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Midwifery > Postpartum Haemmorhage > Flashcards

Postpartum Haemmorhage Flashcards

1
Q

Define Primary Postpartum Haemorrhage

A
  • excessive bleeding in the first 24 hours post birth
  • usually considered as >500mL after vaginal birth and >1000mL after C/S
  • or showing signs of haemodynamic compromise (usually >1000mL, shock, tachycardia, hypotension)
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2
Q

What is considered severe PPH?

A

> 1000mL estimated blood loss

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3
Q

What is very severe or major PPH?

A

> 2500mL estimated blood loss

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4
Q

What 4 factors make a woman more likely to show signs of haemodynamic compromise?

A
  • gestational hypertension with proteinuria
  • Anaemia
  • Dehydration
  • Small stature
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5
Q

What is Secondary Postpartum Haemorrhage?

A

excessive bleeding (>500mL) that occurs between 24 hours post birth and 6 weeks postnatally

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6
Q

What are the 4 causes of PPH?

A
  • Tone
  • Tissue
  • Trauma
  • Thrombin (clotting disorders)
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7
Q

What are the common risk factors for PPH?

A 
Tone
- prolonged labour
- precipitate labour
- grand multiparity
- multiple pregnancy
- polyhydraminos
- macrosomia
- fibroids
- intrauterine infection
- uterine relaxing agents (MgSO4, general anaesthetic, tocolytics)
Trauma
- operative birth
- cervical/vaginal lacerations
Tissue
- retained placenta
- abnormal placentation
Thrombin
- Pre-eclampsia
- HEELP Syndrome
- placental abruption
- FDIU
- Bleeding disorders
- Drugs (aspirin/heparin)
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8
Q

What is meant by establishing IV access?

A

inserting 2 large bore (16G) cannulae

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9
Q

What blood tests are important investigations in PPH management?

A
  • Blood group
  • Antibody screen
  • Full blood count
  • Coagulation screening (INR, APTT, fibrinogen)
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10
Q

Assessment (early recognition, signs/symptoms)
Communication (Call for help, effective teamwork, support for woman and her support people)
Management (resuscitation, vital signs, IV access, monitoring blood loss, oxygen saturation
Investigation

A

Call for help

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11
Q

What management is necessary for PPH where the placenta has not been born?

A
  • call for HELP
  • reassure woman
  • position woman flat/lateral
  • monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
  • consider oxygen by mask (8-12L)
  • keep woman warm
  • IV access
  • catheter
  • repeat oxytocin (another 10IU IM or IV, don’t give syntometrine/ergometrine as it may prevent birth of the placenta)
  • attempt to birth placenta by controlled cord traction and massage uterus once emptied
  • monitor fundal tone
  • check placenta for completeness
  • consider tone, tissue, trauma, thrombin
  • if unsuccessful portable ultrasound, prepare for manual removal of placenta, transfer to theatre
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12
Q

What management is needed for PPH if the placenta has been born?

A
  • call for HELP (and appropriate equipment)
  • reassure woman
  • position woman flat/lateral
  • massage uterus
  • if no contraindications, 250mcg ergometrine IV (or 10IU oxytocin IV if hypertensive) can repeat after 2-3 minutes
  • catheter
  • IV access + collect blood
  • monitor vital signs (heart rate, respiration rate, blood pressure and temperature), oxygen saturation and blood loss
  • oxytocin infusion (40IU/1000mL IV)
  • 800-1000mcg (4-5 x 200mcg tablets) misoprostol PR
    OR intramyometrial injection of Prostaglandin F2a (dinoprost)
  • consider oxygen by mask (8-12L)
  • keep woman warm
  • assess tissue (check placenta for completeness)
  • assess trauma (check episiotomy or tears)
  • assess thrombin (coagulation studies, are there any risk factors for clotting issues?)
  • IV fluids or blood transfusion
  • if bleeding continues consider bimanual compression, or aortocaval compression, transfer to theatre for examination under aesthetic and further treatment
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13
Q

What is the usual dose of ergometrine in the management of PPH?

A
  • 250 micrograms
  • repeat after 2-3 minutes if bleeding continues
  • maximum of 4 doses (1mg)
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14
Q

What are the usual routes of administration for ergometrine?

A

IV or IM

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15
Q

What are the side effects of ergometrine?

A
  • tonic uterine contraction
  • nausea and vomiting
  • hypertension
  • rarely gangrene at site and convulsions
  • cna reduce prolactin levels so potential for delayed lactogenesis
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16
Q

When should ergometrine not be given?

A
  • if placenta has not been born
  • severe hypertension or cardiac disease
  • hypersensitivity to ergometrine
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17
Q

What drug is often given with ergometrine to prevent nausea/vomiting?

A

metoclopramide 10mg IV

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18
Q

What is the usual protocol for giving oxytocin in the management of PPH?

