Postpartum Haemorrhage Flashcards
Define primary postpartum haemorrhage (PPH)
Loss of >500ml of blood <24hrs after delivery (or >1000ml after C-section)
Define minor PPH
Loss of 500-1000ml
Define major PPH
Loss of >1000ml and continuing to bleed
Define massive obstetric haemorrhage
Loss of >1500ml and continuing to bleed (2000ml according to Reg tutorial)
List the causes of PPH
The 4 T’s:
- Tone - atonic uterus (80% PPH)
- Trauma - tears (vaginal or cervical)
- Tissue - retained placenta
- Thrombin - coagulopathy (congenital, anticoagulant therapy, DIC, stop antenatal thromboprophylaxis at least 12hrs before labour or delivery)
What are the risk factors for PPH?
- Antepartum haemorrhage
- Previous hx
- Previous C-section
- Coagulation defect or anticoagulant therapy
- Instrumental or caesarean delivery
- Retained placenta
- Polyhydramnios and multiple pregnancy
- Grand multiparity
- Obesity
- Prolonged and induced labour
How can PPH be prevented?
- Routine use of oxytocin in third stage of labour (10 IU by IM injection if no risk factors and SVD)
- Can use Ergometrine (causes vomiting and CI in HTN)
- If previous C-section all women must have placental site determined by US (placenta accreta)
What steps are taken to prevent PPH when delivering by C-section?
- Oxytocin 5 IU by slow IV injection
- Consider oxytocin infusion (40 IU in 500ml normal saline 0.9% over 4hrs) in addition to bolus
Describe the active management of the third stage of labour
- Uterotonic (oxytocin)
- Early clamping of umbilical cord
- Controlled cord traction for delivery of placenta
What are the clinical features of PPH?
- Blood loss
- Large uterus (above level of umbilicus)
- Inspect vaginal wall and cervix for tears
- Collapse without overt bleeding (rare)
List the priorities in management of PPH
- Support
- Restoration of blood volume
- Treatment of any developing coagulopathy
- Cessation of blood loss
How do we resuscitate a patient with PPH?
- Nursed flat
- O2 given
- IV access obtained
- Blood cross matched
- Fluid +/- blood given
How can we prevent or treat coagulopathy?
- May require FFP
- Tranexamic acid reduces bleeding
How is retained placenta managed?
- Removed manually if bleeding or it is not expelled by normal methods within 60mins of delivery
List the steps to identify and treat the cause of bleeding
- VE
- Uterus bimanually compressed
- Oxytocin and/or Ergometrine IV (if fails prostaglandin F2x injection into myometrium)
- Examination under anaesthetic if above fails
- Surgery
What different surgical techniques can be used in the treatment of PPH?
- Placement of a Rusch balloon
- Brace suture
- Uterine artery embolization
- Hysterectomy
Who is alerted in the case of a minor PPH?
- Midwife in charge
- First line obstetric staff
- First line anaesthetic staff
Who is alerted in the case of a major PPH?
- Midwife in charge
- Obstetric middle grade and alert consultant
- Anaesthetic middle grade and alert consultant
- Consultant clinical haematologist on call
- Blood transfusion lab
- Porters
- One team member to record events, fluids, drugs, vitals
How do we resuscitate in the case of a minor PPH?
- IV access (14 gauge cannula x1)
- Commence crystalloid infusion
- Insert urinary catheter
How do we resuscitate in the case of a major PPH?
- ABC call for senior help
- O2 by mask at 10-15L/min
- IV access (large gauge cannula x2)
- Position flat
- Keep woman warm
- Transfuse blood ASAP
- Infuse up to 3.5L of warmed fluid solution, crystalloid (2L) and/or colloid (1-2L) until blood available
- Recombinant factor VIIa therapy based on clinical evaluation and results of coagulation
List the investigations and monitoring done for minor PPH
- Group and screen
- FBC
- Coagulation screening including fibrinogen
- Pulse and BP every 15mins
List the investigations and monitoring done for major PPH
- Crossmatch (4 units min)
- FBC
- Coagulation screen including fibrinogen
- Renal and liver function for base line
- Temp every 15mins
- Continuous pulse, BP and RR
- Catheter to monitor urine output
- Two peripheral cannulae
- Consider arterial line monitoring
- Transfer to HDU when bleeding controlled
- Record everything
- Documentation of fluid balance, blood, blood products and procedures
How do we treat uterine atony?
- Bimanual uterine compression to stimulate contractions
- Ensure bladder empty
- Syntocinon 5U slow IV injection
- Ergometrine 0.5mg by slow IV or IM injection (CI HTN)
- Syntocinon infusion unless fluid restriction necessary
- Carboprost 0.25mg IM repeated at intervals of not less than 15mins to a max of 8 doses (CI asthma)
- Direct intramyometrial injection of carboprost 0.5mg (unlicensed use)
- Misoprostol 600mcg orally or sublingually
- Balloon tamponade
- Haemostatic brace suture
- Bilateral ligation of uterine arteries
- Bilateral ligation of internal iliac arteries
- Selective arterial embolization
- Hysterectomy
Define secondary PPH
Excessive blood loss occurring between 24hrs and 6wks after delivery
