Postpartum Haemorrhage Flashcards
What do you give to actively manage the third stage?
Oxytocic
- Syntocinon 10 units IV
- Ergometrine 0.25mg IV
- Syntometrine IM (syntocinon and ergometrin combination)
When does the third stage usually occur?
Usually within 10minutes of delivery of baby and within an 1 hour
Why it’s ergometrin used as much now?
Causes hypertension and headache in some women
What do you do in after administering the oxytocic in the third stage?
Look for evidence of uterine contraction - look for lengthening of cord and show of blood that reflect separation of placenta
How do you detect lengthening of the cord?
Tauten the cord and watch for it loosening when it separates
Why don’t attempt to deliver an attached placenta?
Risk of inversion of the uterus - vasovagal shock - high risk of maternal death
How long does it take to deliver the placenta without oxytocic?
Up to an hour
Might have to do manual delivery
How do you manually delivery the placenta when you think it’s separated
Cord traction and fundal pressure
Then examine it to see if it’s complete
Definition of primary vs secondary PPH?
Primary: Greater than 500ml in the first 24 hours
Secondary: Excessive amount of blood loss after 24 hours and within 6 weeks
What is the common causes of primary PPH?
Uterine atony (70%)
What controls bleeding from the uterus postpartum?
Contraction of the uterine muscle compression vessels
What are the causes of uterine atony?
Macrosomnia Multiple pregnancy Polyhydramnios Mass in the uterus - retained placenta, fibroid Prolonged labour Idiopathic
What are some other causes of primary PPH?
Trauma (20%) - tears of the cervix, vagina, perineum, uterine rupture, episiotomy
Retained products
Coagulopathy (1%)
How do you determine when PPH is uterine atony or other?
Look for uterine contraction
What are some DDx for coagulopathies in pregnancy?
HELLP, preecclampsia, DIC
Placental abruption - if clotting factors are consumed
Pulmonary embolus
How is PPH managed?
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
What the blood loss trigger for transfusion?
Greater than 1500ml irrespective of HR and BP
What is the treatment for uterine atony?
Monitor ABCs and the volume of blood loss IV access and fluids if required Bloods Oxytocic - usually ergometrine Rub up the uterus Catheterise
What do you do if blooding continues greater than 1500ml and the cause can’t be found?
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
How do you replace losses?
Start with hartmans
If more than 1500ml loss or tachy - blood
Consider FFP or platelets
Causes of secondary PPH?
Infection - eg puerperal sepsis
Retained products of conception
How does retained products present?
Febrile
Bulky tender uterus
Open, erythematous cervical
How do you exam a secondary PPH?
Abdominal exam
Speculum exam
Swabs
Which Abx are given?
Broad spectrum penicillin
Metronidazole
Gentamicin if very sick
How do you check for retained products in secondary PPH?
US
Hysteroscopy D&C
Why don’t use a sharp curette in secondary PPH?
Don’t want to induce Ashimann’s syndrome if infection is present
What are the risk of uterine rupture in VBAC?
1/200 if spontaneous labour
1/100 if induced
1/50 if oxytocic used
