Postpartum Haemorrhage Flashcards
1
Q
What is PPH?
A
- excessive blood loss of more than 500ml from the genital tract following the birth of the baby up to the end of the puerperium
- a fall in haemocrit of 10% or more of the requirement for a blood transfusion
- or the presence or absence of haemodynamic compromise or shock
2
Q
What is minor PPH?
A
- 500- 1000 mls
3
Q
What is moderate PPH?
A
- 1000-2000 mls
4
Q
What is severe PPH?
A
- over 2000mls
5
Q
What is the difference between primary and secondary PPH?
A
- primary is within the first 24 hours
- secondary is after the first 24 hours
6
Q
What is the incidence of PPH?
A
- PPH remains the most common cause of maternal mortality worldwide
- it is responsible for around 30% of maternal death
- there is evidence that the rate of both retained placenta and PPH is increasing in western settings
7
Q
What are the causes of PPH?
A
- tone —> state of uterine stony (70%)
- trauma —> cervical, vaginal lacerations, uterine inversion (20%)
- tissue —> retained placenta, invasive placenta (10%)
- thrombin —> clotting disorders (1%)
8
Q
What is atonic uterus?
A
- failure of the myometrium at the placental site to contract and retract and to compress torn blood vessels and control blood loss by a living ligature action
9
Q
What are the risk factors of uterine atony?
A
- incomplete separation of the placenta - maternal vessels are torn, if placental tissue remains partially embedded in spongy decidua, contraction and retraction are interrupted
- retained placenta, cotyledon, placental fragment or membranes - impedes efficient uterine action
- precipitate labour - when the uterus has contracted vigorously and frequently resulting in a labour <1 hour then muscle may have insufficient opportunity to retract
- prolonged labour - where active phase lasts over 12 hours uterine inertia can result from muscle exhaustion
- polyhydramnios, macrosomia, multiple pregnancy - myometrium becomes excessively stretched (less efficient)
- placenta praevia - placental site is partly or wholly in the lower segment where the thinner muscle layer contains few oblique fibres
- placental abruption - blood may have seeped between the muscle fibres, at most severe results in a couvelaire uterus
- general anaesthesia - can cause uterine relaxation in particular volatile inhalational agents e.g. halothane
- full bladder - can interfere with uterine action
- aetiology unknown
- induction of augmentation of labour —> oxytocin can lead to hyperstimulation of the uterus and cause a precipitate expulsive birth
—> uterine fatigue or inertia can occur
10
Q
What are the risk factors of trauma and examples?
A
- episiotomy/perineal trauma
- assisted delivery
- internal manoeuvres e.g. shoulder dystopia
- LSCS
—> EXAMPLES
- perineum
- vagina
- cervix
- urethra
- clitoris
- rupture to uterus/uterine inversion
- haematoma
11
Q
Examples of thrombin causes
A
- coagulation defects e.g. haemophilia
- clotting disorders eg. Van Willie brands disease
- prophylactic heparin within 24 hours
- may be secondary to other bleeding
12
Q
What are other risk factors of PPH?
A
- previous history of PPH or retained placenta
- fibroids - impede uterine action
- mismanagement of 3rd stage
- chorioamnionitis
- obesity
- anaemia
- over 40 years of age
- APH
13
Q
How can midwives prevent PPH antenatally?
A
- detect and treat anaemia
- women with suspected abnormally adherent placenta should have management plan documented in notes
- accurate history taking
14
Q
How can a midwife prevent PPH?
A
- promote mobility and optimal positions to facilitate birth
- nutrition and hydration
- avoid interventions
- promote a nurturing environment to increase own natural oxytocin and reduce catecholmine’s
- regular bladder emptying
- skin to skin
- early breastfeeding
- if augmented with syntocinon- keep going for at least an hour postnatally
- discuss different methods of 3rd stage management antenatally (informed consent) active or physiological
15
Q
How to recognise PPH
A
- be aware of normal observations including present Hb
- be aware of normal blood loss during 3rd stage
- separation bleeding
- recognise deviations from the norm
- check placenta and membranes
- careful examination of perineum and suturing of bleeding points
- vital signs following birth (1st hour care)
16
Q
Drugs that can be given in PPH
A
- Oxytocin —> 10 iu given IM at time of delivery
—> within 1 minute intravenously (only 5 iu)
—> within 2 minutes IM - Syntometrine —> causes intense and sustained uterine contraction
—> associated increases in hypertension, vomiting
17
Q
What are some of the signs and symptoms or PPH?
A
- visible bleeding
- maternal collapse
- pallor
- rising pulse
- falling BP
- altered level of consciousness (restless, drowsy, faint, light headed)
- enlarged uterus as it fills with blood (boggy)
18
Q
What actions should be taken for a PPH in hospital? (Placenta in)
A
- call for help (emergency bell)
- remain with mother
- safety of baby
- explain gently what is happening
- palpate uterus
- rub up a contraction
- give oxytocic drug
- empty bladder
- attempt to deliver placenta by CCT
- consider manual removal of placenta (examine placenta once delivered)
- monitor vital signs
- assess blood loss continuously
- urgent venipuncture (Cannula x 2) - fbc, cross match
- commence IV fluids
- commence O2
19
Q
What effect will emptying the bladder have?
A
- ensures the uterus can contract, even a small volume of urine can prevent this
- keeping catheter in bladder will allow recording of urinary output/fluid balance
20
Q
What is bi-manual compression?
A
- with fingers of dominant hand bent over they are inserted into the vagina, hand made into a fist at anterior vaginal fornix
- palm of other hand placed abdominally using tips of the fingers to lift the uterus slightly forward to position the hand behind the uterus
- uterus compressed between left and right hands
21
Q
What is the medical management for persistent bleeding?
A
- continue bi-manual compression
- if uterus not contracted give further uterotonics
- carboprost - 250 micrograms IM, can be given in repeated 90 minute intervals, can be reduced but not less than 15 minutes
- misoprostol - 100 micrograms can be given PR controls haemorrhage within 3 minutes
- transfer to theatre for EUA
22
Q
What action should be taken if PPH is due to trauma?
A
- pressure
- suturing
- EUA
- analgesia
- haematoma considerations
23
Q
What record keeping should be undertaken in a PPH?
A
- structured proforma
- scribe
- critical incident reporting (datix)
- the staff in attendance and when they arrived
- sequence of events
- administration of pharmacological agent, their timing and sequence
- the timing of surgical intervention where relevant the condition of the mother throughout the different steps
- the timing of the fluid and blood products given
- observations taken
