Obstetrics (PPH)

Question 1

When should fundal massage be applied?

Answer 1

• only when the fundus is not firm
• massaging a fundus that is firm, central and contracted may interfere with normal placental post birth separation and worsen bleeding
• normal the fundus with not become firm and contracted until the placenta is delivered. Avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs

Question 2

What are the causes of PPH? “Four T’s”

Answer 2

• Tone (uterine atony) ***most common
• Trauma (to genital structures)
• Tissue (retention of placenta or membranes)
• Thrombin (coagulopathy)

Question 3

Which patients are at higher risk of PPH?

Answer 3

• multiple pregnancies (more than 4)
• past history of PPH
• history of APH
• large baby

Question 4

Recite the PPH CPG

Answer 4

Question 5

if the patient has a firm fundus do they recieve O2 therapy?

Answer 5

• Yes - high flow

Question 6

What IVT does a patient with PPH recieve if their BP <90

Answer 6

• consider Normal saline IV (Max 40ml/kg) titrated to patient response
• consult for further fluid.
  
  • If consult unavailable repeat NaCl 20ml/kg

Question 7

When do you administer Oxytocin?

Answer 7

• if the fundus remains nor firm

Question 8

What is the dose of Oxytocin if the fundus is not firm and can you repeat?

Answer 8

• Oxytocin 10 IU IM
• repeat 10 IU IM after 5 minutes if bleeding continues

Question 9

When do you perform external abdominal aortic compression? and how do you apply it?

Answer 9

• when there is intractable haemorrhage
• locate the point of compression just above the umbilicus and slightly to the left
• apply downward pressure with a closed fist directly through the abdominal wall

Question 10

How do you assess effectiveness of external abdominal aortic compression?

Answer 10

It can be evaluated by assessing palpable femoral pulse with pressure applied

Question 11

What is the technique of massaging the fundus?

Answer 11

• use a cupped hand
• apply firm pressure in a circular motion

Question 12

when do you go down the PPH pathway?

Answer 12

>500mls blood loss in first 24 hours of birth

Question 13

What treatment is required if the fundus is firm?

Answer 13

• high flow O2
• analgesia
• BP <90
  
  • consider NaCl IV (max 40ml/kg) titrated to patient response
  • consult for further fluid.
  • if consult unavailable repeat normal saline 20ml/kg IV
• Manage any visible laceration with a dressing and firm pressure

Question 14

What treatment is required if the fundus is not firm?

Answer 14

• manage as per fundus firm
• normally the fundus will not become firm and contracted until the placenta is delivered
  
  • avoid fundal massage prior to placental delivery and continue checking for PV bleeding and observing vital signs
• Massage fundus until firm and blood loss reduces
  
  • use a cupped hand
  • apply firm pressure in a circular motion
• Encourage mother to empty bladder if possible
• encourage baby to suckle breast

Question 15

What do you do if despite initial interventions, the fundus remains NOT FIRM

Answer 15

• oxytocin 10 IU IM
• repeat Oxytocin 10 IU IM after 5 minutes if bleeding continues

Question 16

if the fundus is not firm, can you attempt the delivery of the placenta?

Answer 16

No - DO NOT ATTEMPT. Due to risk of uterine inversion

Question 17

What do you do if there is intractable haemorrhage despite efforts

Answer 17

• perform external abdominal aortic compression
  
  • locate point of compression just above the umbilicus and slightly to the left
  • apply downward pressure with a closed fist directly through the abdominal wall
  • effectiveness of compression may be evaluated by assessing palpable femoral pulse with pressure applied