Postpartum haemorrhage Flashcards
What is primary postpartum haemorrhage?
Greater than >500ml of blood loss in the first 24 hours
What would be considered a moderate amount of blood loss in primary postpartum haemorrhage?
1000ml-2000ml
What would be considered a severe amount of blood loss in primary postpartum haemorrhage?
> 2000ml
What is secondary postpartum haemorrhage?
Abnormal bleeding that occurs from 24 hours - 12 weeks after delivery
What property of blood in postpartum haemorrhage should be looked for?
Clotting
What are the causes of primary postpartum haemorrhage? (4Ts)
Tone - the tone of the uterus itself
Trauma - lacerations in vagina/uterus
Tissue - retained products i.e. placenta
Thrombin - Coagulopathy
What is the most common cause of postpartum haemorrhage?
Uterine atony
What is uterine atony?
Oxytocin levels are increased during delivery, causing contractions of the uterus, and these compress the myometrial blood vessels, preventing haemorrhage
If there are no contractions, there is no compression of the blood vessels and haemorrhage occurs
What is the key risk factor for uterine atony?
Multiple gestation
Uterus is stressed so much that contractions fail to compress vessels adequately
What are the risk factors for placental retention?
Structural abnormality e.g. placenta accreta, percreta and increta
What is one of the key signs of trauma as the cause of postpartum haemorrhage?
Shock disproportionate to blood loss
How can postpartum haemorrhage due to coaogulopathy be prevented?
Check clotting factors, Hb, INR etc at antenatal screening
What other antenatal factors can increase risk of postpartum haemorrhage?
Previous caesarean section Placenta praevia, percreta, accreta Pre-eclampsia Previous PPH or retained placenta Multiple pregnancy
What active management in the third stage of labour can prevent postpartum haemorrhage?
Syntocinon given just after delivery of anterior shoulder
What intrapartum factors increase risk of postpartum haemorrhage?
Prolonged labour (particularly in nulliparous women) Mediolateral episiotomy Arrest of descent Lacerations Augmented labour
How should a lady with mild postpartum haemorrhage but no signs of shock be managed?
Close monitoring
Start fluids
How should a lady with postpartum haemorrhage >1000mls and/or signs of shock be managed?
Resuscitate: call for help & ABCDE Lie patient flat Uterine massage 5 units IV syntocinon 40 units Syntocinon in 500ml hartmanns - 125 ml/h
Who should be called and in what order for help in obstetric emergency?
Senior midwife, senior obstetrician, anaesthetist, haematologist, blood transfusion lab, porter, someone to note everything down
How can postpartum haemorrage due to tone be managed?
Uterine massage/bimanual compression Ergometrine Synctocinon Carboprost Misoprostol
What surgical management can be given for postpartum haemorrhage?
Undersuturing Brace Sutures Uterine Artery Ligation Internal Iliac Artery Ligation Hysterectomy
What is uterine inversion?
A complication of childbirth that occurs when the placenta fails to detach from the uterus as it exits, pulls on the inside surface, and turns the organ inside out
What might uterine inversion look like on examination?
Looks like mass protruding from vagina
How does uterine rupture present?
Shock disproportionate to bleeding
Loss of contractions
Obstructed labour
Peritonism
What changes on CTG might be seen in uterine rupture?
Fetal bradycardia or intrauterine death
