Postpartum Haemorrhage (PPH)

Question 1

What are the changes in blood volume during pregnancy?

Answer 1

Increase in blood volume by 50%, increased CO and increase in red cell mass

Question 2

What is the definition of shock?

Answer 2

Circulatory failure leading to hypoperfusion and poor oxygenation of tissues

Question 3

What is the 15-30-40 rule for signs of blood loss?

Answer 3

15% loss - tachycardia
30% loss - tachycardia, hypotension
40% loss - tachycardia, hypotension, cool and clammy (shock)

Question 4

Define primary and secondary PPH.

Answer 4

Primary - occurs in first 24 hours following delivery
Secondary - occurs 24 hours to 6 weeks following delivery

Question 5

Define moderate and severe PPH.

Answer 5

Moderate - blood loss >500ml
Severe - blood loss >1000ml

Question 6

What are the causes of PPH? (4 T’s)

Answer 6

Tone - uterine atony (placenta praevia, twins, prolonged labour)
Tissue - retention of placenta
Trauma - C-section, episiotomy, instrumental delivery, large baby >4kg
Thrombin - congenital, anti-coagulants, DIC

Question 7

How are high risk patients for PPH managed pre-delivery?

Answer 7

Risk stratification
MDT discussion and planning
Optimise nutrition and iron levels

Question 8

How is the risk of PPH reduced during labour?

Answer 8

1. Oxytocin in third stage
2. Cord clamping
3. Controlled traction

Question 9

What are the four types of medication that can be given to control PPH?

Answer 9

1. IV fluids
2. Uterotonics
3. Blood products
4. Pharmatonics

Question 10

How is a minor PPH managed?

Answer 10

ABC and continuous reassessment
Supplemental oxygen (40%)
IV access and bloods (FBC, group and save, fibrinogen)
Foley catheter

Question 11

How is a severe PPH managed?

Answer 11

Modh PPH drill:
ABC
Venturi (O2 @ 40%)
Vitals

2 IV cannulas + bloods (FBC, group and X-match)
Start IV oxytocin 40IU
Start IV fluid replacement

Uterine massage
Second dose of syntemetrine IM
First dose of carboprost (C/I asthma)

Speculum exam - high vaginal or cervical tears
No tears - go through 4 T’s systematically
Bimanual exam - try to compress uterus

PR misoprostol
Consent for emergency laparotomy
Surgical management
- Balloon tamponade
- B Lynch suture
- Vessel ligation
- Hysterectomy

Question 12

What level should fibrinogen be maintained at?

Answer 12

> 2g

Question 13

What are the treatment goals in PPH?

Answer 13

1. Restore blood volume
2. Restore oxygen carrying capacity

Question 14

Name 4 uterotonics.

Answer 14

Oxytocin
Ergometrine
Misoprostol
Carbiprost

Question 15

What is the surgical management of PPH?

Answer 15

Balloon tamponade
Compression suture
Ligation of pelvic vessels
Hysterectomy

Question 16

What is the antidote in local anaesthetic toxicity?

Answer 16

Intra-lipid