Postpartum Haemorrhage Flashcards
What is the historic definition of a PPH?
Blood loss after delivery > 500mls
What is the current definition of a PPH?
Minor (500-1000mls)
Major (More than 1000mls)
What is considered as a moderate major PPH?
1000-2000mls
What is considered as a Severe major PPH?
More than 2000mls
What is the classification of a primary PPH?
Within 24hrs of delivery
What is the classification of a secondary PPH?
Between 24hrs and 6weeks
What is the incidence of PPH?
Approx 5-10% of all deliveries
What are three recommendations provided by the RCOG (2009;2016)?
Active Management of Third stage
Oxytocin
Multi-professional management
What are some mistakes made by professionals that can increase the risk of PPH?
With reference?
Lack of routine observation in postnatal period.
Failure to appreciate bleeding
lack of accurate observation of pulse and BP
poor recognition of abnormal signs such as oxygen saturation or respiratory rate
Untreated Anaemia
Inaccurate use of MEOWS chart
(MMBRACE, 2006-2008)
What are the recommendations given to professionals when treating PPH with ref?
staff should have regular training on identification and management of maternal collapse and identification of hidden bleeding
An early warning scoring system may help in recognition
With severe haemorrhage, the help of colleagues with greater gynaecological surgical experience should be sought
Management of women with placenta percreta requires careful multidisciplinary planning and a Consultant led team at delivery
Guidelines for women who refuse blood products must be made available
Women should be advised that caesarean sections are not an entirely risk free procedure
All women who have had a previous caesarean section must have their placental site determined
(MMBRACE)
What is classified as anaemia in the 1st trimester? with ref
haemoglobin less than 110g/l
RCOG,2015
What is classified as anaemia in the 2nd and 3rd trimester? with ref
haemoglobin less than 105g/l
RCOG,2015
What is classified as anaemia in the postpartum period? with ref
haemoglobin less than 100g/l
RCOG,2015
What should be considered when haemoglobin levels are below the normal range of pregnancy? with ref
Iron supplementation
MBRRACE,2015
What should be considered when PPH occurs? with ref
Stimulating or augmenting uterine contractions should be done in accordance with current guidance and paying particular attention to avoiding uterine hyperstimulation.
Fluid resuscitation and blood transfusion should not be delayed because of false reassurance from a single haemoglobin result.
What are the two main physiological disturbances shown in a significant haemorrhage?
Tachycardia
bradycardia
hypo tension (late sign)
what are the three difficulties when recognising a PPH?
underestimation of blood loss
Occult blood loss missed
Slow, steady bleeding underestimate
Name the risk factors in the history of a woman?
Previous PPH
Grand multiparity (parity 5 or more) or nulliparous
Obesity
Asian Ethnicity
Name the risk factors in the antenatal period?
Maternal Hb below 8.5 gd/l at labour onset (investigate and treat antenatally )
BMI greater than 3
APH
Platelets <100
Over distension of the uterus (polyhydramnios, multiple pregnancy, macrosomia >4kg)
Existing uterine abnormalities
Abnormal Placentation
Women with large fibroids >5cm
Maternal age over 35
Name the risk factors in the intrapartum period?
Prolonged 1st , 2nd or 3rd stage of labour
Induction of labour
Oxytocin use
Episiotomy (mediolateral & midline)
Lacerations
Precipitate labour/ delivery
Operative deliveries or caesarean section
Assisted delivery
Shoulder dystocia
(NICE,2014)
Name three recommendations by NICE guidelines 2014?
women with risk factors for PPH should be advised to give birth in an obstetric unit where emergency treatment options are available
If a woman has risk factors for PPH, these should be highlighted in her notes and a care plan covering the third stage should be made
The unit should have strategies in place in order to respond quickly and appropriately should a PPH occur
Name the 6 potential complications
Severe anaemia
Pituitary infarction
Coagulopathies
Renal damage
Coma
Death
What 4 things can be done to prevent a PPH?
