Intrapartum Care: Perineal Tears & Post-partum haemorrhage Flashcards
What is a perineal tear?
Where the vaginal opening is too narrow to accommodate the baby.
This leads to the skin and tissues in that area tearing as the baby’s head passes.
Risk factors for perineal tears?
1) primigravida (first births)
2) large babies (>4 kg)
3) precipitate labour (i.e. very rapid)
4) shoulder dystocia
5) forceps delivery
What are the 4 classifications of a perineal tear?
First degree
Second degree
Third degree
Fourth degree
What does a first degree perineal tear involve?
- Injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin.
- No muscle involvement
- Does not require any repair
What does a second degree perineal tear involve?
Injury to the perineal muscle, but NOT involving the anal sphincter.
Require suturing on the ward by a suitably experienced midwife or clinician.
What does a third degree perineal tear involve?
Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS) but does NOT affect the rectal mucosa.
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
What does repair of a 3rd degree perineal tear involve?
require repair in theatre by a suitably trained clinician
What does a fourth degree perineal tear involve?
Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa.
How can 3rd degree perineal tears be further categorised?
3A - less than 50% of the external anal sphincter affected
3B - more than 50% of the external anal sphincter affected
3C - external and internal anal sphincter affected
What additional measures re taken to reduce the risk of complications in perineal tears?
1) Broad spectrum Abx: to reduce risk of infection
2) Laxatives: to reduce risk of constipation and wound dehiscence
3) Physiotherapy: to reduce the risk and severity of incontinence
4) Followup: to monitor for longstanding complications
When would a woman with a perineal tear be ffered an elective caesarean section in subsequent pregnancies?
Women that are symptomatic after third or fourth-degree tears
Short term complications of perineal tears?
- pain
- infection
- bleeding
- would dehiscence or wound breakdown
What are some long term complications of perineal tears?
1) urinary incontinence
2) anal incontinence and altered bowel habit (3rd and 4th degree tears)
3) fistula between vagina and bowel (rare)
4) sexual dysfunction and dyspareunia (painful sex)
5) psychological & mental health consequences
What is an episiotomy?
An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered.
When may an episiotomy be performed?
This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery).
What anaesthetic is an episiotomy performed under?
Local
How is an episiotomy done?
A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter.
This is called a mediolateral episiotomy.
The cut is sutured after delivery.
What is one method for reducing the risk of perineal tears?
Perineal massage
What does a perineal massage involve?
It involves massaging the skin and tissues between the vagina and anus (perineum).
This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
What is the 3rd stage of labour?
from the completed birth of the baby to the delivery of the placenta
What are the 2 options for the 3rd stage of labour?
1) physiological management
2) active management
What is physiological management of the 3rd stage of labour?
Where the placenta is delivered by maternal effort without medications or cord traction.
What is active management of the 3rd stage of labour?
Where the midwife or doctor assist in delivering of the placenta.
1) IM oxytocin to help uterus contract
2) Careful traction to the umbilical cord to guide the placenta out of the uterus and vagina
What drug is given for active management of the 3rd stage of labour involve?
IM oxytocin
Benefits vs disadvantages of active management of 3rd stage of labour?
Benefit:
- shortens the 3rd stage
- reduces risk of bleeding
Disadvantages:
- N&V
Who is active management of 3rd stage of labour offered to?
All women to reduce risk of postpartum haemorrhage.
Main benefit of active 3rd stage of labour?
Reduced risk of postpartum haemorrhage.
In what 2 scenarios is active management of 3rd stage of labour initiated?
1) haemorrhage
2) more than a 60-minute delay in delivery of the placenta (prolonged third stage)
When is IM oxytocin given in active management of 3rd stage of labour?
After delivery of baby
Steps in active management of 3rd stage of labour
1) IM dose of oxytocin after delivery of baby
2) The cord is clamped and cut within 5 minutes of birth.
3) The abdomen is palpated to assess for a uterine contraction before delivery of the placenta.
4) Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance
5) At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse.
6) After delivery the uterus is massaged until it is contracted and firm.
7) The placenta is examined to ensure it is complete and no tissue remains in the uterus.
When should cord be clamped after delivery?
Within 5 minutes of birth BUT there should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).
What is postpartum haemorrhage (PPH)?
Bleeding after delivery of the baby and placenta.
What is the most common cause of significant obstetric haemorrhage?
PPH
What is PPH defined as?
The loss of :
- 500ml blood after a vaginal delivery
- 1000ml blood after a caesarean section
PPH can be classified into minor and major.
What defines a minor PPH?
