Postpartum Haemorrhage

Question 1

What is PPH?

Answer 1

• 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

Question 2

What is minor PPH?

Answer 2

• 500- 1000 mls

Question 3

What is moderate PPH?

Answer 3

• 1000-2000 mls

Question 4

What is severe PPH?

Answer 4

• over 2000mls

Question 5

What is the difference between primary and secondary PPH?

Answer 5

• primary is within the first 24 hours

- secondary is after the first 24 hours

Question 6

What is the incidence of PPH?

Answer 6

• 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

Question 7

What are the causes of PPH?

Answer 7

• tone —> state of uterine stony (70%)
• trauma —> cervical, vaginal lacerations, uterine inversion (20%)
• tissue —> retained placenta, invasive placenta (10%)
• thrombin —> clotting disorders (1%)

Question 8

What is atonic uterus?

Answer 8

• 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

Question 9

What are the risk factors of uterine atony?

Answer 9

• 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

Question 10

What are the risk factors of trauma and examples?

Answer 10

• episiotomy/perineal trauma
• assisted delivery
• internal manoeuvres e.g. shoulder dystopia
• LSCS

—> EXAMPLES

• perineum
• vagina
• cervix
• urethra
• clitoris
• rupture to uterus/uterine inversion
• haematoma

Question 11

Examples of thrombin causes

Answer 11

• coagulation defects e.g. haemophilia
• clotting disorders eg. Van Willie brands disease
• prophylactic heparin within 24 hours
• may be secondary to other bleeding

Question 12

What are other risk factors of PPH?

Answer 12

• previous history of PPH or retained placenta
• fibroids - impede uterine action
• mismanagement of 3rd stage
• chorioamnionitis
• obesity
• anaemia
• over 40 years of age
• APH

Question 13

How can midwives prevent PPH antenatally?

Answer 13

• detect and treat anaemia
• women with suspected abnormally adherent placenta should have management plan documented in notes
• accurate history taking

Question 14

How can a midwife prevent PPH?

Answer 14

• 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

Question 15

How to recognise PPH

Answer 15

• 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)

Question 16

Drugs that can be given in PPH

Answer 16

• 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

Question 17

What are some of the signs and symptoms or PPH?

Answer 17

• 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)

Question 18

What actions should be taken for a PPH in hospital? (Placenta in)

Answer 18

• 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

Question 19

What effect will emptying the bladder have?

Answer 19

• 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

Question 20

What is bi-manual compression?

Answer 20

• 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

Question 21

What is the medical management for persistent bleeding?

Answer 21

• 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

Question 22

What action should be taken if PPH is due to trauma?

Answer 22

• pressure
• suturing
• EUA
• analgesia
• haematoma considerations

Question 23

What record keeping should be undertaken in a PPH?

Answer 23

• 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