Post-partum haemorrhage

Question 1

What is the definition of post-partum haemmorhage?

Answer 1

It is a medical emergency characterised by excessive bleeding from the placental implantation site or from trauma to the genital tract

• defined as blood loss of 500ml from vaginal delivery
• and 1000ml of blood loss from c/s

Question 2

What are the other definitions of post-partum haemmorhage?

Answer 2

• a decreasing haematocrit of more than 10%
• or blood loss leading to haemodynamic instability like hypotension and tachycardia
• blood loss necessating blood transfusioin

Question 3

What is post-partum haemorrhage classified into?

Answer 3

1. Primary post-partum haemorrhage(within 24 hours)

2. Secondary post-part I’m haemorrhage (between 24 hours and 42 days after delivery)

Question 4

What do we need to ensure we do when we transfer a bleeding patient to a tertiary hospital?

Answer 4

1. Make sure that the patient is stable-a systolic blood pressure of >90mmHg is needed
2. Insert two well running IV lines-blood in one line and oxytocin in another line
3. Insert Foleys catheter
4. Transfer with nurse and biannual compression of the uterus is needed to stop the bleeding

Question 5

Why is it important about achieving haemostasis in patients With post-partum haemorrhage?

Answer 5

Contraction of the uterus to ensure that the perforating blood vessels are compressed at the placental site

Question 6

What is uterine atony?

Answer 6

This occurs after delivery where the contracted uterus relaxes again and causes profuse bleeding from the uncompressed blood vessels
-fundal massage usually does not help treat these patients and oxytocin is needed

Question 7

What are the causes of uterus atony?

Answer 7

1. Full bladder
2. Retained placenta pieces or membranes which prevents effective contraction of the myometrium
3. Drugs: halothane
4. Obesity
5. Chorioamnionitis
6. Prolonged labour

Question 8

What increases the risk of experiencing post-partum haemorrhage?

Answer 8

1. Previous Caesarean section and placenta praevia which leads to possible placenta accreta and increta

Question 9

What is the management of a patient with post-partum Haemorrhage?

Answer 9

1. Refer to higher level of care
2. Prepare blood for possible blood transfusion of patient
3. Feel for the uterus -if it is enlarged then massage it to stimulate myometrial contraction
4. Empty the bladder with a foleys catheter and 2 IV lines
5. Start oxytocin infusion in Ringer’s lactate
6. Give misoprostol or prostaglandin if there is no retained placenta or membranes

Question 10

How do we manage a patient with massive haemorrhage?

Answer 10

1. Try to maintain the systolic above 100mmHg and the heart rate below 100 bpm and urine output above 30ml/hour
2. Bloods: haematocrit, clotting profile, urea and electrolytes

Question 11

How do we evaluate the patients clotting status/clotting time?

Answer 11

Take a tube of blood from the patient
Leave for 10 minutes
If normal-clot, retract and remain stable
Not normal- if no clot develops or the clot dissolves(most likely DIC)

Question 12

How do we treat DIC?

Answer 12

We should give the patient fresh frozen plasma which takes 30 minutes to act

Question 13

Why is DIC dangerous?

Answer 13

Disseminated intravascular coagulation is a consequence of massive bleeding and carries the risk of increased haemorrhage and damages organs by blocking the micro vascular network in a particular organ
We can try treat it with heparin

Question 14

What should be mentioned antenatally to patients in regards to post-partum haemorrhage?

Answer 14

We can tell them about the prospect of sterilization and a hysterectomies if significant bleeding is experienced

Question 15

What is a retained placenta?

Answer 15

A placenta that is not delivered within 20 minutes after labour

Question 16

What is the management of retained placenta?

Answer 16

1. It depends on whether there is bleeding or no bleeding
2. The general rule is to start the patient on an oxytocin infusion
3. If no bleeding- wait an hour before attempting manual removal of the placenta in theatre

Question 17

What management can we try if the patient has a retained placenta with bleeding?

Answer 17

1. Administer syntometrine
2. Start an oxytocin infusion IV
3. Then attempt manual removal of the placenta in theatre in case of severe bleeding

Question 18

What is a contracted uterus?

Answer 18

It is a hard uterus with vaginal bleeding and characteristic of a traumatic cause of post-partum haemorrhage

Question 19

Where can the laceration be in a contracted uterus?

Answer 19

1. The cervix
2. The uterus
3. The vagina or vulva

Question 20

What is secondary post-partum haemorrhage?

Answer 20

Occurs 24 hours to 42 days after delivery

-mostly caused by retained products of conception and a haematoma in the vagina or perineum draining spontaneously

Question 21

How do we manage retained products of conception?

Answer 21

1. We can try evacuating the uterus in theatre

2. If the bleeding is not controlled then we have to do a hysterectomy

Question 22

What is the classification of haematomas according to the level of injury?

Answer 22

• vulvar
• vaginal
• Vulva-vaginal
• retroperitoneal (above pelvic floor)