Postpartum Haemorrhage (PPH)

Question 1

Definition

Answer 1

Excessive bleeding from the genital tract following birth upto 6 weeks after delivery resulting in a blood loss of more than 500mls

Primary PPH - PPH in first 24 hours
Secondary - After 24 hours to 6 weeks

TIME CRITICAL EMERGENCY

Question 2

Incidence

Answer 2

Between 2006-08 5 women died from PPH due to poor observations and underestimating blood loss.

Question 3

Risk factors

Answer 3

• Prev PPH
• Maternal Hb below 85 at onset of labour
• BMI greater than 35
• Low lying placenta or placenta praevia
• Multiple pregnancy
• IOL and oxytocin use

Question 4

Help

Answer 4

Senior midwife - Aware
Senior OBS - For expertise and in case of theatre
Anaesthetist - In case we need to go theatre
Scribe - To document everyhting
Runner - To provide equipment needed

Question 5

Signs and symptoms

Answer 5

4 T’s
Tissue - Retained placenta, placenta accreta
Tone - Failure of the myometrium at placenta site to contract and compress torn blood vessels
Thrombin - Coagulopathy
Trauma - Cervix, perineal tears, episiotomy, uterine rupture

Symptoms

• Tachyapnoea
• Tachycardia
• Hypotension
• Shock and clammy skin
• Uterus boggy

Question 6

Midwifery Management

Answer 6

• Call for help
• Rub up a contraction
• Catheterise if bladder full or palpable
• If atony, bimanual compression
• Repeat oxytocin drug
• Ensure uterus empty, repair trauma
• Consider balloon tamponade if haemorrhage continues after drugs

Question 7

A B C D E

Answer 7

• Check airway, administer 15l oxygen and clear airways
• Check breathing, listen to breathing sounds and check sats
• Circulation, gain two IV access, take FBC, group and save, cross match 4-6 units of blood, clotting if PPH related to thrombin, administer Hartmans crystalloid fluid.
• Keep warm, provide dignity, baby with partner or in cot.

Question 8

Fluid replacement

Answer 8

• Crystalloid, 0.9% sodium chloride or Hartmans 2L

MAXIMUM 3.5L UNTIL BLOOD AVAILABLE

Provide cross matched blood or O- Blood

FFP - replaces coagulation factors

Cryoprecipitate - Replaces fibrinogen

Platelets - If <75

Question 9

Drugs 1st Line

Answer 9

A bolus of either

• Oxytocin 10IU IM
• Ergometrine 0.5mg IM
• Syntometrine 5IU oxytocin combined with 0.5mg ergometrine IM

Question 10

Drugs 2nd Line

Answer 10

Repeat a bolus of first line drugs

2nd Line
- Syntocinon infusion 40IU in 500ml normal saline using infusion pump at 125mls/hr

Prostaglandins

• Carboprost (Haemabate) 0.25mg IM every 15 minutes with MAX 8 dose
• Misoprostol 800mcg sublingual, PR, PV
• Transexamic acid 0.5-1g IV

Question 11

Surgical

Answer 11

PERFORMED BY DOCTORS

• Arterial ligation
• Internal iliac ligation
• Hysterectomy
• B Lynch suture

Question 12

Aftercare

Answer 12

• Observations
• Monitor urine output hrly
• Transfer to HDU
• Monitor blood loss, CVP to avoid over or under transfusion
• Repeat FBC, clotting and U&E 6 hourly
• Debrief

Question 13

Documentation

Answer 13

• Proforma
• observations
• Drugs given
• Procedures performed
• Cause of PPH
• Staff present
• Blood amount
• Incident forms