Treat anaemia antenatally
Avoid routine episiotomy
Actively manage third stage (Mbrrace 2016)
Close observation post delivery
Name the 4 major causes of PPH (think of the 4 T’s) and their percentages
Tone 70%
Trauma 20%
Tissue 9%
Thrombin 1%
What is considered the first line prevention of PPH, when using drug therapy?
Syntometrine 1ml IM
Syntocinon 10 iu IM (if hypertensive)
Reduces PPH by 60% with active management
What would you give to a woman without the risk factors of PPH delivering vaginally?
Oxytocin- 10 IU IM
What would you give to a woman that is delivering by CS and why?
Oxytocin- 5IU by slow IV injection
To encourage contraction of the uterus and to decrease blood loss
when would could you give Syntometrine, if a women is at risk of a PPH, why?
In absence of hypertension
it is given to reduce the risk of a minor PPH
In addition to oxytocin at CS what drug can clinicians consider, why is it given and how much is usually given?
Tranexamic acid- 0.5-1.0g
reduces blood loss in women at increased risk of PPH
Claire’s blood pressure measures @ 190/90 and is at risk of a PPH, Syntometrine 1mg IM is the best drug to give her in active 3rd stage, justify the reasons for your choice and provide a solution
FALSE
Ergometrine in Syntometrine, can cause an increase in blood pressure, causing an increase risk of PPH,
Give Syntocinon 10iu IM instead
When should introperative cell salvage (blood transfusing using blood loss) be considered ?
for emergency use in PPH associated with CS and with Vaginal delivery
What 4 things can be done/given before greater intervention if PPH has not been resolved?
repeat syntometrine
Syntocinon infusion (40iu in 500mls N/Saline at 125mls per hour)
Haemabate (carboprost) – 250mcg IM/Intramyometrially every 15 mins up to 8 doses
Misoprostol 800 micrograms PR
Haemabate should be given IV, True or False?
False
it should be given Intra -myometrially once
Sharon is experincing a PPH, the DRs mention that Haemabate should be given- as a midwife, what should you mention with Sharon prior to the drug being given?
It can cause Nausea, dizziness, flushing and headaches
When should caution be taken if Haemabate is considered to be given?
hypertension,
cardiac disorders
pulmonary disease
Asthma
What doe should Haemabate be given?
250mcg
Can be given up to a maximum dose of 2mg with no less than 15 mins between doses (8 doses)
What is the rationale behind giving Misoprostol
Misoprostol induces uterine contractions
Approximately 70% of PPH cases are due to inadequate uterine contraction
How should Misoprostol be given?
800micrograms sublingually
How would Tone be treated, in the case of a PPH?
rub up contraction
Bi-manual compression
Empty bladder – indwelling catheter
How would Tissue be treated, in the case of a PPH?
Deliver placenta
Manual removal if
necessary
Check placenta for retained products
How would Trauma be treated, in the case of a PPH?
Check for tears/episiotomy
Particularly high vaginal/cervical
Assess depth & difficulty
Appropriate personnel & place
Analgesia
Lighting
Commence suturing when able
What questions will be asked when treating Thrombin?
blood clotting on the floor?
Have you checked clotting?
Is there an underlying medical condition?
Does lady require platelets?
Liaise with Consultant Haematologist
What additional treatments can be considered in a severe PPH?
Massive Obstetric Haemorrhage policy
If lost more than 2000mls
Will require CVP line & monitoring
Transfer to theatre earlyBaloon Tamponade (Bakri balloon catheter (with Syntocinon infusion, to remain in situ for 24 hrs)
B lynch suture
Embolizing uterine vessels +/- hysterectomy
What can be classified as trauma that can cause a PPH?
Inverted uterus
Ruptured uterus
Lacerations/ episiotomy
Haematoma
what would be the treatment in case of an inverted uterus?
