O&G: Postpartum Haemorrhage Flashcards
Bleeding
Before delivery: Antepartum haemorrhage
After delivery: Postpartum haemorrhage
- Primary / Secondary
Postpartum haemorrhage (PPH)
One of major causes of direct maternal death
Significant loss of blood after blood:
- **>500mL in Vaginal delivery
or
- **>1000mL in Caesarean section
Primary PPH (90%): **<24 hours of delivery
Secondary / Late PPH: **>24 hours after delivery
Effect:
- Primary PPH often torrential —> can cause shock + death within short time
Pathophysiology of Primary PPH
After delivery
—> Uterus rapidly decrease in size
—> Separation of placenta from uterus
—> Raw area left by placenta in uterus is very vascular
—> Bleeding from this raw area is heavy
Normal situation:
- Uterus rapidly contracts
—> Occlude mother’s blood vessels (supplying placenta implantation site) which course through uterine muscles
—> Only small amount of bleeding (200-300mL)
Uterine atony:
- Contraction not strong enough
—> Raw placental site in uterus exposed
—> Cannot stop bleeding
How to estimate blood loss
Soiled sanitary towel: 30mL
Soaked sanitary towel: 100mL
Small soaked gauze swab (10x10): 60mL
Large soaked gauze swab (45x45): 350mL
Incontinence pad: 250mL
100cm diameter floor spill: 1500mL
PPH on bed only: 1000mL
PPH spilling to floor: 2000mL
Full kidney dish: 500mL
Risk factors for PPH
- ***Antepartum haemorrhage
- ***Previous history of manual removal of placenta, PPH, precipitated labour, repeated suction evacuation
- ***Previous surgery on uterus (C-section, myomectomy)
- ***Grand multiparity
- Anaemia (Hb <10) at onset of labour
- ***Large for gestational age baby (>3800g) (Fetal macrosomia)
- ***Multiple pregnancy
- Polyhydramnios
- ***Induced / Augmented labour
- ***Bleeding tendencies
- Pre-eclampsia
- Failure to progress in 2nd stage
- Prolonged 3rd stage of labour
- ***Retained placenta
- ***Placenta accreta
- Episiotomy
- ***Perineal laceration
- GA
***Causes of PPH
4”T”s:
1. Tone: Uterine atony, Distended bladder
2. Tissue: Retained product of gestation, clots
3. Trauma: Laceration (Vaginal, Cervical, Uterine injury)
4. Thrombin: Coagulation disorders (Pre-existing / Acquired)
5. Iatrogenic
Identifying source of bleeding
- ***Palpate uterus
- check if contracting well - ***Vaginal examination
- from cervix down to introitus —> identify any lower genital tract bleeding
- local / regional / GA - ***Check placenta for completeness
- Arrange emergency operation for **examination under anaesthesia (EUA)
- explore inside of uterus for:
—> **Retained placenta
—> ***Rupture of uterus (usually done through cervix and not require laparotomy, but regional / GA is required)
- seldom needed and often needed for stopping bleeding - Laparotomy
- required in exceptional circumstances when source of bleeding cannot be identified / need to stop bleeding
- Always do 1-3
- Do 4 if 1-3 fail to identify source of bleeding / bleeding persist
- Tone: Uterine atony, Distended bladder
Lack of uterine tone (i.e. **Soft uterus)
- **most common cause of Primary PPH (70%)
- abnormalities of uterine contraction
—> uterus fail to contract following delivery of placenta
—> placental arteries do not clamp down
—> continuous bleeding
Signs:
- ***Soft uterus on palpation
Causes:
1. Any condition that overstretch uterus
—> interfere with efficient uterine contraction
—> diminished tone
- **Repeated distension of uterus (∵ multiple pregnancies)
- **Multiple pregnancies (e.g. twins, triple pregnancies)
- Uterine muscles **fatigue during delivery process
- ∵ **Prolonged labour - Unable to empty ***bladder
- ∵ Full bladder push against uterus + interfere with uterine contraction
Management:
1. **Uterine massage
2. **Bimanual compression
3. Empty bladder
4. **Oxytocics
- **Syntocinon (Synthetic oxytocin) (IV 10 units in divided doses of 5+5 units over 1-3 mins)
- **Carboprost (Synthetic prostaglandin) (IM 250mcg repeat every 15 mins later, up to max of 2mg (i.e. 8 doses))
- **Misoprostol (Synthetic prostaglandin) (800-1000mcg per rectal / sublingual)
5. Surgery to stop bleeding
- Tissue: Retained product of gestation, clots
- 10% of PPH
