Postpartum Haemorrhage

Question 1

Define Primary Postpartum Haemorrhage

Answer 1

Primary PPH is defined as bleeding of >500ml from the birth canal in the first 24 hours following delivery

Question 2

Define Major Post Partum Haemorrhage.

Answer 2

Major PPH is similar to primary PPH but it is defined as greater than 1000ml of blood loss. It is a major cause of maternal death world wide.

Question 3

What is the incidence of PPH? How often does it go on to cause maternal death?

Answer 3

PPH occurs in around 4% of pregnancies and accounts for 10% of direct maternal deaths.

Question 4

What are the most common causes of PPH?

Answer 4

Hint: 4 Ts

Tone - Uterine Atony
Tissue - Retained placental tissue
Trauma - birth canal laceration
Thrombin - Coagulopathy

Question 5

In 6 steps, describe the initial management of a PPH in the birth suite

Answer 5

1. Summon Assistance
2. Simultaneous resuscitation - IV line, blood for cross match, fluid infusion
3. Contract the Uterus - uterine massage , oxytocic administration
4. Empty the uterus - if placenta still retained controlled cord traction if cord attached and fundal pressure if cod has avulsed. If placenta has been delivered then check if it is complete.
5. Check the lower birth canal - look for any obvious traumatic bleeding site in the low vagina or perineum
6. Prepare for operating theatre if bleeding is continuing - bimanual compression will reduce blood loss

Question 6

In 8 steps list the progressive management considerations for PPH in the operating theatre.

Answer 6

1. Summon further assistance if needed
2. Simultaneous resuscitation
3. Explore the uterus - look for retained products of conception or traumatic site of bleeding in the uterus, cervix or upper vagina
4. Contract the uterus - oxytocic administration
5. Balloon tamponade or packing - if bleeding from the placental
6. Compression sutures
7. Internal iliac ligation or placental site radiological embolisation
8. Hysterectomy

Question 7

Discuss uterine atony.

Answer 7

After the baby is delivered and then placenta is delivered, the vessels supplying the placental bed occlude because the uterus contracts. If there is no contraction and the vessels do not occlude, PPH results.

Question 8

Discuss retained products of conception leading to PPH

Answer 8

If there is non-separation or retention of part or all of the placenta, this will inhibit the closure of the arterial and venous sinuses in the placental bed. Since even a small part of the placenta being retained could actually lead to a PPH, it is important to thoroughly examine the placenta following the 3rd stage of labour. Surgical exploration may be required if there is a significant ongoing bleed.

Question 9

Discuss placenta previa as a cause of PPH

Answer 9

In placenta praevia, there is less muscle in the lower uterine segment means that there is less efficient contraction of the uterine wall around the vessels which are supplying the placental bed. Since women with placenta praevia are most likely to have a CS then surgical measures can be undertaken immediately to stem the bleeding.

Question 10

Explain what Placenta Accreta is.

Answer 10

Placenta accreta is the adherence of the placenta to the uterine wall. Associated with previous CS, the more the higher the chance. Can be tested for by US or AFP (elevated). 25% with previous CS and placenta praevia. 60% after 2 CS. There will be heavy and persistent bleeding in Stage 3 of labour. Not much bleeding antenatally.

Question 11

How do you manage a patient with confirmed placenta accreta?

Answer 11

It is a life-threatening condition and the minimising of maternal risk is imperative. CS needs to take place to manage the potentially massive haemorrhage. Options include:
1. Attempt to remove placenta and control subsequent bleeding
2. High classical CS leaving the placenta in situ in the lower segment.
Hysterectomy can take place at this point.
Alternatively, can let placenta to pass vaginally which can take weeks but some present with sudden haemorrhage and this may be fatal.

Question 12

Discuss uterine inversion.

Answer 12

When the uterus descends through the cervix and lies either in the vagina or outside the introitus with the placenta usually still adherent.
Extremely rare, esp with active management in the 3rd stage of labour.
Mass is felt and there is no uterus palpable in the abdomen. Shock can follow.
Mx: replacing of the uterus. IV therapy and then manually attempt to replace the uterus.

Question 13

What are the 3 predisposing factors for uterine rupture leading to PPH?

Answer 13

1. Uterine Scar - Upper Uterine Segment scars from classical CS are more likely to rupture.
2. Obstructed Labour - meglected obstrcuted labour as the lower uterine segment thins as it is drawn up and over the presenting part.
3. Trauma

Question 14

What are the clinical features of uterine rupture?

Answer 14

Fetal compromise if significant bleeding. If true rupture, rapid compromise leading to hypoxic death if fetus or placenta into peritoneal cavity.
Pain at site of rupture with intra peritoneal bleeding signs (shoulder-tip pain) then hypovolaemic shock

Question 15

What are the three ways a woman can get a cervical laceration?

Answer 15

1. Pushing on an undilated cervix
2. Hypotonic Labour
3. Traumatic tearing of cervix - instrumental vaginal delivery, internal podalic version or treatment of shoulder dystocia

Question 16

What are the clinical features and management of cervical lacerations?

Answer 16

Features:
Steady loss of bright red blood straight after the delivery of the baby but can only be confirmed following inspection of the cervix.
Mx
bimanual compression while waiting for access to operating theatre.

Question 17

What is a secondary PPH and how is it managed?

Answer 17

bleeding in excess of normal lochial loss between 24hrs and 6 weeks post partum. Caused usually by infection due to retained fragments of placenta.
Mx: degree of blood loss is important to ascertain. Hb check, vaginal swab. Oxytocics control the bleeding. ABx is begun because endometriosis is likely.
US to determine extent of retained placenta and need to further surgical management.