Post partum haemorrhage

Question 1

Define post partum haemorrhage PPH

Answer 1

blood loss >= 500 ml after delivery of the baby

Question 2

Define primary PPH

Answer 2

within 24 hours of delivery

Question 3

Define secondary PPH

Answer 3

between 24 hours - 6 weeks post delivery

Question 4

Define minor PPH

Answer 4

blood loss of 500-1000ml without clinical shock

Question 5

Define major PPH

Answer 5

blood loss >1000ml
signs of CVS collapse
ongoing bleeding

Question 6

what are the causes of PPH

Answer 6

4 T's 
Tone - uterine atony 
Trauma - operative vaginal delivery
Tissue - retained products of conception 
Thrombin - coagulation disorder

Question 7

What is the most common cause of PPH

Answer 7

Uterine atony

Question 8

What is uterine atony

Answer 8

Failure of uterus to contract after delivery

Question 9

List risk factors for PPH

Answer 9

anaemia 
placenta previa / accreta / percreta
previous c-section 
previous PPH 
multiple pregnancy 
polyhydramnios
foetal macrosomia 
obesity 
prolonged labour 
operative vaginal delivery 
c-section 
retained placenta

Question 10

Should the 3rd stage of labour be latent or active in PPH

Answer 10

Active management is necessary with syntocin

Question 11

initial management of PPH

Answer 11

ABCDE + NEWS every 15 minutes 
Determine cause - 4T's
2 large bore IV access 
FBC, U+E, LFT, clotting/coagulation, fibrinogen, lactate 
crossmatch 6 units 
major haemorrhage protocol

Question 12

What is done to attempt to stop the bleeding initially

Answer 12

Bimanual compression/massage of the uterus to stimulate contractions 
expel clots 
IV syntocin in 500ml Hartmann's 125ml/hr
Foleys catheter
Ergometrine (avoid in HTN + PET)
repair trauma - vaginal 
Carboprost / haemobate IM every 15 minutes (prostaglandins)
misoprostal PR 
Tranexamic acid IV

Question 13

If pharmacological/initial management is unsuccessful what is the next step in management of PPH

Answer 13

Examination under anaesthesia - EUA in theatre to look for trauma, retained products of conception, uterine rupture

Question 14

List non-surgical management options for PPH

Answer 14

balloons and packs
tissue sealants
Artery embolisation by IR

Question 15

List surgical management of PPH

Answer 15

undersuturing
brace suture
uterine artery ligation
hysterectomy - only thing that stops the bleeding

Question 16

what is the function of ergometrine and when should it be avoided

Answer 16

uterotonic agent used in PPH atony

avoid in hypertensive diseases

Question 17

what is uterine inversion

Answer 17

when the fundus of the uterus inverts within the endometrial cavity

Question 18

what are the stages of uterine inversion

Answer 18

1st degree - reaches the internal os
2nd degree - protrudes through the cervix
3rd degree - completely inverted and outside the vulva

Question 19

complications of uterine inversion

Answer 19

maternal shock and collapse 
PPH 
pain 
hysterectomy 
endometritis 
damage to intestines or bladder

Question 20

you should continue oxytocin in the case of uterine rupture / inversion, true or false

Answer 20

FALSE

Question 21

what is terbutaline

Answer 21

anti-contraction drug

tocolytic