Postpartum

Question 1

How is post partum haemorrhage (PPH) defined?

Answer 1

Blood loss > 500ml after the birth of the baby

• if within 24 hours –> primary PPH
• if from 24 hours to 6 weeks post delivery –> secondary PPH

Question 2

How is minor PPH defined?

Answer 2

500 - 1000ml blood loss

Question 3

How is major PPH defined?

Answer 3

> 1000ml
or signs of CV collapse
or ongoing bleeding

Question 4

What are the causes of PPH?

Answer 4

4 T’s:
Tone –> uterine atony
Trauma –> vaginal tear, cervical laceration, rupture
Tissue –> retained products of conception
Thrombin –> coagulopathy

Question 5

What are the principles of managing PPH?

Answer 5

Resuscitate
Stop the bleeding
Fluid replacement
Prevention of secondary PPH

Question 6

What should be given immediately to stop the bleeding in PPH, regardless of cause?

Answer 6

Tranexamic acid 0.5 -1g IV

Question 7

What is the definitive management for PPH caused by uterine atony?

Answer 7

Bimanual compression
- insert gloved hand into vagina + apply pressure on abdomen with other hand
Pharmacological measures
Surgical measures

Question 8

Which drugs are used to manage PPH?

Answer 8

Syntocinon
Ergometrine
Carboprost
Misoprostol

Question 9

What are the surgical measures for managing uterine atony?

Answer 9

Intrauterine balloon tamponade
Haemostatic suture around uterus (B-lynch)
Bilateral uterine or internal iliac artery ligation
Hysterectomy (last resort)

Question 10

What is the management for retained products of conception?

Answer 10

Administer IV oxytocin
Manual removal of placenta with regional or general anaesthesia
IV oxytocin infusion after removal

Question 11

How can PPH be prevented?

Answer 11

Active management of the 3rd stage of labour:

• if vaginal delivery –> 5-10 units IM oxytocin
• if C-section –> 5 units IV oxytocin

Question 12

What are the main causes of secondary PPH?

Answer 12

Uterine infection (endometritis)
Retained placental fragments or tissue
Abnormal involution of the placental site
Trophoblastic disease

Question 13

How are perineal tears classified?

Answer 13

1st degree: skin only
2nd degree: skin + levator ani
3rd degree: partial anal sphincter involvement
4th degree: complete tear of anal sphincter

Question 14

How is a 2nd degree tear managed?

Answer 14

Usually stitches

Question 15

How is a 3rd or 4th degree tear managed?

Answer 15

Surgical repair to prevent faecal incontinence

Question 16

What is an episiotomy?

Answer 16

Surgical cut made by a medical professional to prevent an impending tear from involving the anal sphincter

Question 17

What is baby blues?

Answer 17

Brief period of emotional instability - tearful, irritable, anxious + confused

Question 18

When does baby blues tend to occur?

Answer 18

Day 3 postnatally until about 1 week later

Question 19

How is baby blues managed?

Answer 19

Support + reassurance

Question 20

What are the features of puerperal psychosis?

Answer 20

Sleep disturbance
Confusion
Irrational ideas
–> mania, delusions + hallucinations

Question 21

When does puerperal psychosis usually present?

Answer 21

2 weeks postnatally

Question 22

How is puerperal psychosis managed?

Answer 22

Emergency admission to mother-and-baby unit

Question 23

When does postnatal depression tend to occur?

Answer 23

Around 2-6 weeks postnatally

Can last weeks, months or up to a year