Postpartum Haemorrhage (PPH)

Question 1

How much blood would she lose before it is classed as PPH?

Primary vs Secondary PPH?

What about if she delivered via CS?

How much blood would she lose before it is classed as a MAJOR PPH?

Answer 1

500 ml NVAD
1000ml CS

Primary - within 24hrs of birth
Secondary - 24hrs to 3 months after birth

> 1000 ml

> 1000 ml

Question 2

Causes:

4T’s

Answer 2

Tone (uterine atony)
Tissue (retained placenta)
Trauma (e.g. perineal tear)
Thrombin (bleeding disorder)

Question 3

Prevention:

Treating anaemia
Emptying bladder
Active management of 3rd stage of labour
IV tranexamic acid during CS

What is done during the 3rd stage of labour to prevent PPH?

Answer 3

Oxytocin (or oxytocin + ergometrine if high risk)

Question 4

Risk factors:

Words - Big Old Long Bleed

What do they mean?

Answer 4

Big uterus - multiple pregnancies, macrosomia, polyH

Old - increased maternal age

Long or complicated (induction, instrumentation, CS) labour

Bleed history - previous PPH, APH or bleeding disorder

Question 5

Management:

1. Resuscitate - what does this involve?
2. Identify the cause - what position should the woman be put in to look for this?

MAJOR HAEMORRHAGE PROTOCOL ACTIVATED!!

Answer 5

High flow oxygen
IV fluid though large bore cannula - transfuse if a major bleed
FBC, blood group, and coag
——-
Lithotomy position for examination

Question 6

Management:

Mechanical - 2

Treat as uterine atony if tissue, trauma and thrombin are ruled out.

Medical - Stimulate uterine contractions - 4
1 drug to reduce bleeding

Answer 6

Bimanual uterine compression/massage uterus
Cathertirisation (Bladder distension prevents uterine contractions)

Oxytocin IV slow bolus
Ergometrine IV/IM - Stimulates contractions

Prostoglandin Analogues:
Carboprost (PGF2alpha) IM or intramyometrial - stimulates uterine contractions
Misoprostol sublingual - stimulates uterine contractions

Trabexamic acid - antifibrinolytic

Question 7

Surgery if medical management unsuccessful:

What is used? - 2

Answer 7

Balloon tamponade
Uterine artery ligation

Hysterectomy - last resort

Question 8

Secondary PPH:

Why is it called secondary?

What is this usually due to? - THINK OF 4T’s

Surgical evaluation needed!

Answer 8

Blood loss after 24 hrs and up to 12 wks usually after 7-14 days

Retained tissue or clot, often associated with endometritis (give IV antibiotics)

FBC
Blood culture and swabs
Urinalysis
Consider USS

VIsualise tissue and remove using forceps if possible