Post-partum Care

Question 1

How is PPH defined?

Answer 1

Postpartum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary

Question 2

Define a primary PPH

Answer 2

• Primary PPH
• occurs within 24 hours
• affects around 5-7% of deliveries
• most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors

Question 3

Define a secondary PPH

Answer 3

Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until six weeks postpartum. Normally due to retained placental tissue or endometritis

Question 4

What’s the difference between a minor and major PPH?

Answer 4

Minor is under 1000ml

Major is over 1000ml

Question 5

Risk factors for primary PPH

Answer 5

• previous PPH
• prolonged labour
• pre-eclampsia
• increased maternal age
• polyhydramnios
• emergency Caesarean section
• placenta praevia, placenta accreta
• macrosomia
• ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)

Question 6

Name the 4 Ts of PPH:

Answer 6

Tone: uterine atony, distended bladder.
Trauma: lacerations of the uterus, cervix, or vagina.
Tissue: retained placenta or clots.
Thrombin: pre-existing or acquired coagulopathy.

Question 7

Management of PPH:

Answer 7

1. Communication
   Alert all relevant professionals. In minor PPH, this is the midwife in charge, and first-line obstetric and anaesthetic staff. For major PPH, this also includes alerting the obstetric, anaesthetic and haematology consultants as well as the blood transfusion laboratory and porters.
2. Resuscitation- fluids and blood transfusions, continuous monitoring of obs.
3. Measures to arrest the bleeding

Examination to establish cause, and exclude other causes than uterine atony (the most common cause).

If the cause is established to be uterine atony, the following measures are taken in turn:
Bimanual uterine compression to stimulate contraction.
Ensure the bladder is empty via catheter.

• Oxytocin 5 units by slow IV infusion. May require repeat.
• Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.
• Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma.

-Misoprostol 1000 micrograms rectally. If these are not successful consider surgical options:
Balloon tamponade.
Haemostatic brace suturing - eg, the B-Lynch compression suture.
Bilateral ligation of the uterine arteries/ internal iliac arteries.
Selective arterial embolisation.
Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture. If possible, a second consultant should be involved in this decision.

Question 8

Measures to prevent PPH?

Answer 8

The active management of the third stage of labour significantly reduces the risk of PPH. Prophylactic oxytocics should be routinely used in the third stage of labour, as they decrease the risk of PPH by 60%. For most women delivering vaginally, oxytocin 5 or 10 IU IM is the prophylactic agent of choice. It is used as an infusion for women having caesarean sections. Syntometrine® (oxytocin plus ergometrine) may also be used in the absence of hypertension.

Question 9

Symptoms of secondary PPH?

Answer 9

Fever.
Abdominal pain.
Offensive smelling lochia.
Abnormal vaginal bleeding - postpartum haemorrhage.
Abnormal vaginal discharge.
Dyspareunia.
Dysuria.
General malaise.

Look for history of extended labour, difficult third stage, ragged placenta, PPH.

Question 10

Investigations in suspected secondary PPH:

Answer 10

FBC.
Blood cultures.
Check MSU.
High vaginal swab; also gonorrhoea/chlamydia.
Ultrasound - may be used if RPOC are suspected, although there may be difficulty distinguishing between clot and products. RPOC are unlikely if a normal endometrial stripe is seen.

Speculum!

Question 11

Management of secondary PPH:

Answer 11

For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactim.For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed.

If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. These women are carrying a high risk of uterine perforation.

The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.