Mx - PPH Flashcards
How is PPH defined?
Primary PPH is defined as >500mL vaginal blood loss during 3rd stage of labour or in first 24 hours after delivery.
Secondary PPH is excessive vaginal bleeding from 24 hours to 6 weeks after birth.
What preventative measures are best practice?
1) Prevention of anaemia prior to delivery
2) Active management of the third stage of labour - reduces risk of PPH by one third. Active mx of the third stage includes - administration of prophylactic uterotonic (syntocinon), controlled cord traction and fundal massage immediately after placental delivery
What are the 4 Ts that cause PPH?
TONE (70%) - uterine atony most common cause
TRAUMA (20%) - usually episiotomy or lacs
TISSUE (10%) - retained
THROMBIN (1%) - clotting abnormality
How should I manage a patient with PPH?
1) Early recognition and call for help - obstetrics, anaesthetist, senior midwife, plus alert OT, ICU
2) Assessment - level of consciousness, haemodynamic instability - direct one person for record keeping.
3) Resuscitate patient - Establish IV access with 2 large bore cannulae, send bloods for FBE, Gp and cross-match 4 units, and coags
3) Consider cause - TONE, TRAUMA, TISSUE or THROMBIN
4) Facilitate TONE - Fundal massage. Bimanual compression of uterus if unresponsive.
5) UteroTONICS - ergometrine and syntocinon infusion, if insufficient give rectal misoprostol and prostaglandin ideally in OT
6) IDC to reduce bladder
7) Check for TRAUMA and repair tears appropriately
8) Exclude TISSUE - retained products - check placenta and membranes complete
If PPH is unable to be controlled, surgical mx is required. This involves -
1) Examination under anaesthetic (EUA) and manual removal of products
2) Recheck for and repair lacerations
3) If haemorrhage persists - lapartomy for: B-Lynch suture, Backri intrauterine balloon, uterine/internal iliac artery ligation, or as a last resort hysterectomy (these patients are often coagulopathic and correction of coagulopathy is essential)
