Post partum bleed Flashcards
What is a PPH?
Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death. To be classified as postpartum haemorrhage, there needs to be a loss of:
500ml after a vaginal delivery
1000ml after a caesarean section
How is PPH classified?
It can be classified as:
Minor PPH – under 500ml to 1L blood loss
Major PPH – over 1L blood loss
How do you sub-classify major PPH?
Major PPH can be further sub-classified as:
Moderate PPH – 1-2L blood loss
Severe PPH – >2L blood loss
How is PPH categorised (primary/secondary)?
It can also be categorised as:
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth
Causes of PPH?
There are four causes of postpartum haemorrhage, remembered using the “Four Ts” mnemonic:
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear) + episiotomy, cervical laceration
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
Most common cause of PPH? What increases risk?
Uterine atony
- prolonged labour
- grand multiparty (4+ before current baby)
- infection
- macrosomia/ multiple pregnancy
What increases risk of thrombin (clotting disorder)?
- servere pre-eclampsia
- sepsis
- placental abruption
Risk factors for 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
Preventing PPH?
Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
Initial management?
Stabilise mum
- ABCDE approach
- Lie flat, keep her warm and communicate with her and the partner
- Insert two large-bore cannulas
- Bloods for FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
- Fresh frozen plasma if clotting abnormalities or after 4 units of blood transfusion
Initial step in severe case?
activate the major haemorrhage protocol.
gives rapid access to 4 units of crossmatched or O negative blood.
Treatment options to stop bleed?
- Mechanical
- Medical
- Surgical
Mechanical options to stop bleed?
- Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
Medical options?
- Oxytocin (slow injection ‘10 units’ followed by continuous infusion ‘40 units’)
- Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
- Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
- Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
When would you transfer to theatre? Surgical options?
If uterus hasn’t contracted after 30 minutes:
- Intrauterine balloon tamponade
- B-Lynch suture
- Uterine artery ligation
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