Failure of placenta to be delivered within **30mins after delivery of fetus
- Retained placental fragments in uterine cavity
- No signs of placenta separation
- Retained **cotyledon / ***succenturiate lobe
—> in turn can prevent effective uterine contraction
—> uterine atony
Triad signs to look out for placenta expulsion:
1. **Lengthening of umbilical cord
2. **Gush of blood from vagina
3. ***Firming of uterine fundus (contraction of uterus —> become smaller + harder)
Causes:
- ***Placenta accreta (invade myometrium —> difficult to separate from uterus)
RPOG should be suspected if:
1. Placenta found to be incomplete
2. Uterine atony refractory to medical treatment
—> ***Exploration of uterus should be done in OT under GA
Management:
- When 3rd stage >=30 mins + Absence of active bleeding
—> **Intraumbilical venous injection of 20IU **Oxytocin in 20mL normal saline can be considered
—> ***Manual removal of placenta (could be considered without trial of intraumbilical Oxytocin)
Active management of 3rd stage of labour (From SpC OG):
1. Use of uterotonic (oxytocin)
2. Controlled cord traction
3. Uterine massage
4. Early clamping of umbilical cord
- Trauma: Laceration (Vaginal, Cervical, Uterine injury)
Causes:
1. Laceration of cervix, vagina, perineum
- ***cervix: very heavy bleeding
- vagina, perineum: not very heavy
- Extensions, lacerations at Caesarean section
- Uterine rupture
- more often in woman with **previous operations in uterus (e.g. lower segment C-section, myomectomy with entrance of uterine cavity)
- woman given birth to **many children
- blood can escape into ***abdominal cavity and not show in vagina - Incidental trauma from baby coming through vaginal canal
- Trauma due to instrument used in delivery
- e.g. forceps, vacuum extraction, episiotomy
Suspect laceration if:
- Bleeding persists despite good uterine contraction
Treatment:
- **Repair accordingly +/- **Exploration of lower genital tract + **Exploration of uterus under **GA in OT immediately
- Incision + **Drainage to look for source of haematoma —> **Vaginal pack
- Thrombin: Coagulation disorders (Pre-existing / Acquired)
Causes:
1. Pre-existing coagulopathy
- ***vWD
- DIC
- **Eclampsia
- **Placental abruption
Management:
1. Check medical history, drug history (anticoagulants), blood results
2. Maintain good **circulation + good **urine output
—> help to clear fibrin degradation products which cause further DIC
- Iatrogenic
When attempts made to deliver placenta:
- Pulling on umbilical cord before placenta has separated
—> placenta separates partially
—> expose placental site but uterus cannot contract well
—> heavy bleeding
—> sometimes uterus will come out like a reversed pocket with attached placenta (uterine inversion)
Management:
- Do NOT attempt to deliver a placenta which has NOT separated from the uterine wall yet if there is little bleeding
Prevention of PPH
Active management of 3rd stage of labour
1. **Early clamping of umbilical cord
2. **Controlled cord traction for delivery of placenta
3. Use of ***uterotonics
For low risk delivery + uncomplicated instrumental deliveries:
- ***Syntometrine (Ergometrine + Oxytocin) 1mL IM at crowning / delivery of baby’s shoulder
- Oxytocin if Syntometrine CI
for high risk case (with risk factors)
- ***Syntocinon 5 units Bolus followed 40 units Infusion in 500mL of normal saline over 4 hours
- Carbetocin 100mcg IV Bolus for C-section with high risk of PPH
Management of PPH
- Communication with all relevant professionals
- Obstetrician, Anaesthetist, Senior midwife
- Alert Haematologist
- Alert Blood transfusion laboratory
- Alert Consultant obstetrician on call - Resuscitation
- Monitoring + Investigation
- Arrest the bleeding
- Resuscitation
- Assess ABC
- Lie patient flat
- Set up IV access
- ***2 IV lines with 16G catheter
- Type + screen
- Hemocue
- CBC
- Clotting profile
- LRFT - IV fluid
- Crystalloid / Colloid solution full rate if in shock - Mobilise satellite blood bank at labour ward if blood products indicated
- Monitor BP + Pulse every 5 mins
- Give O2 if SaO2 <95%
- Monitor temp + keep patient warm using appropriate measures
- Catheterise bladder to monitor urine output