<1000ml blood loss
What defines a major PPH?
> 1000ml blood loss
Major PPH can be further sub-classified as:
a) moderate
b) severe
What blood loss defines each?
a) mod: 1000-2000ml blood loss
b) severe: >2000ml blood loss
PPH can be categorised as primary and secondary.
Define 1ary PPH
Bleeding within 24 hours of birth
Define 2ary PPH
From 24 hours to 12 weeks after birth
What are the 4 major causes of 1ary PPH? (4 T’s)?
T - Tone (uterine atony - the most common cause)
T - Trauma (e.g. a perineal tear)
T - Tissue (retained placenta)
T - Thrombin (bleeding disorder)
What does ‘tone’ refer to in PPH?
Uterine atony
What is the most common pause of 1ary PPH?
Uterine atony
What is uterine atony?
This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle.
What are the risk factors for uterine atony?
1) Maternal profile:
- age >40
- BMI >35
- Asian ethnicity
2) Uterine over-distension:
- multiple pregnancy
- polyhydramnios
- fetal macrosomia
3) Labour:
- induction
- prolonged (>12 hours)
4) Placental problems:
- placenta praevia
- placental abruption
- previous PPH
What does ‘tissue’ refer to in PPH?
Retention of placental tissue - this prevents the uterus from contracting.
What is the 2nd most common cause of PPH?
Retention of placental tissue that prevents the uterus from contracting.
What does ‘trauma’ refer to in PPH?
Damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears).
What are some risk factors for ‘trauma’ leading to PPH?
1) instrumental vaginal deliveries (forceps or ventouse)
2) episiotomy
3) C-section
What does ‘thrombin’ refer to in PPH?
Coagulopathies and vascular abnormalities which increase the risk of 1ary PPH.
What vascular abnormalities can lead to PPH?
- placental abruption
- HTN
- pre-eclampsia
What coagulopathies can lead to PPH?
- von Willebrand’s disease
- haemophilia A/B
- ITP or acquired coagulopathy i.e. DIC, HELLP
General risk factors of PPH:
- Previous PPH
- Multiple pregnancy
- Obesity
- Large baby
- Failure to progress in the second stage of labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Retained placenta
- Instrumental delivery
- General anaesthesia
- Episiotomy or perineal tear
Clinical features of PPH?
1) bleeding from vagina: main feature
2) dizziness, palpitations, SOB: if significant blood loss
3) general exam: may reveal haemodynamic instability with tachypnoea, prolonged capillary refill time, tachycardia, and hypotension.
4) abdo exam: may show signs of uterine rupture i.e. palpation of fetal parts as it moves into the abdomen from the uterus.
5) speculum exam: may reveal sites of local trauma causing bleeding.
6) examine placenta: to ensure that the placenta is complete (a missing cotyledon or ragged membranes could both cause a PPH).
Why is it important to examine the placenta?
To ensure that the placenta is complete: a missing cotyledon or ragged membranes could both cause a PPH.
Initial lab investigations in PPH?
1) FBC
2) Cross match 4-6 units of blood
3) Coagulation profile
4) U&Es
5) LFTs
The management of primary post-partum haemorrhage should include the simultaneous delivery of TRIM.
What is TRIM?
Teamwork: immediate management
Resuscitation: immediate management
Investigations & Monitoring: immediate management
Measures to arrest bleeding: definitive management
What does ‘teamwork’ involve in PPH management?
Involve appropriate colleagues for minor and major PPH, including the midwife in charge and midwives, obstetricians, anaesthetists, blood bank, clinical haematologist and porters. Communication between the team, and diligent documentation is vital.
What does ‘investigations & monitoring’ involve in PPH management?
Investigations as above.
Monitoring should include RR, O2 sats, HR, BP, temperature every 15 mins.
Consider catheterisation and insertion of a central venous line.
General management of PPH?
1) ABCDE approach
2) Lie the woman flat, keep her warm and communicate with her and the partner
3) Insert two large-bore cannulas
4) Bloods for FBC, U&E and clotting screen
5) Group and cross match 4 units
6) Warmed IV fluid and blood resuscitation as required
7) Oxygen (regardless of saturations)
8) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
In severe cases, activate the major haemorrhage protocol.
What does the major haemorrhage protocol give rapid access to?
4 units of crossmatched or O negative blood.
What is the definitive treatment for primary post-partum haemorrhage largely dependent on?
Underlying cause
Management options in PPH due to uterine atony?
