Post Partum Haemorrhage

Question 1

What is primary PPH?

Answer 1

Loss of >500ml of blood in first 24 hours after delivery

Question 2

What is secondary PPH?

Answer 2

Blood loss after 24 hours of delivery until 12 weeks

Question 3

How is blood loss classified in primary PPH?

Answer 3

Minor: 500-1L
Major: more than 1L
Major moderate - 1L to 2L
Major severe - more than 2L

Following CS: more than 750ml

Question 4

What risk factors are there for PPH?

Answer 4

Antenatal: previous PPH or retained placenta, APH, maternal Hb<85 at onset of labour, BMI >35, multiparity >4, maternal age >35, uterine malformations, large placenta site, overdistended uterus - twins, polyhydramnios, placenta praevia/accreta

In labour: prolonged labour, induction, precipitate labour, operative birth, large baby, episiotomy/tear

Question 5

What is the most common cause?

Answer 5

Uterine atony 90% - a soft, spongy, boggy uterus (slow and steady loss of blood) 
Other cause: 
Tissue - retained products 
Trauma - genital tract trauma 
Thrombin - clotting disorders

Question 6

How is PPH managed?

Answer 6

Call for help - life threatening emergency, senior midwife, obstetric registrar and SHO, anaesthetic reg, scribe, if massive: 2222 call alert to haematologist, blood bank, porters and theatres

High flow oxygen
Assess airway and intubated if decreased conscious level
Insert 2 large bore cannula (grey) and take blood for FBC, u&E, LFT, clotting, cross match 4-6 units
If blood loss torrential and mother unstable: use emergency group O rhesus neg until cross match available- transfuse 1L go packed red cells to 1u FFP
Start IV fluids - hartmanns 1L stat
Catheterise
Deliver placenta - empty uterus of clots or retained tissue
Massage uterus to generate contractions/bimanual compression
Give drugs to contract uterus
Identify cause and treat - suture trauma, correct coagulation
If ongoing bleeding take to theatre for examination under anaesthesia

Question 7

When managing PPH p, what drugs are given to contract the uterus?

Answer 7

Syntometrine IM 1 amp
Oxytocin infusion 
Ergometrine 0.25mg IV/IM
Misoprostol 100mcg PR 
Carboprost 250mcg every 15 mins up to 8 doses

Question 8

What is an appropriate first line surgical management if uterine atony is the main cause?

Answer 8

Intrauterine balloon tamponade

Question 9

If uterus still atonic despite drugs, balloon tamponade, what can be done in theatre?

Answer 9

Insert B Lynch sutures - a compression suture, inserted through lower segment over the top of uterus (looks like a belt and braces)
If bleeding still ongoing - consider internal iliac or uterine artery ligation
Uterine artery embolisation helpful but not option everywhere
Subtotal or total hysterectomy - decision should not be delayed as maternal death may result

Question 10

What are the side effects of oxytocin?

Answer 10

Hypotension
Flushing
N&V
Vasospasm 
No contraindications

Question 11

What are the side effects of ergometrine?

Answer 11

HTN
Vasospasm
N&V
Contraindications: PET, HTN, CVD

Question 12

What are the side effects of carboprost?

Answer 12

Vomiting and diarrhoea
Vasospasm
Bronchospasm
Flushing
Shivering 
Contraindications: CVD, asthma

Question 13

What are the side effects of misoprostol?

Answer 13

Nausea and diarrhoea
Pyrexia
Shivering
Contraindications: none

Question 14

What factors suggest significant blood loss? It can be difficult to measure or sight

Answer 14

Decrease >10% haematocrit

Change in mother’s HR, BP, oxygen sats

Question 15

Describe what happens in uterine atony

Answer 15

Failure of contractions to clamp down on uterine arteries

Question 16

What can cause uterine atony?

Answer 16

Repeated distension - multiple pregnancies, overstretching from twins/ triplets
Muscle fatigue from delivery - prolonged labour
Unable to empty bladder - pushes on uterus and interfere with contractions
Obstetric medications - especially anaesthetics, magnesium sulphate, nifedipine, terbutaline

Question 17

How can uterine atony be treated?

Answer 17

Fundal massage - causes smooth muscle to contract
Urination/ catheter to empty bladder
Medication
Surgery

Question 18

How can trauma cause PPH?

Answer 18

Incision from CS
From baby coming through vaginal canal
From medical instruments - forceps, vacuum, episiotomy
Haematoma can form and go unnoticed - severe pain and persistent bright red bleeding inspite of firmly contracted uterus

Question 19

What can cause retained parts of placenta?

Answer 19

Accreta

Too much traction on umbilical cord

Question 20

What does thrombin refer to?

Answer 20

Mother has a blood clotting condition that prevents her clotting normally
Von Willebrand
Obstetric - eclampsia, placental abruption
Can lead to DIC

Question 21

What should be done if haemorrhage continues after 4 units of RBCs and haemostatic tests unavailable?

Answer 21

Give 4 units of FFP