograms IM
OR Ergometrine 250 micrograms IV. (This should be injected slowly over one minute or diluted to a volume of 5 mL with sodium chloride 0.9% before administration to prevent serious side effects.)
Do not add ergometrine to IV flasks containing other drugs
ergo side effects
nausea, vomiting abdominal pain headache dizziness rash peripheral vasoconstriction hypertension cardiac arrhythmias chest pain anaphylactoid reactions
prostin (dinoprost trometamol)
Mix 5mg prostaglandin F2 alpha (1mL of a 5mg/mL solution) with 9mL normal saline.
The Medical Officer injects 1 mL (0.5 mg) transabdominally into the myometrium on each side of the fundus i.e. 1mg (2mL of prepared solution) into the uterine fundus. This may be repeated at the doctor’s discretion if atonia persists, to a maximum dose of 3mg (6mL of prepared solution).
Alternatively, a transcervical injection at 9 and 3 o’clock can be given
prostin (dinoprost trometamol) side effects
nausea, vomiting, diarrhoea, headache, flushing, pyrexia, cardiac arrest relative risks include pelvic
intractable PPH
fluid and blood components
- Bilateral ligation of the uterine arteries
- Bilateral ligation of the internal iliac arteries
- Selective arterial embolization (requires radiological support)
- Hysterectomy
degree of shock
compensation
mild shock
moderate shock
severe shock
compensation
blood loss 900mLs 15%
BP (systolic) no change
minimal signs and symptoms
mild shock
blood loss 1200-1500mls
20-25%
bp (systolic) minor 80-100mmHg
signs - weakness, anxiety, tachy, slow capillary refill
moderate shock
blood loss 1800-2000mls 30-35%
bp (systolic) marked fall 70-80mmHg
signs - tachy, restlessness, cold/clammy, pallor
severe shock
blood loss 2400mls 40%
bp (systolic) profund fall 50-70mmHg
signs - collapse, depressed, air hunger, anuria
resus PPH
wide bore cannula x2
collect bloods for FBC, cross match and HB
crystalloids - n/s, hartmanns in a volume at least 3 times the measured volume lost
blood
colloids
uterine inversion
incorrect management
short cord
precipitate labour and/or birth
manual removal
pathologically adherent placenta
spont. with no obvious cause
classification of uterine inversion
1st degree - fundus reaches the internal os
2nd degree - the body of the uterus is inverted to the internal os
3rd degree - the uterus, cervix and vagina are inverted and are visible
spontaneous perineal trauma
Perineal trauma involves any type of damage to the female genitalia during labour, which can occur spontaneously - Anterior perineal trauma can affect the anterior vaginal wall, urethra, clitoris and labia.
1st degree tear
injury to skin
2nd degree tear
injury to the perineum involving perineal muscles but not involving the anal sphincter
3rd degree tear
injury to the perineum involving the anal sphincter complex, 3a, 3b, 3c
4th degree tear
injury to the perineum involving the external anal sphincter and internal anal sphincter and anal epithelium
episiotomy
- Surgical incision made into the end perineum, which is required should be performed only immediately prior to birth to enlarge the vaginal outlet and to assist the birth of the baby
- Problems include unsatisfactory anatomical results, increased blood loss, perineal pain
- Indications – fetal distress, short or rigid perineum, shoulder dystocia, fetal malposition, instrumental
types of episi
- Midline – cut vertically from the fourtchette down towards the anus
- Mediolateral – starts in the midline position at the fourchete but is then directed diagonally outwards to avoid the anal sphincter
complications of the puerperium
- PPH
- Thrombophlebitis
- Deep vein thrombosis
- Pulmonary embolus
- Puerperal infection
- Puerperal haematoma
- Breast problems
puerperal infection
- Temp of 38 occuring on a single occasion or of 37.5 occuring on three or more successive occasions within 28 days of childbirth
- Deaths from puerperal sepisis in Australia are 0.1 per 1000 births
factors of puerperal infection
- Preconception
- H/O venous thrombosis, UTI, mastitis, pneumonia
- Diabetes
- Anemia, malnutrition
- Alcohol/drug abuse
intrapartum factors of infection
- PROM
- Chorioamnionitis
- Prolonged labour
- Bladder catheterisation
- FSE
- Retained placental fragments
general plan for infection
- Antibiotics
- Obs 4th hrly
- Fluids
- Comfort measures
- Assistance with mothercrafting
- Education
- Documentation