1) Bimanual compression to stimulate uterine contraction: referred to as ‘rubbing up the fundus’
2) Medical management to increase uterine myometrial contraction
3) Surgical measures: ntrauterine balloon tamponade, haemostatic suture around uterus (e.g. B-lynch), bilateral uterine or internal iliac artery ligation, hysterectomy (as a last resort).
What does bimanual compression of the uterus involve in PPH?
1) Insert a gloved hand into the vagina
2) Form a fist insider the anterior fornix to compress the anterior uterine wall
3) The other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).
What must you ensure before starting to induce uterine contractions in PPH?
Catheterisation: bladder must be emptied
Why should the patient be catheterised in PPH?
As bladder distension prevents uterus contractions.
What are some options for medical management in PPH?
1) Oxytocin
2) Ergometrine
3) Carboprost
4) Misoprostol
5) Syntocinon
6) Tranexamic acid
How is oxytocin given in PPH?
Slow IV injection then continuous IV infusion
Role of oxytocin in PPH?
Offered to mother immediately after birth: helps to prevent PPH by helping the uterus to contract.
Note: if the patient chooses not to have the oxytocin injection and the placenta isn’t delivered within 1 hour, or they have heavy blood loss, they’ll be advised to have the injection.
How is Ergometrine given in PPH?
IM injection or IV
Role of Ergometrine in PPH?
Stimulates smooth muscle contraction of uterus.
Side effects of ergometrine?
- HTN
- Nausea
- Bradycardia
What is the main contraindication of ergometrine?
HTN
What are 3 contraindications for ergometrine?
1) HTN
2) Eclampsia
3) Vascular disease
What class of drug is carboprost?
Prostaglandin analogue
How is carboprost given in PPH?
IM injection
Role of carboprost in PPH?
It is s a prostaglandin analogue that stimulates uterine contraction.
Side effects of carboprost?
1) bronchospasm (caution in asthma!)
2) pulmonary oedema
3) HTN
4) CVS collapse
Contraindications of carboprost?
1) cardiac disease
2) pulmonary disease i.e. asthma
3) Untreated PID
Why should Carboprost be avoided in patients with asthma or pulmonary disease?
Can cause acute bronchoconstriction
How is Misoprostol given in PPH?
Sublingual
Mechanism of misoprostol in PPH?
Prostaglandin analogue - stimulates uterine contraction.
Main side effect of misoprostol?
Diarrhoea
How is tranexamic acid given in PPH?
IV
Mechanism of tranexamic acid in PPH?
Antifibrinolytic that reduces bleeding
What is the IV infusion of oxytocin given as in PPH?
Given as 40 units in 500 mls.
You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.
What are the 4 surgical options in PPH?
1) Intrauterine balloon tamponade
2) B-Lynch suture
3) Uterine artery ligation
4) Hysterectomy
What does an intrauterine balloon tamponade involve in PPH?
Inserting an inflatable balloon into the uterus to press against the bleeding.
What does a B-Lynch suture in PPH involve?
Putting a suture around the uterus to compress it.
What does uterine artery ligation in PPH involve?
Ligation of one or more of the arteries supplying the uterus to reduce the blood flow
When is a hysterectomy indicated in PPH?
It is the “last resort” but will stop the bleeding and may save the woman’s life
Mechanism of Syntocinon in PPH?
Synthetic oxytocin, act on oxytocin receptors in the myometrium –> stimulate uterine contractions.
Side effects of Syntocinon?
- N&V
- Headache
- Rapid infusion can cause hypotension
Contraindications of Syntocinon?
1) Hypertonic uterus
2) Severe CVS disease
When does 2ary PPH occur?
Where bleeding occurs from 24 hours to 12 weeks postpartum.
What is 2ary PPH more likely to be due to?
1) retained products of conception (RPOC)
2) infection (i.e. endometritis)
2 key investigations in 2ary PPH?
1) US: for retained products of conception
2) Endocervical and high vaginal swabs for infection
Management of 2ary PPH?
1) Surgical evaluation of retained products of conception
2) Antibiotics for infection
What are 4 preventative measures that can reduce the risk and consequences of postpartum haemorrhage?
1) Treating anaemia during antenatal period
2) Giving birth with an empty bladder (a full bladder reduces uterine contraction)
3) Active management of 3rd stage of labour: with IM oxytocin in 3rd stage
4) IV tranexamic acid: can be used during caesarean section (in the third stage) in higher-risk patients
Active management of the 3rd stage of labour routinely reduces PPH risk by what?
60%
What does active management of 3rd stage of labour involve?
1) Women delivering vaginally should be administered 5-10 units of IM Oxytocin prophylactically.
2) Women delivering via C-section should be administered 5 units of IV Oxytocin
