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Midwifery emergencies > Postpartum Haemorrhage > Flashcards

Postpartum Haemorrhage Flashcards

1
Q

What is the historic definition of a PPH?

A

Blood loss after delivery > 500mls

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2
Q

What is the current definition of a PPH?

A

Minor (500-1000mls)

Major (More than 1000mls)

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3
Q

What is considered as a moderate major PPH?

A

1000-2000mls

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4
Q

What is considered as a Severe major PPH?

A

More than 2000mls

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5
Q

What is the classification of a primary PPH?

A

Within 24hrs of delivery

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6
Q

What is the classification of a secondary PPH?

A

Between 24hrs and 6weeks

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7
Q

What is the incidence of PPH?

A

Approx 5-10% of all deliveries

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8
Q

What are three recommendations provided by the RCOG (2009;2016)?

A

Active Management of Third stage

Oxytocin

Multi-professional management

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9
Q

What are some mistakes made by professionals that can increase the risk of PPH?

With reference?

A

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)

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10
Q

What are the recommendations given to professionals when treating PPH with ref?

A

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)

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11
Q

What is classified as anaemia in the 1st trimester? with ref

A

haemoglobin less than 110g/l

RCOG,2015

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12
Q

What is classified as anaemia in the 2nd and 3rd trimester? with ref

A

haemoglobin less than 105g/l

RCOG,2015

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13
Q

What is classified as anaemia in the postpartum period? with ref

A

haemoglobin less than 100g/l

RCOG,2015

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14
Q

What should be considered when haemoglobin levels are below the normal range of pregnancy? with ref

A

Iron supplementation

MBRRACE,2015

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15
Q

What should be considered when PPH occurs? with ref

A

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.

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16
Q

What are the two main physiological disturbances shown in a significant haemorrhage?

A

Tachycardia
bradycardia
hypo tension (late sign)

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17
Q

what are the three difficulties when recognising a PPH?

A

underestimation of blood loss

Occult blood loss missed

Slow, steady bleeding underestimate

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18
Q

Name the risk factors in the history of a woman?

A

Previous PPH

Grand multiparity (parity 5 or more) or nulliparous

Obesity

Asian Ethnicity

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19
Q

Name the risk factors in the antenatal period?

A

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

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20
Q

Name the risk factors in the intrapartum period?

A

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)

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21
Q

Name three recommendations by NICE guidelines 2014?

A

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

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22
Q

Name the 6 potential complications

A

Severe anaemia

Pituitary infarction

Coagulopathies

Renal damage

Coma

Death

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23
Q

What 4 things can be done to prevent a PPH?

A

Treat anaemia antenatally

Avoid routine episiotomy

Actively manage third stage (Mbrrace 2016)

Close observation post delivery

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24
Q

Name the 4 major causes of PPH (think of the 4 T’s) and their percentages

A

Tone 70%

Trauma 20%

Tissue 9%

Thrombin 1%

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25
Q

What is considered the first line prevention of PPH, when using drug therapy?

A

Syntometrine 1ml IM

Syntocinon 10 iu IM (if hypertensive)

Reduces PPH by 60% with active management

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26
Q

What would you give to a woman without the risk factors of PPH delivering vaginally?

A

Oxytocin- 10 IU IM

27
Q

What would you give to a woman that is delivering by CS and why?

A

Oxytocin- 5IU by slow IV injection

To encourage contraction of the uterus and to decrease blood loss

28
Q

when would could you give Syntometrine, if a women is at risk of a PPH, why?

A

In absence of hypertension

it is given to reduce the risk of a minor PPH

29
Q

In addition to oxytocin at CS what drug can clinicians consider, why is it given and how much is usually given?

A

Tranexamic acid- 0.5-1.0g

reduces blood loss in women at increased risk of PPH

30
Q

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

A

FALSE

Ergometrine in Syntometrine, can cause an increase in blood pressure, causing an increase risk of PPH,

Give Syntocinon 10iu IM instead

31
Q

When should introperative cell salvage (blood transfusing using blood loss) be considered ?

