Postpartum Haemorrhage

Question 1

What do you give to actively manage the third stage?

Answer 1

Oxytocic

• Syntocinon 10 units IV
• Ergometrine 0.25mg IV
• Syntometrine IM (syntocinon and ergometrin combination)

Question 2

When does the third stage usually occur?

Answer 2

Usually within 10minutes of delivery of baby and within an 1 hour

Question 3

Why it’s ergometrin used as much now?

Answer 3

Causes hypertension and headache in some women

Question 4

What do you do in after administering the oxytocic in the third stage?

Answer 4

Look for evidence of uterine contraction - look for lengthening of cord and show of blood that reflect separation of placenta

Question 5

How do you detect lengthening of the cord?

Answer 5

Tauten the cord and watch for it loosening when it separates

Question 6

Why don’t attempt to deliver an attached placenta?

Answer 6

Risk of inversion of the uterus - vasovagal shock - high risk of maternal death

Question 7

How long does it take to deliver the placenta without oxytocic?

Answer 7

Up to an hour

Might have to do manual delivery

Question 8

How do you manually delivery the placenta when you think it’s separated

Answer 8

Cord traction and fundal pressure

Then examine it to see if it’s complete

Question 9

Definition of primary vs secondary PPH?

Answer 9

Primary: Greater than 500ml in the first 24 hours
Secondary: Excessive amount of blood loss after 24 hours and within 6 weeks

Question 10

What is the common causes of primary PPH?

Answer 10

Uterine atony (70%)

Question 11

What controls bleeding from the uterus postpartum?

Answer 11

Contraction of the uterine muscle compression vessels

Question 12

What are the causes of uterine atony?

Answer 12

Macrosomnia
Multiple pregnancy
Polyhydramnios
Mass in the uterus - retained placenta, fibroid
Prolonged labour
Idiopathic

Question 13

What are some other causes of primary PPH?

Answer 13

Trauma (20%) - tears of the cervix, vagina, perineum, uterine rupture, episiotomy
Retained products
Coagulopathy (1%)

Question 14

How do you determine when PPH is uterine atony or other?

Answer 14

Look for uterine contraction

Question 15

What are some DDx for coagulopathies in pregnancy?

Answer 15

HELLP, preecclampsia, DIC
Placental abruption - if clotting factors are consumed
Pulmonary embolus

Question 16

How is PPH managed?

Answer 16

Monitor ABCs and the volume of blood loss
IV access and fluids if required
Bloods
Give oxytocic - preferably containing ergometrine
Rub up the uterus
Look inside the vagina for tears
Catheterise

Question 17

What the blood loss trigger for transfusion?

Answer 17

Greater than 1500ml irrespective of HR and BP

Question 18

What is the treatment for uterine atony?

Answer 18

Monitor ABCs and the volume of blood loss 
IV access and fluids if required
Bloods
Oxytocic - usually ergometrine
Rub up the uterus 
Catheterise

Question 19

What do you do if blooding continues greater than 1500ml and the cause can’t be found?

Answer 19

Take to theatre
Thorough examination, manual exploration/clearance of the uterus
More oxytocic
Balloon catheter into uterus or IM PEG alpha
If all els fail s consider uterine artery ligation, hysterectomy

Question 20

How do you replace losses?

Answer 20

Start with hartmans
If more than 1500ml loss or tachy - blood
Consider FFP or platelets

Question 21

Causes of secondary PPH?

Answer 21

Infection - eg puerperal sepsis

Retained products of conception

Question 22

How does retained products present?

Answer 22

Febrile
Bulky tender uterus
Open, erythematous cervical

Question 23

How do you exam a secondary PPH?

Answer 23

Abdominal exam
Speculum exam
Swabs

Question 24

Which Abx are given?

Answer 24

Broad spectrum penicillin
Metronidazole
Gentamicin if very sick

Question 25

How do you check for retained products in secondary PPH?

Answer 25

US

Hysteroscopy D&C

Question 26

Why don’t use a sharp curette in secondary PPH?

Answer 26

Don’t want to induce Ashimann’s syndrome if infection is present

Question 27

What are the risk of uterine rupture in VBAC?

Answer 27

1/200 if spontaneous labour
1/100 if induced
1/50 if oxytocic used