A
  • 10IU/1ml IM or IV for active managment of 3rd stage
  • may give repeat bolus of 10IU IM or IV (instead of ergometrine if placenta has not been born or if blood pressure is elevated)
  • 40IU in 1000mL of sodium chloride 0.9% IV infusion at rate of 250mL/hour if placenta has been born
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19
Q

What is the usual dose of misoprostol in the management of PPH?

A

800 to 1000 micrograms PR (4-5 tablets)

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20
Q

What is the usual stock strength of misoprostol given PR?

A

200 microgram tablets

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21
Q

What are the side effects of misoprostol? When should it not be given?

A
  • nausea and vomiting
  • diarrhoea
  • abdominal pain
  • headache
  • flushing
  • chills
  • pyrexia
  • hypersensitivity to misoprostol
  • may cause GI upset in infant due to transfer in breastmilk
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22
Q

When is misoprostol given in management of PPH?

A

when neither oxytocin or ergometrine are successful at stopping bleeding

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23
Q

Other than oxytocin, ergometrine and misoprostol, what drugs may be given in managing PPH?

A
  • prostaglandin F2a intramyometrial injection

- syntometrine (oxytocin and ergometrine)

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24
Q

What are the main complications of major PPH?

A
  • shock
  • anaemia
  • clotting disorders
  • organ damage (particularly lung injury and renal failure)
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25
Q

What are the main signs of hypovolaemic shock?

A
  • hypotension
  • anxiety
  • confusion
  • decreased level of consciousness
  • shortness of breath/ hyperventilation
  • restlessness
  • palpitations/ tachycardia
  • chills
  • pale and clammy
  • thirst
  • oliguria
26
Q

What are the risk factors for postpartum venous thromboembolism?

A
  • age>35
  • parity>4
  • clotting disorders
  • dehydration
  • pre-eclampsia
  • prolonged labour
  • immobility
  • obesity
  • varicose veins
  • surgery
  • excessive blood loss
  • instrumental birth
27
Q

What equipment should be in a PPH box?

A
  • cannulation (16G, 18G, swabs, tegaderm, tape)
  • pathology (23G, 21G needles, blood tubes, tourniquet, swabs, bags, slips, 10mL syringes)
  • IV giving sets (standard/pump) + accessories (luer-lock connectors, additive labels, multi-adapters, 3-way adapter)
  • bags of sodium chloride/hartmanns/gelofusine
  • catheter (14ch foley, bag/urimeter, 10mL water for injections, 10mL syringe)
  • ampules of saline/water for injections
  • misoprostol 200mcg tablets

in fridge :

  • oxytocin 10IU ampoules
  • ergometrine 500mcg ampoules
  • prostaglandin F2a (dinoprost)
  • additive lables
  • syringes (2mL, 5mL)
  • needles (19G, 23G, 25G and spinal)
28
Q

In many healthy pregnant women there are no clinical signs of shock until what volume of blood loss?

A
  • > 1000-1500ml of blood loss
29
Q

Apart from the 4 Ts, what other causes may cause PPH?

A
  • uterine rupture
  • uterine inversion
  • puerperal haematoma
  • other causes (liver rupture, amniotic fluid embolism)
30
Q

Once bleeding is controlled, what ongoing midwifery care is vital for women who have had PPH?

A
  • monitoring vital signs, fundal tone, blood loss, haemoglobin
  • promote mother/infant bonding
  • transfer (to postnatal ward/ICU/HDU/tertiary facility)
  • documentation
  • psychological support and debriefing
  • management of anaemia
  • VTE prophylaxis, monitor for DVT/PE
  • education about self care
  • advice regarding follow up
31
Q

What IV fluids/blood products may be given in managing PPH depending on the severity of the clinical situation?

A
  • crystalloids: normal saline
  • colloids: hartmann’s solution
  • red blood cells (O-neg if group unknown or crossmatched)
  • fresh frozen plasma
  • cryoprecipitate
  • platelets
  • IV calcium gluconate
32
Q

What are the signs that a massive transfusion protocol should be used?

A
  • assessed by lead clinician (will seek advice of haematologist)
  • woman actively bleeding and any of:
  • greater than 4 units of RBC in 2500mL
  • clinical or laboratory signs of coagulopathy
33
Q

In a massive transfusion protocol, the lead clinician in consultation with a haematologist will be monitoring which clinical parameters?

A
  • temperature
  • pH
  • base excess
  • lactate
  • Ca2+
  • Platelets
  • Prothrombin time (PT) and activated partial thromboplastin time (aPPT)
  • International normalised ratio (INR)
  • Fibrinogen
34
Q

What is the usual indication to give fresh frozen plasma?

