OGCO-C3.7 Prevention and management of PPH Flashcards
What is the levels of PPH severity and level of staff involvement?
What is level 4 critical PPH?
How to prevent PPH?
Which high risk PPH patients should have type and screen and insertion of 16G IV catheter done?
Antenatal anemia should be investigated and treated appropriately to reduce morbidity associated with PPH.
High risk patients
* Antepartum hemorrhage
* Previous history of MROP, PPH, precipitated labour, repeated suction evacuation
* Previous surgery on uterus (Caesarean section, myomectomy)
* Grand multipara
* Anaemia (Haemoglobin < 10g/dL) at onset of labour
* Large for gestational age baby (>3800g)
* Multiple pregnancy
* Polyhydramnios
* Induced or augmented labour
* Bleeding tendencies
* Stillbirth
What is the strategy of 3rd stage labor in all deliveries?
Strategies include:
* Early clamping of umbilical cord
* Controlled cord traction for delivery of placenta
* Use of uterotonic
What is the Mx of 3rd stage labor for Low risk delivery and Uncomplicated Instrumental Deliveries?
Syntometrine 1 ml to be given intramuscularly at crowning or delivery of baby’s shoulder
What is the Mx of 3rd stage labor for high risk cases?
- Syntocinon 5 units is to be given intravenously at delivery of baby’s shoulder
- Followed by infusion of 40 units of oxytocin in 500ml of normal saline over a total of 4 hours to prevent uterine atony.
- An additional dose of 5 units of oxytocin can be given in slow IV bolus if uterine contraction is inadequate after the initial 5 units.
- Further infusion of another 40 units of oxytocin in 500ml of normal saline is to be given only if considered necessary by attending obstetrician.
What is the Mx of 3rd stage labor for patients with heart disease or when ergometrine is contraindicated?
Syntometrine should not be given. Oxytocic drug is to be given as ordered by attending doctor.
What is the Mx of 3rd stage labor for patients with severe preeclampsia complicating pregnancy?
Syntocinon 5 units IV, then 40 units of oxytocin in 250ml normal saline to be given over 8 hours
What is the Mx of 3rd stage labor for patients with substance abuse?
Syntocinon should be given in patients with drug abuse instead of syntometrine unless the patient has indicated earlier that she has quitted substance abuse and latest urine toxicology in pregnancy is negative.
What is the Mx of 3rd stage labor for patients after C-section?
What are the indications for Mx?
What are the contraindications?
Give Carbetocin 100 microgram (1mL) IV bolus for Caesarean section with the following risk factors for PPH:
* Multiple pregnancy
* Placenta praevia and morbidly adherent placenta
* Fetal macrosomia (>3800g) or polyhydramnios
* Presence of uterine fibroids
* Two or more previous Caesarean sections
* Previous myomectomy
* Past history of postpartum haemorrhage
* Use of syntocinon infusion for more than 12 hours
* Second stage Caesarean section
* Classical Caesarean section
Contraindications to carbetocin
Known allergy to oxytocin or carbetocin
Vascular disease
Coronary artery disease
4Ts of PPH?
- Tone: uterine atony, distended bladder
- Tissue: retained placenta and clots
- Trauma: vaginal, cervical, or uterine injury
- Thrombin: coagulopathy (preexisting or acquired)
Mx of uterine atony?
Mx of retained placenta?
Mx of lower genital tract bleeding?
Bleeding from lower genital tract should be suspected if bleeding persists despite good uterine contraction. Initial vaginal examination can be carried out in the labour ward but if lighting or exposure is inadequate or if no obvious source of bleeding is seen, exploration of the lower genital tract + exploration of the uterus under GA in OT should be arranged immediately.
Consider concealed haemorrhage such as pelvic haematoma or other non-genital cause if the amount of bleeding which cannot account for the degree of shock.
Other means to stop bleeding?
What is fluid therapy and blood product transfusion for major PPH?