Call for help
Manually replace uterus immediately (longer the time lapse- uterus harder to replace)
Monitor condition A B C
Treat vasovagal shock
If initial manual replacement unsuccessful, may need:
- tocolysis
- hydrostatic measures - surgical replacement
What are the different types of uterine rupture?
Partial
Complete
What is the incidence of a uterine rupture?
1:1,500
What are the main risk factors for a uterine rupture?
Previous uterine surgery or trauma
Oxytocin usage in multiparous women
Forcep deliveries (high rotational)
Previous LSCS + oxytocin in this labour
IOL with prostaglandins]
Cephalopelvic disproportion
What are the signs and symptoms for a uterine rupture?
Sudden change in fetal heart rate pattern
Abdominal pain
Change in abdominal shape
Palpable fetal parts
Vaginal bleeding
Cessation of uterine contractions
Maternal tachycardia/ signs of shock
What are the treatments for Uterine rupture?
Treatment = surgical repair or hysterectomy
What can be the cause of PPH when considering tissue?
Retained placenta
not delivered within
30 minutes with
active management
Approx 3% of all deliveries (ALSO, 2001)
Varies with gestational age
Retained placental / membrane fragments
Morbidly adherent/ invasive placenta
What is considered as a Placenta Accreta?
Placenta morbidly adherent infiltrating endometrium
What is considered as a Placenta Increta?
invades into myometrium
What is considered as a Placenta Percreta?
invades through myometrium and into serosa
How is retained placenta managed?
not use excessive cord traction
Keep uterus well contracted- massage, oxytocin infusion
Manual removal of placenta in theatre if placenta not delivered in 2 hours (approx) or bleeding not controlled
Intra-umbilical oxytocin (on Cochrane Database)- reduces rate of manual removal- 20iu of oxytocin in 20 mls N/Saline- injected into placental side of clamped cord
Aspirin and Heparin can cause Thrombin disorders
True or False?
True
Name 5 obstetric related causes of Thrombin disorders
pre-eclampsia
HELLP
Abruption
IUD
Sepsis
How would you recognise a thrombin disorder?
Watery’ blood loss
No evidence of blood clotting
Oozing from puncture sites
Bruising
How are Thrombin disorders treated?
Treat underlying condition
Involve Haematologist
Transfusion of blood / Fresh Frozen Plasma (FFP’s)/ cryoprecipitate/ platelets
What should be done when treating a Major PPH (blood loss > 1000mls)
Call for Help
SOAPS
Alert Blood Transfusion
Alert Consultant on Call
ABC; O2 Mask (15l)
Fluid Balance (e.g. 2 litres Isotonic crystalloid; 1.5 litres colloid)
Blood Transfusion
Blood products (FFP, PLT, cryoprecipitate, factor V11a)
Keep Patient Warm
9 things to be monitored and investigated during a PPH?
14 Gauge cannula x2
FBC, coagulation, U&E’s, LFT’s
Cross match (4 units, FFP, PLT, cryoprecipitate)
ECG, Oximeter
Foley Catheter
Hb bedside testing
Consider central and arterial lines
Documentation
Weigh all swabs and estimate blood loss
list in summary, the medical treatment that can be given to treat PPH
rub up the uterine fundus
Empty bladder
Oxytocin 5 IU, slow IV (repeat if necessary)
Ergometrine 0.5mg, slow IV or IM
Oxytocin infusion (40IU in 500ml)
Carboprost 0.25mg IM every 15 minutes up to 8 times
Carboprost - intramyometrial 0.5mg (anaesthetist)
Misoprostol 800mcg sublingually
Consider Tranexamic Acid 1g IV
What treatment can be considered in theatre?
intrauterine balloon tamponade
Brace suture
Consider interventional radiology
What treatment can be considered in surgery?
Stepwise uterine devascularisation
Bilateral internal iliac ligation
Hysterectomy
Uterine artery embolization