A

for emergency use in PPH associated with CS and with Vaginal delivery

32
Q

What 4 things can be done/given before greater intervention if PPH has not been resolved?

A

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

33
Q

Haemabate should be given IV, True or False?

A

False

it should be given Intra -myometrially once

34
Q

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?

A

It can cause Nausea, dizziness, flushing and headaches

35
Q

When should caution be taken if Haemabate is considered to be given?

A

hypertension,

cardiac disorders

pulmonary disease

Asthma

36
Q

What doe should Haemabate be given?

A

250mcg

Can be given up to a maximum dose of 2mg with no less than 15 mins between doses (8 doses)

37
Q

What is the rationale behind giving Misoprostol

A

Misoprostol induces uterine contractions

Approximately 70% of PPH cases are due to inadequate uterine contraction

38
Q

How should Misoprostol be given?

A

800micrograms sublingually

39
Q

How would Tone be treated, in the case of a PPH?

A

rub up contraction

Bi-manual compression

Empty bladder – indwelling catheter

40
Q

How would Tissue be treated, in the case of a PPH?

A

Deliver placenta
Manual removal if
necessary

Check placenta for retained products

41
Q

How would Trauma be treated, in the case of a PPH?

A

Check for tears/episiotomy

Particularly high vaginal/cervical

Assess depth & difficulty

Appropriate personnel & place

Analgesia

Lighting

Commence suturing when able

42
Q

What questions will be asked when treating Thrombin?

A

 blood clotting on the floor?

Have you checked clotting?

Is there an underlying medical condition?

Does lady require platelets?

Liaise with Consultant Haematologist

43
Q

What additional treatments can be considered in a severe PPH?

A

Massive Obstetric Haemorrhage policy

If lost more than 2000mls

Will require CVP line & monitoring

Transfer to theatre earlyBaloon Tamponade (Bakri balloon catheter (with Syntocinon infusion, to remain in situ for 24 hrs)

B lynch suture

Embolizing uterine vessels +/- hysterectomy

44
Q

What can be classified as trauma that can cause a PPH?

A

Inverted uterus

Ruptured uterus

Lacerations/ episiotomy

Haematoma

45
Q

what would be the treatment in case of an inverted uterus?

A

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
46
Q

What are the different types of uterine rupture?

A

Partial

Complete

47
Q

What is the incidence of a uterine rupture?

A

1:1,500

48
Q

What are the main risk factors for a uterine rupture?

A

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

49
Q

What are the signs and symptoms for a uterine rupture?

A

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

50
Q

What are the treatments for Uterine rupture?

A

Treatment = surgical repair or hysterectomy

51
Q

What can be the cause of PPH when considering tissue?

A

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

52
Q

What is considered as a Placenta Accreta?

A

Placenta morbidly adherent infiltrating endometrium

53
Q

What is considered as a Placenta Increta?

A

invades into myometrium

54
Q

What is considered as a Placenta Percreta?

A

invades through myometrium and into serosa

55
Q

How is retained placenta managed?

A

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

56
Q

Aspirin and Heparin can cause Thrombin disorders

True or False?

A

True

57
Q

Name 5 obstetric related causes of Thrombin disorders

A

pre-eclampsia

HELLP

Abruption

IUD

Sepsis

58
Q

How would you recognise a thrombin disorder?

A

Watery’ blood loss

No evidence of blood clotting

Oozing from puncture sites

Bruising

59
Q

How are Thrombin disorders treated?

A

Treat underlying condition

Involve Haematologist

Transfusion of blood / Fresh Frozen Plasma (FFP’s)/ cryoprecipitate/ platelets

60
Q

What should be done when treating a Major PPH (blood loss > 1000mls)

A

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

61
Q

9 things to be monitored and investigated during a PPH?

A

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

62
Q

list in summary, the medical treatment that can be given to treat PPH

A

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

63
Q

What treatment can be considered in theatre?

A

intrauterine balloon tamponade

Brace suture

Consider interventional radiology

64
Q

What treatment can be considered in surgery?

A

Stepwise uterine devascularisation

Bilateral internal iliac ligation

Hysterectomy

Uterine artery embolization

Midwifery emergencies (8 decks)

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