A
  • to replace clotting factors, plasma proteins and other substances
  • where there is coagulopathy and excessive bleeding
  • acute disseminated intravascular coagulopathy
  • generally 10-15mL/kg per dose, often around 100ml, depends on clinical situation and coagulation assay
35
Q

What is the usual indication to give packed red blood cells (PRBC)?

A
  • for excessive blood loss
  • to correct anaemia
  • 1 unit PRBC (about 220ml) increases haemoglobin by around 1g
36
Q

What adverse reactions and precautions are important to remember when giving blood products?

A
  • human tissue so strict protocols on collection, storage, administration, monitoring, reporting adverse events, disposal of equipment
  • potential for infusion reaction (increased temperature, backache, rash)
  • anapylaxis
37
Q

When are platelets usually given in treatment of massive PPH?

A
  • to prevent platelets from dropping below 50x10^9/L which may contribute to excessive bleeding
38
Q

Why may cryoprecipitate be given in treatment of massive PPH?

A
  • to maintain fibrinogen levels above 2.5g/L
39
Q

When may calcium gluconate be given in management of massive PPH?

A
  • if calcium levels drop too low

- Ca2+

40
Q

What is the trade name of oxytocin?

A

Syntocinon

41
Q

What are the three main indications for oxytocin?

A
  • induction/augmentation of labour
  • active managment of third stage
  • management of PPH
42
Q

What is the mode of action of oxytocin?

A

Oxytocin is a uterotonic, it stimulates smooth muscle of uterus producing rhythmic contractions, particularly towards term when receptors are more sensitive.

43
Q

What is the stock strength of oxytocin?

A
  • 10IU/ml ampule and 5IU/ml ampule
44
Q

What is the usual dose of oxytocin for IOL/augmentation and third stage management?

A
  • dosage depends on indication and local protocol
  • IOL or augmentation: usually 10IU/1000ml saline IV infusion commence at 12ml/min and increase 30 minutely
  • 3rd stage: usually 10IU/ml IM or IV given after birth (sometimes 5IU IV post LUSCS)
45
Q

What are adverse reactions/precautions are important to remember for oxytocin?

A
  • painful contractions
  • nausea and vomiting
  • headache
  • flushing
  • water intoxication
  • hypotension
  • fetal distress
  • disseminated intravascular coagulation
46
Q

What is the trade name of ergometrine maleate?

A

Ergometrine (or syntometrine when combined with oxytocin)

47
Q

What class of drug is ergometrine and what is it’s usual indication?

A
  • uterotonic

- management of postpartum haemorrhage

48
Q

What is the stock strength of ergometrine?

A

500 micrograms (0.5mg) per 1 mL ampoule

49
Q

What is the mode of action of ergometrine?

A
  • stimulates strong sustained rhythmic contractions of the uterus and other smooth muscle (including cervix)
  • increases action of living ligatures to reduce uterine blood flow and contribute to haemostasis
  • stimulation of alpha adrenegic receptors and causes vasoconstriction, which increases blood pressure
50
Q

Why might syntometrine be the drug of choice in the active management of third stage of labour?

A

combines rapid action of oxytocin with the sustained uterotonic effect of ergometrine

51
Q

What are the two main indications for giving misoprostol in the maternity setting?

A
  • managment of post partum haemorrhage

- midtrimester termination of pregnancy

52
Q

What is the usual dosage when giving misoprostol for termination of pregnancy?

A

200-400 micrograms Q4H PO/PV

53
Q

What is the classification of misoprostol?

A
  • Hyperacidity
  • licensed for treatment of acute duodenal/gastric ulcers
  • used off-licence
54
Q

How long does it usually take misoprostol to have an effect when using to treat PPH?

A

20-30 minutes

55
Q

What is the mode of action of misoprostol?

A
  • synthetic prostoglandin

- causes sustained uterine contractions

56
Q

What is the trade name of misoprostol?

A

Cytotec

57
Q

Why is misoprostol a good option for management of PPH in developing countries?

A

it is shelf-stable at room temperature

58
Q

What is the trade name of dinoprost trometamol?

A
  • dinoprost

- prostin f2 alpha

59
Q

What is the mode of action of dinoprost?

A
  • prostaglandin

- rhythmic contractions of smooth muscle including uterus and GI tract (nausea, vomiting, diarrhoea, hypertension)

60
Q

What is the usual stock strength and dose of dinoprost?

A

5mg/ml given IV into myometrium and repeated 10-15 minutes later
- administered by senior obstetrician, usually guided by ultrasound or in operating theatre

61
Q

What measures for extreme PPH management may be considered in theatre?

A
  • intramyometrial dinoprost
  • hysterectomy
  • bakri balloon
  • internal iliac artery ligation
  • pelvic artery embolisation
62
Q

What is water intoxication?

A
  • a life threatening adverse effect of large doses of oxytocin - may cause water retention, leading to hyponatremia, seizures and coma

Midwifery (27 decks)

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